S 2728APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII.DINc-ELEa,-rRICAL PERNIII NO, �
BUILDING DIVISION AIIIIIACATIONAIERMIT PIAPM wG-MECUANICAL2720
BUILDING PROJF.CI'IUFN'I'IFICAIION S L O
BUILDINGADDRI'll I SANI'I'ARYNO. AI'I'I.ICA'I'IONSUIi MI'I'TALDAI'1:
lIgIi ` d 1 /yew Sf (�' ;.� 7504 _- -3
LIC NO:
-
AU/URF. S: /
�f
El
CON'I'ACD IB Ii.
IIGFLDING PERbIl I' INIr0
BLDG IiLECr PLUMB MECH
K ❑ ❑ ❑
d�
��✓,w Kerr -334
❑ COnsullanl Fees Paid by Applicant (Initial)
IJCENSEu Cu 'nsed hadcrpnisum R f Chap
heeby(Bolmal1n1,licensednnner pmdnonrmChapbry fmnnnemis
suint %salon nXXO of Division cosine>. and Pmressinns Cudc. and my liccntt i.
n full Gncc and c c'. ��✓�a
to, CF,s a"�I Lic.X
Uaw Como NCI `
QTY. ELECTRICPERMIT FEFi
JOB DESCRIPTION
RIi51DENT1A1,:
CSil)N'L CKITCHIiN REMOUIdI.
[:1 ADDITION ❑PLUMBING RE-PII'li
❑MULTI -UNIT' CS'FRUCI'URAL
MODIFICATION
❑INTERIOR ❑CHININ17Y REPAIR
IMPROVE SWIMMING POOLS
1�Z
IOp
1UUbice
i W
Z
oQa
D m
Z
M
YF.RNIIT ISSUANCE
AI'P1,IANCIiS-RESIDENTIAL
-
AHCHI'I'I:C PS DECLARATION
I undcdunJ my plan%shull M1c used m public rccoMs
1'ANIii.S
UP TO 200 AMPS
hiccnseJ l'rofcesinnal
2(11-I(XNIAMPS
rJ
WQ
a U
OWNER RUII,DER DECLARATION
F wmby ailuro if., 1 um mental fm11, the Coonacmd Lmcnac Law for ,he
following reamn. (Section 9031.5. Imsine,x rend I•mfas%inns Calc Any city or county
❑BATA REMUUF REPAIR DEMOI.I'I'ION
�1THIik-lsL�/�
OVER 000AMPS
_
SIGNS ELECTRICAL
ON
sQL
5
; O0I,uvownernt'the
13 m
which requires a pmmil m construct, alter, improve, demolish, or repair any suucwm
Pne, t,I y ,I'PPI_ main hpv 'tt ]lie g J.t t mem
IIrlt It, is Iu,rh,vdI II tlhe p ,ion—I tire C 1"1 Ulchw I' ((I pn.f9
(conmvu:ingwlh Schon70(XBIf D'vivon 3otmc Brei urs and Vwml,i ,' Cda) I,,
thin he is cnemp, ,hcrcfmm and the M1a,is 6r the alleged exanp,ion. Any violminn of
Semior 7031.5byhey applicant fora permit whysec, the applicant,. a civil Penalty of
mainre, run live hundred dollars (SSTI
property,oranycmpluyve, will, w-gcs as their enle linowaxaft".
wiIldodm,. ,andth ,l...he it am mtndedoroRcred foraale(Sev. 744,Itusinckk
The Comror'c License Law m does nn, apply an limner of
and Professions Code, va
propcny who build%or impmvcs thcmon. and who does such work himwafor thmugh
hl, own employees, pnwided (hal such improvcn¢nu me not amended or nrfared fn,
pnuc11t in,old withmoneycarofunnplet iun,the
hLdmgm imwmIF
elc.11,m%vVvr. thcic
nerbuilder will have 0e burden of proving that he did not build cr improve for pur-
SPECIAL CIRCUI r/MISC.
..
TF,MP. METER OR I101,1
COMMERCIAL
❑ NEW BLDG/AUDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
CGiI1i-R
POWER DT,VICF_S
SWIMMING POOL ELECTRIC
OU LIDS -SWITCHES -FIXTURES
NEW RRSIDEN'TIN, HLECTR . Q P
SQ. FI'.II f IORARIIA
$ISQ. FI'.
_
--
'2
TOTAL
pore of sale.).
❑ 1, as owner of the pmpeny, am excitonely contracting with licensed convoctnn or
instruct 0th pmjcct (Svc. 744. Bu%imms and Professions Code:) Be Comma a Li-
neLaw duvscut appl,11-11 owner of property who Mitek or anmruve%,hereon,and
Q'I'Y. PEUMBING PERMIT FHH
who clmmetw for such prnjeeta with a contruch us) licensed pumnam to the Clmracmr'.
Limn, Law.
❑ l um exempt under Sec. .B&P C forthis octom
PIiRMI'1'IS NCI:
own',Uulc
WORKERSunderPCOM UITCLARSHONfbefiAlowing
ALTER -DRAT &VE -WATER (EA)
VALUATION
/'�
O( {r
�.%
BACK II.fIW PROTIiCC 'V li
1 hereby offer yonION
and%affirm under penalty of perjurynucofine Insture or dcwlacmaohWorker's Ca:
](have and willmaintain a Ccnilica¢nfCon,nuo¢If-inwrcfor Worker's Camper-
anon, -s provided tur by Senbn 37(X1 of the Lahnr Cnde lir, ov perfurmum,c of the
k Goy which lho ,,enuh is lxwcl.
have and will maintain Wnrkcr'r Comp nsrlmn Inwmnee, as requhed by Section
11
x7l11of the Labor Code. for the performance ofthe work for which this Noun is i„1W.
