S 2398 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BDIL DING-ELECTRICAL PERMII'NO.
nU11.DING DIVISION APPLICATIONIPERMI'I' rl.0>IBkn'c-M1u?cunNN:AI, S 2 3 9 8
BUILDING PROJF:CI'IDIi.1"1'IPIi:A'f10N
IIUILDINGADDR0.S5: SANITARY NO. APPLICATION SUHMI CI'AL HATE
as �3 EEN c-r, i— C?7-
Lee OWNER'S NAML a� I'In I _Q, it C'O' R :mlµ:ti Npllp (r���� l;O - - NIC CONTROL#
eq 15 ARCHITECTIENGINBER: LICNO. �Jr ALM
�IVl• ef[s! es �s-s_4 ❑
CONTACT: PHONE: /�j HUILDING PE_RMITINFO
�� ❑ Consullanl Fees Paid by Applicant(Initial) BLDG Ii1.11C'1' PLUMB MECU
Lz El Er
LICENSI!D CON I RAU I OIiS DI(IARnrION QTY. I"LE6TRIC'PERMI'P FCL
hereby:,u linmw Ian,rrr„eel d p .nrcl p1 9( ..nn ',g - _ JOB DESCRIPTION
HOZ with Section of Dvµm 3.10 c4
Bus dl I ,..on C i I a,,license is PERMIT ISSUANCE RESIDENTIAL:
I,,,�O in full force and effecl/�w ��qq((pp (y ❑SFDWI. ❑KITCIII'NREAIODEL
V U Licenza Class_ Li ��� { �� APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
t<;Q6 Dvtc _ Contract..
C
ARCHITETS DECLARATION [I MULTI-UNIT ❑STRUCTURAI.
Fb y Z I understand my plans shall he used as puhlic record. PANELS MODIFICATION
^z,-0 UP To 200 AMPS [I INTERIOR El CHIMNEY REPAIR
h�E'ul
Lar ad
Profcsslonrl 201-INXIAMPI IMPROVEMHNG'I' E]SWIMMINPOOLS
OWNlilt-❑UILDHR UUCLAItA'I'IfIN OVER ImN]AMI'S E:1 BATH RIiMUIII!LIREPAIR ❑DEMOLIHON
1 hereby arrml oat I am excmm from me a,mmmar,license Law I ole
E O U following rcaron.(Scclinn 7031.5,Rosiness and Profcssionn Code:Any city or moray SIGNS ELECTRICAL ' ❑OTHER
3 a.y which narrates a permit In construct.alter,improve.demolish.or repair any.structure
F1='�Q pnnno it,illrurce.A.rn rcynimsrhe applicant for such permit to file a signed tatentern SPECIAL CIRCUrrIMiSC. / L
f }-4 Inst he is licensed pursuant lir the provisions of the Contractors License Law(Chuple,9 _ - -
WtypO (annmencut
g with Section 9lNM))nfDivision Joflhe Business and Proves.inn.Ccur)nr TEM('.Mii l'IiR OR POLE(NST. RC
COMMEIAL:
6 y mal he is manful therefrom and me basis forms alleged urmptian.Any violation of _ E)NEW BLDGIADEA I[ON [jDEMOLITION
^u' Scotian 7011,1 by any applirnm fora permit nnMecu the uppllrvmml:civil penult,of 'OWER DEVICES
of hdmddo ($5(10). ❑TENANT ❑FOODSIiRVICE
r NY minor frvo unllurs IMPROVBMEN'I'
Q [,a,owner ofthe moped,or my employees with wages as lhciesolemmpcnsulion, SWIMMING 11001,I!LECTRIC -
PS.� will dotbewcah,and lhcsim,urn, not imended orna oud fmmle(Sa.91144.Ifusine, ❑OTHER
W and Profcs,ions Coda The Cummaoi`a License Law docs no,imply mon owner M OOI'LETS-SWITCHES-IlX'I'l]i :S
property who build,or Improves dermon,and who docs such work ninunl.nr ihnmgb
his own employees,provided that such improvements am not intended ser oRered for NEW RESIDENIIAI.ELECTR SQ
sale.If.however.the buildingor improvement is sold within oncyearofcomropletiogforlhe SQ.FI'.I L(R)R ARBA $ISQ.noweenbuilder will have the burden of proving that he did nor build or impve pnr-
pnac of sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
,nrnrel d,e pr je,(Sea 9044,Bi mmnev,and Pofli,imis Gdr:)The Cm.dona lin I.,
rrvu Law does nmupplymavownaofprnperly who bnllJs nrlmpmvra dmrcnn.nnn QTY. - I'LUMHING PP.RMITI FI?li
who nnnoets far such projects wahoeanlrm'ruin)liernud pnrsunnuo plc Cnnlmaors
License Low. PERMIT'ISSUANCE
❑I am ecempr unacr Sec. .H R P C Lor thin«soon
ALTER-DRAIN X VENT-WAG ER Ds) VALUATION
Owner Dam
WOR under
p COM of arim on DECLARATION BACK PLOW I'ROI'ECI'.DEVICE.
