S 1390 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'I?RTINO BUIUMNC,.ELEiUpRICAL Pldu'LNO
IIIJII,DING DIVISION APPLICATION/PERMIT PING igomc F:npbri-CN' 1390
Itllll.l)INI:PROJECT IDI?NTIFIG('LIOS
IIUII.DINOADDIt IiSS: SANITARY NO. TAP�PUICAI'[ON SURMI ITAL DATL
a� 7 ap �SCv � �UF� rna/ Q�, 1 -�a
O 1:1S NAME: IQ HO 1�f ^//1� C 'R ,YOB'S NAML: � OEC NIC CONI'HOLp
. ARCHITEC7HENGINF,ER: [AC NO: R/. Y A :'ti: � o _ Pri a(,J ❑
CONTACT: n PHONE: BUILDING PIiRMI'1'INFO
if/� / ❑ Consullanl Fecs Paid by Applicant(Initial) RL❑DC LO PLU❑M11R MIiCH
LICENSED CONTRACTOR'S DECLARATION (, /�//'// QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby anthill that Ina lirenwd under provisions OuChipar 9(cnimnencing
WOZ with Seuam700E)o1 Division 3ofthe Business and prrofe.sssiiyonnss]Code,and my license is RESIDE NTIAI;
CWF In Lica e[5 ,2 9/l� I'IiRMI'1'ISSUANCIi
F full forearm f , 0SFDWI, ❑KITCHEN REMODIR.
U Liana Class APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
Y Z W
"me
Canwcmr
ARCIIITIcC:s DECI,ARATION ❑MULq'bUNI'f ❑MODCTURN.
F D y PANELS MODIFICATION
ZpyZ I todccsand my Plan ,dull he uscdmpuhinacro x, UP'F02110AMPR
OZ4� INTERIOR ❑CHIMREV REPAIR
1:-'Gtt:ty Liccmed Professional 201-1000AMPS IMPROVEMENT' SWIMMANG POOLS
CY�J OWNHR-RUII.DER DECLARATION OVER 110f1AMPS C1 PATH REMODFUMEPAIR ❑DEMOLITION
C C 6 I herchy ul'Orn that 1 not exempt filum the Conkatual"hlcmw I,uw fur the ❑OI'HEk
following rcawn.(Section 7131.5.Rosales,and 1'mhaouns Gde:An,city or county SIGNS IiI.ECTRICAI,
1+131+-y which requires a permit to OuNhow,,alter,improve,demolisic or repair any xwcmrc
gpilortNn,i...unce.III...rcquim the upplicnm forwah l+mmiu.rile a,ignedmnmmen, SPECIAL.CIRCUS'/MISC. El
� IhuthrolicenrdlursuumR,thep,ovi,lonsof the Conm+anr's Licence Law(Clmpar9
F 1 L
4�15^LO (commencing with Section 01X1(17 of Division3 afthe Business and Profeoi.nsCMgor '1'EMI'.MISTER IIB POLE INST
ilia he is exempt therefrom and the
their ar the alleged eaemptinn.Any virlmion of NEW BLDG/ADDITION C)DI'.hfOLl'I'ION
f
,-H Seelion]0315 by any upplicnm fa u pennil suhoah,thunpPliumi foa,eivill,cnally of POW17R DEVICES ❑TENANT ❑FOOD SERVICE
marc than five hundred dollars(S5(A). IMPROV EMEN'I'
HZO CI I.as owner of the pms,mrf Ile my employees with rages as their sole compensation. SWIMMING POOL,ELECT RIC ❑OTHER
(5.97 wtl do the eek.mal lhestnmuueis not Int ended mothered fa ,alc(See 7044.mines,
1.3 and Pmle,sai x Code:The CantracaK,lJot Ldoes m
aw ds not apply ua owner of l)lIl'1,1;15-SWI'ICUPS-IEXTURLS
propcnY who build,.,,.prove,thereon and who does such workhim.¢If nr through NEW HCgIDENfIAL F.hIiCfR SQ IT
his own employees,pnrvidnl Ihat wch impnrvetnent,arc not imentied or nRemd far SQ.FL FLOOR AREA SISQ.P.
sale.It,bow uc.the building or impoolman t is old within one ycur of cmq+Ictinn,da
er-builder, will have the burden of proving that he did not build Or improve for pur-
"a nfsull), TOTAL'
0 I,a owner,,(the property,um axel-hely eonnactin,with Iicen,N cohnia, s to
'woeemauct the prnjM(See.V(Wq,business and Profession,CoJ0]lie C maunor's I.--
estate Law docs not apply,,,an..har.f property who mild,.1 imphmxsthneon.and QT1'. LU RINGPERMIT FEE
who aabacu fall,project,with a commemrp)becood puamrm to the Contractor's
Liecme law. 1'ERMI' .UANC.
