S 1088 APPLICANTTO FILL INANFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY-
CITY OF CUPERTINO _ - BUILDING-ELECTRICAL. PFTITN0, 1 088
BUILDING DIVISION APPLICATION/TERMIT PLUMBING-MECHANICAL J 1
s�.t+s BUIIAINGPROJECT IDENTIFICATION -
BUILDING ADDRFSS: - - SIC
ANITARY NO. - APPLATION SUBMI'TIAL PATI
X18 4q tendo C�uo t
OWNERS AME: PII1:: CONTRACTORS NAME. LIC NO:
f flit LSV_ NIC CON'I'kOl.p
ARCHITPCLUNGINLHR: - LIC NO: ADDRESS: - ❑
CONTACT: PHONE: - J ,EUILDINCCPE IT INFO,,, ,
n'�� `, � \( - -��.�bg' ❑ Consdtent Fees Paid by Applicant(Initiap BLDG I- Ii1,hCI' PhUMH M�x
7 f LICCENSS`EDA_CO•NFTRRAACTLOJRSIIICLARAl10N - f ®/ '
QTY + + ECG6TRI4 PERMIT; PEG
'- pnereny nffrmmll r d a `p " ren It-9(� e g ,-, + • :. -•- + + '. � ]06 DESCRIPTION
oaz withS lon]00)of0 on3nfmhe9hv a and oUssm Cooend nyl ce TI I'
won PCRNH ISSUANCE S -
P+ws in full force and effect r,✓� -DWL. _ TCI{EN REMODEL
aUF License Class Lie#'
6 U - APPLIANCES-RESIDENTIAL ❑gpDl'r10N - [I PLUMBING RE-PIPE
I` EJDam Comrnaor
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
'z Oy,.7 I 1 e dmypl .hall leased amble records - MODIFICATION
UPTO200AMPS
O z.+O - (]INTER]OR ❑CHIMNEY REPNR
J La IPnI :.' ml 201-1000 AMPS IM VEMENT �SWIMMINGPOOLS
a OWNER BUILDFR DECLARATION OVERIXMAMPS ATH REMODEL/REPAIR ❑DEMOLITION
I hereby ff that I Pt f the C ntmt L L for the
iC L U Tolls -g a. (S i ]031 5 13 d P F" C J A y ty nunly SIGNS ELGC'I REAL e, 0 G'rHER
W 3{z,Iv¢'"s'whih requires a perinut toconstruct,alter,improve. f fish m' yet cure
b'yOy.i
"icarn.in,'......anc.dVinectima,the pplt famm,armit tofilati,haread,witown, SPECIAL CIRCE]VMISC. t�
�y
that he is licensed ptionsid to Rievowiotei,olNC t t- License L (Chapter 9
a
(commencing with Sect ](1007 of isi i fth f encs, IP Re nGdc)Ir TEMP METER OR POLE_INST, s COMMERCIAL:
t1 '
0.c W in.,he s exempt therefrom d the h sis the alleged 1 exe pt Any violation of - - ❑NEW BLDG/ADDITION 0 DEMOLITION
W,,,m Secl on 70315 by tiny.1plican,to,.permit lb t.11bro,plicarl to I perky f POWER DEVICES n TENANT ❑FOOD SERVICE
�C+ m inure than Five hundred dollars S5011).
A Cl ❑I as owner of the property, y ply with wages as tharsolc oonparsa OTHER
. SWIMMING POOL ELECTRIC - .
2y22will thekind thea t .e' tintendeJ r Re dfor.al (S 44
]0 ,Busi mase ❑
y4
Cl�a�a and Prf .In. Code Th Ct rue L' L Ices tapply m nIwner of OUTLETS-SWITCHES-FIXTURES _
B'a..
property w Im builds orimproves thereon,and who does such s ork hi mwIf or through - - -
' his own employees,provided that such impro tarents arc not ma nded or offered for NEW 125SIDENTIAI.P,hECTR - SQ Er. _
' csle.IL however,mhcbniltling arimpravemem issold within one ynuefa�mpletion,the - _ 7�/'''1 � SfSQ?_T
er-nauder will have the human of proving that lie did not build or Improve for par- Y CEIVE
' ( Liv ` -
p unlre owner of
project
Property a IIcontrolling with l tcontractorsm DIAL:
., arneune pndG'I(sa.]1W4 ata. e P r .cod )The c I t L' 2
OCT 197
axe Law dce.nmappa fp m ty wit bud. t e d QTY ,.iPI;UMBING PF.I2MIT FEF,. ++
who contracts for nuchp projects thn
s wiwm tmrts)IittmWpursuant C,omrucnms ` + + tans
n ro .
