S 2768 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMn'NO.
BUILDING DIVISION APPI,ICA'1'ION/PN:KMPP rlunuunc.MRCBMIL Q 2768 C O
BUILDING I'RIIJI!CT iD1iN'i'IF'ICA'I'ION S L 6 0
SANITARY NO. AP['IICAI'ION SUBMITTAL DATE
BUILDING ADDRESS:
V P�„n ! Ln
O rNE.R:S N ME: YHON]i: CONTRACTORS NAME: LIC NO: NIC COM' OL N
-n wvh !� J ❑
1 A CHITECIAINGINEER. &L11p j(I- AD
I'1 DRESS:
CON'IAC.'I't PHONE: ylpp BUILDING PERMIT INFO
INl
PI �� INli� "e4_r } dTy /JQ fVVO2g6 [jConsultant Pces Paid by Applicant(Initial) 1{LDG ULEC'I PLUMB MIFCiCH�
El El 1:1L5
LICENSED CONI RACIOR'S IJEO.AKATION QTY ELECTRIC PERMIT FEE
I hereby at int that I ant licensed under provisions of chapter 9(cnn,n,cimins JOB DHtiCRIP'I'ION
Q=Z. win Sectian7")nf Ui.icion3ofthe Busincssand Fmfessions Coale,andmylicenuix RUIDENTIAL'
WC, PERMIT ISSUANCE
F•� in full form unJlo. 20 t(0�(,, ❑SFUWL ❑KITCHEN RFMODFI.
�UU license Class hic.M n APPLIANCES-RE.SIDEN'I'IAL - ❑ADDHION ❑PLUMBING bit PIPE
vFi Q W Uam Cnntructat
ARCH]TECTS DEC RA'T'ION Ptr 1'ANT;IS ❑MULTI-UNIT' ❑S'I'kUCTURAI.
ZFot K Iand,ro,ricny p1anx shall he mad ac public record. CHIMNMODIFEYRCAl EN
OZ=� DPTU 21X1AMPS [_1 INTERIOR ❑S CHIMNEY REPAIR
Licem-d Promsianal 201-1000AMPS BATH V13A11iNT SWIMMING WOIS
OWNER-BUILDER DECLARATION El RIiMODEURITAIR ❑01;MOLITION
C C Q I h,echy affirm 111.11 Int exempt font:the Comumo r,L come Low far the
OVER I(gIf1AMPS
L V InRowiag mason.(Section 7031 5,]mines and Pro1'aysinm Cod,Any city c lam l SIGNS EIXCtI tICAI, ❑O'fI lER
3lLti which requires a permit to cunetruct,antics,mtpmvo,ten bsn.or repair anY ouuaum
F�O� gib I t: 9 dieapplicantf suchpe 'O fl 'g d.ltement SPECIAL CIRCUIT/MISC
y n,; n l :d1 .t a l p -t tea Contractor's I L (Chapter9 COMMERCIAL
W��O i Ica securing with Srcdtn71XIs' ,,,I 3ofmts Btktess II (.vvo,CoJc)ot TI:M P.MLI'ERORPOLCINST.
Q.a e C that he I%exempt therefrom and the Kaci%for me alleged exemption.Any violation of ❑NEW BLDGIAUDII'ION ❑DEMOLITION
Way Section 7031.5 by any applicant for apemot%object%the applicanunucis'il penally of POWER DEVICES ❑TIiNANT ❑FOOD SERVICE
m more Ihun Gvchundmtl ch,lues(S500). IMPROVEMENT
Sp ❑ Lasownc,ofine prap,c,o,,uycmpluyces wish wa,c,.,Imorsnle runfen,aloo, SWIMMING POOL 1.111MRIC
L will do the work,andmeslmcmm is not inamdeJs-.11,rd for sale(Sec.7UU.Busincnv ❑O'I'HIiR
W 3 m and Profession,Cale:The Contractor's Licerets Law does nm apply m an,tuner of OVINETS-SwLTCHILS-EI%TURIi.S
propre,y who hulls ur i ut,......boom,and who Jocv ouch work hin,wlf ar thrn,di
Ili,own c:od,cr'.c,provided thin such improvement,arc not intended a int ed for NEW KESIDIIN'I'IAl.I!IJ;C71R SQ IT.
vale.if,however,the building or supervenient issuld within one year of complctlath
n. e Q.PI'.FLOOR ARIiA SISQ.PI'.