1 am c,empt under See. .B&P C lir,this reason
ALTER-D 'VE WATER LEA) VALUATION
Owner Dae
WORKIiH:S CUMI'T;NSAI'ION DLCLARAI'IUN BACK I'hOW I' l'.Dli
t� l hereby aRnn under Penalty of penury One of the fallowing declarations:
�yl h:rve:md will mnimoinaCenilic;nc of Consent e+set pinsurc lire Workers Con,1^'n- DRAINS-FLO(Jk,R "AREA.CDND. S'1'ORII!qtTYI1ECDNSTRUCI'IOF
x tmn,as provided for by Section 38X1 of the labor Calc,for the plifoo Calle of the
work for which Nis permit is issued. FI%I'URCS-PIiR'TRAP
1 have and will maintain Worker's Compenxaion Insurance,Its required by SectiontIGAS-EA.SYSTEM-I INC,J OUI'IJOS 3]011ofalelabor CC�ode.far tthh�e performance al'thewerk lor which this pemdt,siaued, OCC.Gk(UpAPNMy W sC•1 I1�(Isa—PYI�I — ITJ -ePoliy No: � {�= GAS-W.SYSTEM-OVER4(EA)
C,RTI CACATIilll+F[lid I'IION J;RONI WOR KERS' GRIiNSHIINOUti'Tk1.WA$'TR IN'I'ERCBI'I'OkCOMPENSATION INSURANCE M
B1JIl UfS
GRMSI7TRAP vi. NC1ka Pili-
or less,)
Iccnify tlml lathe p,rf.nnancco(the work l'u,which Nis lcnnit In lsxmd,lsl+°I1 SEWER-SANITARY-S'IURM ITA.200 FT.
not employ any Persian in any manner w a,to hecome objeaa to the Worker,Compen- IiNE Y -'P
Z ,anon I,aws al Califoorm [)"a WATIIR HEAl ER WNENT/EI.ECfR AI G Rli
O O Applicant
Z
N NUI ICE TO APPIJCANT:If, it,,maAing this Cenilica a of Exemption,You should WATIiR SYS TEM/LREALING t�
h'
become subject m the WnrAcls Compensation provisions of the latxc Code.you muttM[lFRNIITFEP,
SOILS Iain[ ... Af a l m
fiathwith comply with such pocisiu o,tl+is proud slu ll he dceoed revoked. WATIiR SERVICER1W0CONSTRUCTION LENDING AGENCY NEW RLSIDENU IALPI.MR. rllaE 1`f Dwe a PI NUC) Ihareby Iffirm that mere is a e.nswclion lendingagency fo,the Ierfmmanae of
0. the work to,.hid,nilsIennit Is issued(Sm.3097,civ.C.) 'la)'fALC)V lender's Name UIwndcr's Address .DING IEEI ,,tinyuad I hove mod Ibisapplinnion and nmtc that the uoovc inftuation is
small I agree to comply with all city and Count,ofdicame- ad,tam lows rclalngm Q'I'Y. MF;CHANICAMIC I+EEU Z building conamaion,aur hereby amh,,dae representatives of this city u+erne,upon the
above.rmenuourd,rupeny le insivchan indents. PERMIT ISSUANCECI'kIC FEE
(We)agree m save,indemnify and kern harmles,the City,,f Cupertino against
liabiliticsJudgment,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MUCH. PLUMPING FEIi
in consequence of the grunting of this permit. PLUMPING
APPLICANT Ul,DEItS'LANDS AND WILL COMPLY WITH ALA.NON-POINT AIR HANDUN I ONE'L('to 10.000)CFM) MLCHANICA1.lI?Ii s D
SOURCE REGULATIONS. /
AIR HANDLING UNI'1'(OVER 10.100 CFM) CONSTRU(7f10N TAX
Signature of Applieanl/Contmnor Dme EXHAUST HOOD(WIDUCT) I IOUSING MII'RIIATION Hili
HAZARDOUS MATERIALS DISCLOSURE
Willtheh,,1icatn u,future th liimgokeupantmarc ar handle harardom material HEATING ONE(TO 100.(00 it'I UI
m defined by toe Cupertino M rnapal Code,Chupar 9.12,ant the Ilcdlo and Sal itRN
I"I'(OVER 100.001i'rU)
Ede.Sectim.25532m)'
❑Yes E]NO N PAN(SINGLE RESID) PAID
Date ReceiptN
L
Will the applicant or future building occupant use equipment(a devices whichMP(3111'OR 100.00 RTU)
mit haaadous air contaminants as defined by the Ray Arca Air Quality Management T(11'AL
District'! MP(OVF I0OjX)0BTU)
L]Yes nNo
IONER ISSUANCE DATE_
I have read the h ha ,Se tions 2lx 5,25533 an under Chapter understand
of the Cali- 3 IJ(J
fomiu glow ne Safety Coda,gcaiom 25505,2553)and s5Ji,I to notify the
thus il'tboNEWN'CIAI.MIiCH. SQ.PI', r- ply - 4
Of,hcre,murem,,fish have he all, to,n is..responsibilityOfaCnichc Of
of the myuimnend whish mutt Fe ran prion.inwanee of a Canificam.f(kcupancy.
ll ` c 1 ♦ O
Owner or amhonmd agent Du¢ 'IDTAL'. /s/ ISSUED BY: VORr'A
OFFICE