S 0177 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
,CITY OF CUPERTINO -BUILDING..ELEC'TR1CAL PrRM rf No.
BUILDING DIVISIONAPPLICATION/PERMITPLUMBING.-MECHANICAL
0177
BUILDING PROJECT 1nitlor'IF'ICATION
ILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
/0.46' Oh/�AIW
NIiR'S NAMB: /^�>> 1'IIONE: CONTRACTOR'S NAME: LIC No:
r /J� NIC CONTROLM
E-r /'L
ARCHITECTIENGINEER: LIC NO: ADDRESS: - ❑
CONTACT: THONG IU ILDING PERMIT INFO
❑,CansBltent Fees Paid by Applicant(Initial) BLDG IiLECT PLUMB MLCH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT PEE
1 hereby affirm tom Lam Reea.e l under provi.n,ns of chapter 9(commencing JOB DESCRIPTION
�'Tts.'z with Section)OXD of Division 3 of the Business and PndcssionPERMIT ISSUANCE s Code.and my license is RESIDENTIAL:
W - _
CSF bfull force unJ effect. ❑SI'DN'L El KITCHEN REMODELQUV License Class Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
Y Z til Datc Contractor-
Coll;
ontractor
Capy AHCffI'IT:CTS UECLARAI'ION PANELS ❑MUI;I'I-UNIT ❑STRUCTURAL
Os Z 1 understand my plans shall be used as puhlic records MODIFICATIONOZN-0 UPT02MAMPS ❑INTERIOR ❑CHIMN17Y REPAIR
.F•4FW Licensed Professional 2014000AMPS IMPROVT:h1ENT SWIMMING POLIS
OWNER-BUILDER DECLARATION OVER 100 AMPS ❑BATH REMODELtREPAIR ❑DEMOLITION
C w Q I herehy affirm that L am exempt front the Contractor's License Law for the
5L5��6U following reason.(Section 7015,Business and Professions Code:Anycity orcounty SIGNS ELECTRICAL �Cp HhR
LL13 m y which requires a permit to construct,alter,improve.demolish.or repair any.structure
E_'ic,j prior to its'.. I:o requires th ,tilson fill such iu life.li,mi,lOcalement SPFCIALCIRCUITIMISC.
F.�y that M1 d pursuant thep 1 rM1 Contractor s I 1 (Chapter 9
CCd'� (atm neneing w'th Sution 9(XNltnfD v:onJ ITh N . ss JP 1 ms Code)or TEMP.METER OR POLE(NST COMMERCIAL,
A.a c W that he is exempt therefrom rand the basis for the alleged etc floor.Air,violation of El NEW BLDG/ADDITION E3 DEMOLITION
X,00 Section 703 1.5 by any applicant for a permit subjcros the applirnm est a civil"mady of POWER DEVICES ❑}J?NAN'I' ❑FOOD SERVICE
nm more than five hundred dollars($500). IMPROVEMENT
iE ❑I a,ov srnf the per pent Y nphY it g:nstn : rap i n. - SWIMMING POOL ELECTRIC .
oerO will do We work,and the a '1 m': tinie I Jlabeledf r al (} 0(W4B .' s - 0111
¢I'-'� -^d letestator,Cde II Claudio sh 1 nI'pl lYr twner ul OUTLETS-SWITCHE} FIXTURES
pm,,Iy who b 'Idxor nopnoc,It tt,and It,,does such kl if rdo a,h
hist ply :.Art ide1t1 t: hinp r. r nolintended f1"crcnlar NEW RESIDENTIAL LI hC'1'R 'SV PII SQ.lel'.FLOOR AREA
$ISQ,17T
lulu.Lf,Itowcvcr,the bandinmne ea
g err Inpnrvancnl Is sold whhoyr of c n,ledion,the
cnboilder will have the lnnden at proving that he did nut build or improve for par-
,d c of I ). 'TOTAL: -
❑ L I th p . tY IY t r y 'll I'' J t to A
const t 0 p j n o an ii f L tJ 1'131 Contract(),t .L'-
vro 1 J t apply to fp ree nt h es lJ: p J QTY PLUMBING PERMIT FEE .4 O
vshornmoract,ete axcnp 1 to wire acuter r n.>hvtn.w hx 9am bt ton C ca mmvla
1,censor PERMIT ISSUANCE
ex 9
I ten exempt under Sec. .1i&P C for this reason q/
ALTER-DRAIN&VENT-WA'DiR(EA) TIDN
ther Date '-
WORKER'S CO f STI N Dthe following
RACK FLOW PROTECT.DEVICE
alU~��r
1 hereby iirm o
under penalty of perjury one offthe i,llnwing Jedaations:
I have and will maintain a Cenificuut of Consent o Self-insure for Woders Compen- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONSTRUM'[ON
satid,as Provided for by Section 371X1 of the Lather Gidefur rbc Pe forman d,of the
week for which this Permit is issued FIXTURES-PER TRAP
❑1 have and will maintain Workds Compensation Insurance.ac required by Section
3701 of the Lvnnr Code.tonne peritoneums,
of the work for which this permit is issues. GAS-EA.SYSTEM-I INC.J OUH.EI'S (ICC.GROUP APN
My Worker's Compemminn boadmnce carrier and Policy mandate are:
Cance ' Policy No.: GAS-EA.SYSTEM-OVER JILA)
CERTIFICATE OIr EXEMPTION FROM WORKERS' GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section nod not be complded mi
if the pert is for one hundred dollars IS 100/ GREASETRAP
or IIII'IANCIIIiCK FEE
I cenify that in the performance of the work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.2101T.
nor employ any Person in any manner no xs ve s becomsubject to the Waders' peer-ComENERGY IPE
O Z sodium Laws of California.Doc WATER HEATER WNENT/ELECTR GRADING hili
Z O Applicant t
y NOTICE TO APPLICANT:1f,after mowing this Certificate o of E abet ......should WATER SYSTEM?REATING SOILS I:EF
become
,compy the Wnd.eroCompensation pnwii shall
oede Lahr Code.You mast
fonhwirh comply with such provisions or this permit shallbeJeemcJ revoked WATER SERVICE.