jet bai tiler will have the burden of proving thus he Aid not build ear imposts for pur-
Ix n ). TOTAL: /7
❑1.s, f tis p pcmY lycontracting In licensed l nu 7
consumer I protect(S700 1{ e. d Pramosion,Code:)The C d t Li-
se 1 J tapply tfP pt 'h h ill p tis and QTY PLUMBING PERMIT FEE
III calir:,r fora W,pr,111 !ill al,runnotleIN fuurdl mrstim mthcC d trs
lacun.w law, i'IIRMOISSUANCE
p 1 am eaempt nude'see. .n&P c for dhi.musms
At:[ER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dut,
WORKER'S COMPENSATION DECLARATION RACK FLOW PRUDiCI. lE1I'li
1 hereby I affirm anter pen:thy of perjury one'If me bl]me tol Wit
�IhuvcnnAwilllnuinlainuCenibcmcnfCnmmmunaolf-invum(lir Wodcr'a Conpcm DKAINS-II,OOR,R(%V. EA. ON.1 STORIES 'fYPL CON$'rRUCI'ION
salinn,1.v prvvided bur by Section 3700A dim Labor Code,for rhe perfonnnnle Ill the <
al. this permit is rted, PIX'IURES-i'IiR Tk
❑ maintain
/ -
1 have
and will tmaintaino
in Worker's Gnnpcnsainn Insurance,as required by Section GAS-EA.SYSTEM .J ILES
97110 nfthu latx,r CnJc,for the performm�m of dots work iia wM1ieh mis pcnnit ix icmN. .� OCC GROUP AI'N
My Work ,m I Insurance currier and Poliryn : qy m
�^ Canice Policy Na:'�'� Boo 1837 (iAS-IS.SYS'TU VEK4fl?Al 4
GIiRTIFI'A'IEOPEXEMPTONFROMWORKERS' GRIIASPIINDUS Ja�� $TE WTIiRCUYIT)R
COMPENSATION INSURANCE t3' BUILDING DIVISION FEES
O lit wellmmI still nal be-complmrl it mr, c nis,fortmo hundred loll a:l 031(N I) GRE,Asit IIIAP
YLANCHILCK Ilii!
or less.)
!oy any
in he pmfo intoner so
for which lb is the is Warkers' d.lshall SEN'F.R-SANITARY-STORM EA.2( F.NIiRG1'FTai
lid employ any Pc any n.nnvr Ix to bccnnm subjm da the WnrkcN Cumlxry
� Z salinn La" If Culilomio"Date1 an' WATER I{EATI2R Wivip"IELI!C 11 R GRADING FEE
Z Applicant
y NfTI'ICE'1 O APPLICANT:If,after making dhis
Certificate of Exemption,You should
WATER SYSI'Mh1/fRiiATING SOILS FUM
Fa 51 bw,tox,hj-, ,,mm
e IS k 's C ...alimI pro t,, f the Labor Clair,Yen nae
iail:
o
� fnnhwimcomply will such prnv'x"t`nv or this permit shall be deelnd rewecAwnnsk sHuvlcl3
CONSTkUCT10N L' DING AGENCY NEW RES]UGN]'IAI.PLhIB. SQ,191 PAID
1 Dale Receipt
V Q I mobyel6nu that there is a constructors lending agency lards,ped'ornancenf
the w...it In,which this pcmllt Is ivaod(See.3097,Civ.C.) 'TOI'AI.
OF Lender',Name 'TOTAL:
,� Ud lamdcr's Address BUILDIN( Flit!
Iccnifymad Ihavere:ul mixappllewlnn and stale mm meabovei lorinadnn:s
... N correct.lagrcen comply wish all city and county ordinareasand state laws rasing to Q'-Y. MECHANICAL PERMIT FEE SEISMIC H:
V Z building commiction,and hereby auifil mprewntatives of this city to enter upon dile // ��
abav,-ummional propcny in,i'll,cO at purpoccc PERMIT ISSUANCE A N I!LECfRIC 171:
DVel ago h s0,1 jeninify air keep har:nlea the City of Cupertino against
hahiniliccjudgman,ve,sand expcnccs whielt"say in any way accrue against said City ALTER OR ADD'10 MECH. PLUMBING
in consequence ml the graining of this permit.
A I'1'InCANT IN AVER STANDS AND WILL COMPLY \LL NON-WIN"r AIR HANDLING UNI T(TO 10.0X0 CFM) MMCHANLCALF C!
BGORG1i H- dJ LAI
'IONS.
2 Zy AIR HANDLING UNH(OVER 10.00 ClIM) CONS']RUCTION TA
Sigmm� Ill""Applicat/ orcin DRATINGUNI
•J ate ':%HAUNT HOOD(W/DUC) HOUSINGMIfIGATIONFEE
;';,I ZARI IS MATERIALS DISCLOSUIU! L O
:111 the applicanualumre Willing occupant stare or handle haeardnu.v mamrial T(101(NL(H01UU)
as Jclined by the Cupeninn Municipal Gude,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU)
Code,Section 25532(x)I
[-1 ye, ❑No V ENT]LAI ION PA N IS INGU:RESiU) Poll)
Doc kectsipt p
Will the applicant or loran,Wilding occupant use equipment or devices which BOILER-COMP(311P OR 100.gl BTU)
Orris ho,mlou.c air eoulusnimnn.e as JclineJ by Ili,[lay Arca Air Quality Managemcm )
Usloct'I ,,w BOBER-COMP(OVER 100.000 B U)
❑Yee LT:vu
nlR CONDI'IlON13H ISSUANCIi DATE
I Lama,at lbs hauvJu::x mmcrialx �yuiren¢nlnunderChupmrfi!15nf'he Cnli-
AuIdmst--,`hYhrv"
&Salily _ 53a. unlelsland mat if on NEWRESIDENTIALMECtl ,hand is my tesprnsi iliry mnaifY the cecu toil mel rdanate.aanmo enoma r ..a�r. C
nuthnrirsJ agen Dec 'TOT - ISSUEDBY,
OFFICE