S 2617 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Buu.DIN(:-ELECTRICAL PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUafBING-MECHANICAL C 2617
C 7
BUILDING PROJECv /PADEN'PIFICATION J
BUILDING ADDRESS: SA61'TARV 70(1 APPLICATION SUBMI'1']AL DA TL
/OZ- - / F
OWN'R'S NAM:: '2LI�u 1'1111NC: - ��� �)N'C^C'rIIN'.5N 11!: hI�NO:
3 S SIC CON'1ltOhp
ARCIHTECC ' GINEF,R: IJC NO. ADD ESS Elot� r�$,.x s v'g
IiI
CON'1'AC'I': PI IUN14 BUILDING PERMIT INFO
` ❑ Consultant Fern Paid by Applicant(Initial) SLUG ELE❑:CT PLUMB MECCH
El
LIGHNSI!D CONI RACTOR'S DI!CLARA'I ION L Q-ry. ELFC'I'RIC PERMIT FCL? Imp/
I thereby.reran mel I.,it licensed model prevision.."t Chimer 9 cmontenci„g JOB DI?SCRIPTION
p�Z with Seeion iWlD of Uivision3nf the Rmone,,wad Pmfe:.ions Co rey licens is R I F 1
W p PERMIT ISSUANCE
�W� in full force an nLI�O WL D KITCHEN REMODEL.
<UU hiccn%e Class
Lie APPLIANCES-RESIDENTIAL ❑ADDITION DP.UNIBING R17.111'R
FZW Item Gtnu'acln
m6a ARCIIII'I!CTS DIfC,A t,\TION DA1ULTbllNll' DM0UII-TURA.
F'7Z IandeomnJm I hal beuscdas blic records UP TO
CHIMNTCA'REPAI
ION
Op-- yp ansa Pu UP'fO 200 Ahf YS
- ❑INTERIOR El CHIMNEY RIiI'NR
H 41:E Liccnscd 11 fes"onul 201-ISMAMPS IMPROVEMENT ❑SWIMMING POOLS
, OWNI114HUILIJLR DECLARAHON OVER ImXIAMPS ❑HATH RLMODEIJRI!PAIR ❑DI!MOLITION
K Q I hereby aflirnt Ina,l um exempt from the Contractor's Lie e,ne Law for the
XpaU following reason.(Section 7031.5.Busine:and Professions Cole:Any cityor county SIGNS HLECfRICAL DDTHER
IL 3 W N which Nmm,a pconil to c"n%imcl,eller,improve,demolish,or repair any stmetum SL /
plot t I. 'he'ppl'c t]or suchp itt file 'g Ittumenl SPECIAL CIRCUI UMISC.
Y uoul J li d 10he Control,',” Uromse L.ov((hapmr9
�C�Q (coSectionnmncng will,Section 9100)illUsim lot he H-irrs,,oendP I..ions Cme)or I EMP,M ETL'R OR POLE INST. COMMERCIAL
a 6 o K bar lie isexempt therefrom and ml,nasi%for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ElDIiMOLITION
too-hSection 70315 by any applicant for a mmat%objects the applicant to.civil pcnmly of POWER DEVICES [ITENANT DPOOD SERVICE
rn mora[Iran live hundred dollars($5101. IMPROVEMENT
,Zd❑ D I,wawner"f the Pn,pc'tY.„any empinycm with wage^'u%mcir.cnl<cmmprniamtimn, SWIMMING[1001.HLEC'IRIC
Caowill do the work,and the ormat re is no,immnded ornffercd Iia Ionic)Sec.7144,Business ❑OTHER
6 3 m and 1'ntle¢i"m Code:The Continuum's License Ldoesaw ex not apply m an owner of OITfL13T5-SN' rCHEl-FIXTURES
Tommy who builds or improver Ihemon,and who does such work hinvell or through
ill,on
wemployees,ptr,vid,,l mol such inipmvaneat%arc not intended or olTcrud Ill, NEW "ID PIAL IiLECTR SQ IT.