License Law. I PERMIT ISSUANCE
❑I am exempt under See. ,B&P C raids reared BY:
ALTER-DRAIN&VENT-WAIIik(EA) VALUATION
Owner Dole _
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
hereby a0irm underpenalty nit'penury one of the following dwlamtinnc; Q
'❑ Ihnve and will maimain nCeniOarncnf concent ui,elf-insure tut Wader's Camper: DRAINS-FLOOR,ROOF,AREA,COND. ST KISS TYPE CONSTRICTION
sotioq as provided for by Section 3700 of the Lubar Code,for the performance of the -
weak for which phi,Permit ie is.cuad. Fix rukES-PER'HAP .
1 hove and will maintain Worker's Compensation Insnnmce,as...1- d by Sadie'
3700of the lab or Code.for the perfommne,of lh,work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40U'I'LET S OCG GROUP _ APN,
My Worker',Compenmtion Insmmnce wrzier and Policy numhara,, -
Carrier: - policy N.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS I I
'
- COMPENSATION INSURANCE GREASDINDUSTRL WASTE INTERCEPTOR BUI VISION PITHS
(This section need not he completed villa,peran is foriam hundred dollars x It)()) GREASE TRAP
or law.) - PLANCHECK PEG
I cenfy that in the nofournmeacmOmm work forwhith the gempit,,'ssued,I_shall
` SEWER-SANITARY-STORM EA.2011 Ff.
not employ any person in any manucr so as m hecmnc_wM1Ject to the Wnrkere'Cramped- ENERGY FE;,.1
',Z action Laws of California.Date _ _ _' O
WATER HEATER WIVI:NT/ELLCTR
z Q Applicant � � GRAUINC 1't.'
p3 NOTICE.TO APPLICANT.If.1carawkin,has CanofirMe of Imlounitan,yan 111c ld WATER SYSTHMIGRHAI INC
heeome subject to the Wtrkins Cta,,a,h a prewimormof the Lab r Cdr,yen most - SOUS ITH _
� �rat fonhwhh comply with such provisions or this permit shall he deemed revoked.
WATER SERVICE
Q
z - CONSTRUCT LENDING AGENCY 1 NEW RESIDENTIAL PLMFU SQ.ET. PAID
1 M1creby affirmIlial there is a commrction lending agency farmaperformnncc of Uatc Keeeipt#
0. P the work Far which this permil I,issued(Sea.3097,Co.C) '
0 U Lender's Name TOTAL
W Lender's Address - TOTA
I cedfY that I have madt ppl I Llate In,the above r al - � .. x, BUILDING RE
vai corns.Itgree to comply with all cityand county ordinances and.tt laws ralzaingt QTy ' MECHANICAL PERMIT •'EFF I(
V Z haild'mg umapacton and hath malualz m wmutivcs olds any to cuerbpon lho SEISMIC PEE
above-mentioned propeny for inspection purlmse"' "
(We)agnea to save,indemnify and keep harmless Na City of Cupwtino PERMIT ISSUANCE a'ainq ELECTRIC FEE D
l inbilities.judgment..a„is and exPemex whiehmuy In any wayareme against said City ALTER OR ADD TO MECH.
In cot
ion,cmrre of the graming of this permit. PLUMBING FEE f
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,g)0 CPM) '-
SOURCE REGULATIONS,
PEE '
AIR I IANDLING UNir(0VEk 181100 CPM) CONSTRUCTION TAX
Signature of Applicant/Contracmr ,Dime IIXHAUS'1'BOOD(W/DUC'L ' HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthenpplicant or l'nmrebuiWing ncampnnm.vmre or handle hamolou.mmenal HEATING UNIT(TO 100,000 BTU) - -
as defined by the Cupenino Municipal Cade,Chapter 9.12,and the Health and Safety -
Code,Seetien 25532(a)P HEATING UNIT,(OVP.R 1100,1100 8TIJ1 -
E]Yrs DCNa PAID
VENTILATION FAN(SINGLE RBSID) - Oma Rescind#
Will the pplicnnt or fumm building occupand.,a equpmenl or devieas whftll HOIhER-COMP fiHP OR 10011011 BTU
emit hazardous mtann amts as deffi and by th Bay Area A''Quill Management )
❑Ye, I'Wy'C-„ -
BOIL
E3 COME(OVER I00,000 B�1'U)
I Lave mail the hvlJus materials requinaments ender Chapter 695 of ilia Coli- AIR CON OfI ION ER ISSUANCE DATE
fomla Health&Safety Code Sections 25505 25533 and 22534 1 understand ilia I if the NEW RESIUENHAL MF,CIL SQ.FI'.
mild ng Anes nom ct rondyhvvct mnam.mall: esrysmihity,I ..fy theownpaut d�..
< alis Mali,whist cola CenrBente of
I
O n authorized age Dao- - TOTAL: ISSUED BY:
OFFICE