DRAINS -IltF)R,RIX)EAR :. N
CTQR1
TYPE C(INSIRUCI'ION
FI%'R11211S - PI?It'rltAl'
GAS - FA. SYSTEM -1 INC. J OUI LETS
EKG GROUP
$' ?
CarrBorkcrsCnlplreosatioyt ln, rA f:pw ad Policy NoY��(�� � 9%�
GAS-I:A SYSTEM-(IVF,R4IEA)
•7
GREASIVIN DGS, RI. WASTE INTERCEFIYIR
CHKIIFICA✓1'E OF EXINMVI'ION FROM WORKERS
COMPENSAIION INSURANCE
BUILDING DIVISION Il:1:S
GREASEIRAP
VLANCIIECK FEE O
ZZ
o
F+ =
D.
VQ
('Bakseminn need nm MmnnpinW iftbe pvman isforoncnundreddnlluo(SIW)
or less)
Iv,mydnu rude pe,fonnmmcofthe work Ra which this permit is I ... W, 1,mil
not ctnple, uny,,cath i n any nw11nc r... acro woo vscbv1l to the Workv,FCoTTwh-
,min a Laws of Culiliornin. Dae
Apphcmn -
SEWER - SANITARY - STORM F.A. 211B Irl',
ENERGY FEE
WATI:RHEATERW/VENT/ELI:CIR
GRADING I'I:I:
NOTICE TO APPLICANT: 1f, after making this C,homeme of E,emp,ion, you should
becomu,uhjec, to the Worker's Compu11,nuun provisions of the Lulxn Cede, you must
Ibnhwith comply with such pinvki... I h th® permit shall hedvwhvd m-1,vd,
CONS] RUCTION LENDINGAGCNCY
I hereby affirm that is a cunslowfion lending agency for the perhlmanre of
Inc work for which till Penne i, issued (Sec 3097. Co. CJ
Iwnde', Nmnc
WATER SYSTEMI'l KEATING
SOI(S PCE
WATT?It SERVICE
)'AID me Receipt#
NEW RICSIDENTIAI. ('LMR. SQ 19'.
IY)TAL.
o FOIAIL:
F
C) U
11
F' h
V Z
Lenders Addns,
BIBLE, G 19:1:
ov
I certify that 1 have mad this application and state that the above information 1%
c reO.I agree instantly with all city and cnunry mdiumncwandwanclvwsrelml^gm
d hcrvhy;,.Il imem,nhar,e,of this cnyno cmcrupon the
buildingcnn.aruaiun, anp
Q'I'Y MECHANICAL PERMIT FEE
SEISM('
PERMIT' ISSUANCIi
ALTER OR AGO JS p�
I.I. CT IC197E
ahnvcI traced pnolxr,y f or In.pccfmn pnrp....,
(wc) ngrce e, save, indenceifp and kccp mouless the Chy of Cupertino ag-inn
Hathilitics.jodgnan,s.cost% and cxfmi which nay in any way income again%, mid City
1'LU, BI ITE
' nayuence of the granting of this Permit.
A I'I'LICAN"1' UNIT 11 RSI A NDS AND WILT. COMPLY WI'I 11 AL1, NON -POINT
\ o I
AIR IIAN DLING UN' �4 IOJ XX1 CFM) L
MECII (CAI. Iaili
SOIL ERP UhA'I'IONS. /� I
U I),ra--e ��q/qct
�y(4• V///979
u
AIR HANDLING UNI' VCR,l�1. QPM-] IBJ !I
_
CON$'IRUCfIrIN'fA%
Slgnaune of ADPlicunUGmmve I XUmca
HAZARDOUS MA ERIALS DISCLOSURE
P
EXHAUST BUILD fW'/ UCT) a
I IOUFINGMr1IGA'TIONFEE
HEA'IINGON[ "I' 1'I'(, I I%wo if I' ll) l�
Will lh—plIia-ntlrlW,rmhaddinguwcnpumaoeor caulk hmansuknesecal
an. de6md M1y the Cupertino Municipal Code, Chapter 9.12, and the Health end Safety
Code, Section 25532(a)1.
JJ .�
HL'A'TI NO UNIT (OVERBdAU�M/ H'
VIi OLSOONI'vNSINGLERESID)
ElYcs ^No
PAID Dane Hmciptp
Will Ihc upplucamor lotmc hmldingaeeupam saw uryapmem or devise, which
i, harJnus air commensals as definnl by the Hay Arca Air Quality Management
maa
BOIhEN-COMI'13111'OR I(q lXNl ifN)
'I OTAL:
,111110!
❑Ycc �Q No
BOILIiR- COMP(OVER IW,(XX)aW)
AIR CONDI'I ONCIt
I nave cud the hamrdnua material,cqulrchicut, under Chuprer L 95 It'the CNi-
fomia llevlth & Safety Cede, lection, 25505.25533:md 25534. 1 undcusmnd that if the
pan
building does not clemently have a tenant, that it is my responsibility to notify the occut
ISSUANCE DA]A{
VA
NEW RESIDEYI'IAL MECH, SQ. PI'.
'e me r/ �h mine v which must Iw; m prior m iemmec oDa cernfi nr panty.
M
/ • �AA-��
Tow.,.
ISSUED BY:
Own , head -gem � Unm
OFFICE