%ale.If to mthe building orallo cot iso-ald within one Yearolcompletion.We SQ,I F.FLOOR AREA 171U
owner-molder will hove,he burden of proving ohm he did not build or impress for pun
Palo,of sale.)- OTAL:
❑ I,as owner of the property,our exclusively contracting with licensed contractors hi
nemml the pmj,,,(See 7144,Hmat ess aull Ih"I..i mer Code:)*Uw Conttucmrs Li-
ra,
i-
mlawd"esnoutpplyluan”wall of prepertY who build.or improver lhcm"n.and QTY. PLD GP? FEE
wmoctallow,bitstock pmjmtx with a contracmrls)licensed personal in theCommm"r%
Licenm Law. PERMIT ISSUANCE
Dlumexcmpuuuto Sec. ,H&P C for this eca"m
A[IIIN-DRAIN&VENT-WAT' (P. VALUATION
Owner Uwe
. WORKER S COMPF,NSA'I'ION DECLARATION BACK IIAW PRGI HCC.DEVICE .C�
Il, hY rf tih pe fps) ry of the followo,d I ons 0 li1✓
hal III wIf-inlare f N 1 CmT,r DRAINS FLOOR,ROOFAREA,COND. S'I( IES "I'YPE CONSI'RUCI'ION
sello to'ao,idadI 11,Secoula 3700ol'lie Labor Cost,fIM1 perlonaaa,,ofth, /�
work for which this .all is issued PIX'1'11Rh5 Pl!R'I'µAP 61
? have and rill maintain Nbrkers Compensaion Insurance.as required by Section I)IXrnf the LaM,r Code.bribe Iscofmmanm mile work for which this formal is issued. GAS-E;A.SYSTEM-]INC.a OUTLET'S (KC.GROUP ^/ \PNr�
My Workers CuaPrasmi" r. I Policy roamer am: � y ( ,i J
u�, 1 cental nli
Cmder.�')�?(" t"y •"�—r"ueyN". ens-un.sysrl!M-pveRa(Itro 8
CERIIP[C6fC Oto EXEMP1 ION FROM WORKERS' GREASEANDUSTRL WASTE INTERCEPTOR
O
COMPENSATION INSURANCE BUILDING DIVISION PETS _
(This section need not be cumplmed it the permit is furan,hundred dollars.6100) GREASETRAI'
PhANCIIECK FEE
or less)
ecnify that In the perfumwnccof lncwnrk Ili,whlehihis Permit lx l:ncJ,lnh°11 SIiWI!R-SANITARY-STORMIiA.2W PI'.
noucmpby any penon in any mannermas to Mum a Icd total,Wnrol,n'Compen. ENERGY IIiIi
Z %mion laws of Califomia.Dae m. WAIER HEAT ER WNENTIMATC-Ut
C Q Applicant A-A
NOi Up TO APPILICAN'T.Il,olicr making 1111x -cnl0cnm"1'Exemption,you should WRIER SYS'I'EMC BEATING
H 0
CZ Ice subjnn to the Work,,,Cnmpemminn l , %inns of the Labor Gmle,you moxt
CZ
la,ihwithcomplywall,lchpmvi%ions mralk, atshilbedeemeducokcd. WATE SERVICE
a
] z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.f4 c
Ihereb I'Iimt mel there lX uennnmlminn lundt forOm I'omwnceat l ccipS
U O y;, 'g�ugcnry per
,he work for whlcb chis perms to i.xucd lSec.9[19]. .C.1
TOTAL
O 1<nJors Namc— TOTAL:
r� Lender'%Addle: :I certify th:n1 have reaA this pplxlit and sale thin lc abuse information in ��//.�''y cuoccLlugmcl"comply will,tau lily nndn linty onlinum cn:mdxmmluwseIx1ingtu QTY. MECII AL I'F ytD, I RL
above-mentioned pmpeny for inspection puimawl. PERMIT ISSUAN LE
Ovel,a,me m save,indemnify and keep harmless the City of Caperton against AR 1
l ixbiliti-judgmems,costs and expcn¢%which may many way accrue against said City ALTI!R OR At)]) CH. 1'LUMHINGP E
uepmne,el the gmm'ag of this pelout.
APPLICANT UNDERSTANDS AND WILT,COMPLY WI'CH ALL NON-POINT AIR HANDLING U (T(]111100(ICFM) MECHANICAL TCR
SOURCE RI!GULADONS.
r AIRIIANDLINGU I OVER 10.100 CFhfl CONSTRUCI'IUN TAX
Signulurc ai'ApplicaWCm rami v EXHAUST IIODUI HOUSING MHUGATION PIT.
HA RDOUSMArERIALSDISCLOSURE
W,Il the xpplicanwrfuwmbuilding rccurymsum or handle haaNnu.mmeriul HEWING UNIT(TO 100.000 BFU)
as drained by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety ))EATING UNIT(OVER 100,100()BTU)
Code.Section 25532(x).' Iwo
E3 Ye% ,YY o VENN I LAI ION 1 AN(SINGLE RESID) PAID
Doc Receipt
Wi11 Lac applicant or future building rccurym use component or deices which BOILER (3HP OR 110.00 BTU)
m
mil huterdo,%air crommants as defined by the Bay Arca Air Quality htarwgcmem TOTAL
Diarist? IBUI.ER-COMP(OVER Boons)BTU)
Dvcc .o ll
I have real the hvnrmms numerals mmummid,under Chapter,a 95of the Cali AIR CONDITIONER ISSUANCE IJ TIS
brain Health&Sillier,Cast,Sections 25505,25533 and 25534.1 understand that if me NEW RESIDENrIA.MECI. SQ 1T
mlouldingdo,%oluclineI nnthars . %mility m nodrylnhe"'.v
al
e wni. s ceni' I up yaTOTAL
edagcOx'nn one J /
ISSUED HY:
� OFFICE