1 naehy nl maunacr penaltyof perjuryone,, thefollawing mselaW..km"
"C...
t� lhrvr andwillcon,h,Section Beam ofCn,I_,il Conn'elf-iroac far Woo.... Gaal do- DRAINS-VL(If1R,ROOF,AREA,CUND. S'f01211!S TYPIi CONS'I'ItUCT10N
nvlimnf to hick Ili far ni.9,issu 9911(1 n'Inc I�M1ur C'uae i,r the paiommntt of the
for wm<n d,I,permit i.x i,.rlme. Flx'rultlss-PERrR,v` .
w
have dad will ntumain Workers Compensation Ins:ounce,as required by Section
J(xl of the tabor Cele fnnhe perfnrmvna ofthe work far uhichthis mnnil i,iaual. GAS-RA.SYSEEM-I INCAOUI'LES OCC.GROUP MIN
My Wo ompen'nionIImncecnmerind Policy nln
Careen �L .AIS_ R,Iiry No: �p��'��(,V GAS-IiA.SYSTi?M OVL•R4(EA)
CERIIFICA E OF EAlEMPUON FRIM WORKERS'
COMPENSATION INSURANCEGRIIASILINDUSTRLWASTF..INTIiRC1i1'rOR -
HUILI]INC DIVISION IBES
(This section nml not he complain if mats, itit hrnmo hundred dnllura(S IIN) -
uolux.J GREASU'BAP .
I`LANCHECK 17EE
I ccnifymrl in lhe,ndonam c ofthe wink:he which thoo,mnll is ixwetl,ish ll SEWER-SANITARY.ST6RUZA.21X1 FI'.
dol employ any Iaersnn in any mo
anner so us,,became bject m the WorW,Cmnpen- ENERGY FEI3
Z .amino Laws of Culmlbmiu.DamWA'I'F:R IIIiA'1IIH WN I31.
' IeC'I'
Z O Applicant 1 GRADING FEE
NNOTICE TO APPLICANT:IL after making this Car ificmc of Exemption,yon>ho ddl WAFER SYS I EM/fR a (4G SOILS FEE
f-s ' hecome,subject to the Workers Compensation provisions of the Labor Cole,you moa
forthwith comply with such provisions or this m.oil shall be deemed revoked. WATI7R SERVICE
d Q
C(INSTRUCTLON LENDING AGENCY NEW IiESIDHN'11„ LMIl. SQ. T PAID
Z Inereh 1'Bnn lhul lhrnrierim9rnctinn lctulln fnrdm O
L) m'uuwau of Data Rcecip
yu y pct
the work f or which This pcnnu tin Irmed(Sec J119],Civ.CJ
W. Lcders Name TO I^
W IeuJers Adtlresx "OTAL
C :
�+ - BUILDING FEF,
I ceniry d,ar L have orae this npvhcmann and,too mal me above innrnnad:,n i.
ITN conem.I agree to comply with all city and county ordinances and stale laws minting In QTY. MECHANICAL PERMIT ..
V Z building construction,and hereby authonce mprescm:dives of this city to enter main the SIi1SMIC FEE
above-mentioned mammy for impectim,p.,),a, PERMIT ISSUANCE
(We)agree lo,awe,im amnify and keep hnm,lcvs the City of Cupertino agamna 0 ELECTRIC FEE
iahil Jia.judgman6,coas'ad cxponse,wludintoy in:my way accrue ugnimlnald City ALTEIt OR AUDI 0 MUCI I.
In cun.eyreree mr the gnmlin9 ul'this permit. 1`LUMBING FUE
(APPLICANT iRST S AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNI'1'(ID IH.0IXI CFM) '
.SOURC GO .floc r. MECHANICAL. Lilt
/, 2G - 1" 9 AIR HANDLING UNIT(OVER l0a0X)CFM) CONSTRUCT TAX
Signature mf mn
Applicsunummin, Gra Dam PXHAUS'1'HOODOVMUCO HOUSING M11TI( TION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future buildingoccnpum amu or handle haemdo:n marrlal f HEATING ON I'1'(10 l Bd,BIN)B U) Z�
as dcdned by the Cupenmm Man wipvl Code Ch:mlcf 9.12,and the Ilealm and Stdcly
Chile.Scclinn 25532(a)'! IIHATINO UNI'I'(OVER I(Xk000 II'1'U) -
Yes
eq— VCN'rILA'ITON PAN ISINGLI!RESIU) 1'Ail> Ilam Itaei Ib
"Ill the applicant(it future hum Wing occupool use equipment or device,which TT
emit Incrustations air contuminams as defined by the Hay Amu Air Quality Management BOILER-COMP(HIP OR 100,000 BTU) O1 V
Dismal? yes (Q'"15- BOILER-COM 11(OVER I W SM RTU)
AIR CONDITIONER -
have aIlh 1 I t aI y 1—mel Chapter 695 fII,GI' ISSUANCE DATE
halll
Il ltnkl ,f_IYde'I Irai5t255' I
1 12.55141Y1 ti t ratilly 11 d't -Ihc NEW RI:SIDIiN'I'IAL MLCIi. SQ.PC / L / /
Iflhc narryr int.wh,cl 1,uµ1 het cofuC rtllmlc Of(kCl: ' (/ `�
Owner ser am nnttd egcnl _ Dale - AL: ISSU[U BY:
OFFICE