9L Q
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL ('AID
I hereby affirm that there isuconswctlon lending agency for the performance of Uer tvwpra
I.S. . he work for which this PmmJt is Issued See.LP)].Civ.C.) TU'TAL:
OLntder'c Nana:
V Lender's Address 'I OI'A h:
f� W c :1 cenify that I have reed this upplicutlon and sent thr i the above information is - - IIl11LDINd F 11i
& Bed.I agree In emnply wire NI city and eaunry ordinances and state laws rdatin6 a QTY. MECHANICAL PERMIT PEE SEISMIC ITH
V Z wildin6mnsmcnnn,mod hereby.11 rite representative,of BMs city to enter upon the
xMwcnncntioned property Gu inspection purposes. PERMIT ISSUANCE DI.IiCTRIC hili
(We)agree I,save,indemmily and keep hanuless me Cay of Cupeninn against
liabilii¢s,juJgn¢nts,costs and cspcnscs which miry in any way uccmc.ngainsTmiJ City' ALTER OR ADD'IO MECH. PLUMBING ITU
in sequence of he grnoolof this pmmlf
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]'1'('10 11,001 CI Ivb MECHANICAL Rili
SOURCE REGULA'T'IONS. J?
J /�{���' Q [ z� 1;7A(B HANDLING UNIT(OVER IgI NI CI NI [UNS'HUC IflN=1'A%
10
Signammnf A,bermAnntmemr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION IPE
I IA]ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle huxtiodua,moncrial HEATING UNIT(TO 100.000 BTU)
as defined by the Cullen int)Municipal Gale,Chapter 9.12.and the Health and Safety
Code.Section 255321x)1 HEATING UNIT(OVER 100,00X0B'TU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Dare Rot a
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100.0X1 BTU)
emir hazerdous air contaminams as defined by the Hay Arca Air Quality Management TOTAU
District! BOILER-COMP(OVER 100,00 BTU)
❑Yes ❑No
I have read the nrcaudmts matmiuls requiamems under Chapter 6,95 of the Cali- AIRCONDITIONF.R ISSUANCE DATE
Roma Ifeahh&Safety Code,Sections 25505.25533 and 255.u.I understand that if the NEW RESIDENTIAL MECH. SQ.PT.
bmidingdues nor eminently have.board.that it is my mspordbility at notify thestccupant
of the requirements which mum be mer prior to iswattce of a Certificate of Occupancy.
Owncr or..,hailed agent Date TOTAL: ISSUED BY:
OFFICE
City of Cupertino
Department of Community Development
�uaC
10300 Torre Avenue, Cupertino, CA. 95014 (408) 252.4642
(DATE)
I am an adjoining property owner of )`�^'s M0_r ' � Q`�1
(N )
whose property is located at 10LI (�,D C�ak�li� MEQ Ay2y�t1�
(ADDRESS)
I approve (as per Ordinance No. 686, Section 16.28.040 of the Cupertino
Municipal Code) the allowance-of a _Z foot high fence facing my
(8 MAXIMUM)
property.
SIGNED: NAME: �RE�o
ADDRESS: 106(,TorOAKVtccE /ave
G/PF.2 n Vo , �F3 95_0/4f
G'
ocoo v
y
')
Z
O �
m �
City of Cupertino
Department of Community Development
i
10300 Torre Avenue, Cupertino, CA. 95014 (409) 252.4642
(DATE)
I am an adjoining property owner of S rlctc'on �0^�
(NAME)
whose property- is located at _12460 o a1.,u-AU� LmL
(ADDRESS)
I approve (as per Ordinance No. .686, Section 16.28.040 of the Cupertino
Municipal Code) the allowance of a 7 foot high fence facing my
(8 MAXIMUM)
property.
SIGNED: NAME: C-�-— MAT- 0 /r M ,
ADDRESS: I (7 I ( 1.) ,-()
i
i
Qty of Cupertino
Dciwrttnmt of Community Devetopmmt
— —
l�"�
10700 Torre Avenue, Cupertino, CA. 95014 (408) 252-4642
(DATE)
�I
I
I am an adjoining property owner of S"w`Q� m01Cieir' �0 'I Il
whose property is located at -A-046o 0 ak.t eYw 2
(ADDRESS)
I approve (as per .Ordinance No. 686, Section 16.28.040 of the Cupertino
Municipal Code) the allowance of a 7 foot high fence facing my
(8 MAXIMUM)
property.
I
SIGNED: NAME: BO N its
ADDRESS: 10�t`I 1 P I A E V I),\ 1- A I c
L\S �EP�tiNO L� 1Sol
City of Cupertino
?y Department of COmmumity Development
ICA
10300 Torre Avenue, Cupertino, CA. 95014 (408) 252.4642
(DATE)
I am an adjoining property owner of •- )MO-fiDn (��
whose property is located at'
(ADDRESS)
I approve (as per Ordinance No. 686, Section 16.28.040 of the Cupertino
i
Municipal Code) the allowance of a foot high fence facing my
(8 MAXIMUM)
property.
SIGNED: NAME:
ADDRESS: D ,7O
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