S 1466 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELITC I RICA].
CITY OF CUI'FR'I'INO fir Ir No
BUILDING nR9SION APPLICA7'IONWERMIT I'LIIMI4ING.M1IECII,\NIGU' 1466
❑DILDINO 11HOd P.C'1IDEN'I'IFICAFION
BUILDING ADDRESS: SArd LARY NO. APPLICATION SU14MI1'IAh DA[
/oSDD /�c ✓/e 4r Lies �/.%a., E �.ror�� - Z-4
OWMX nn IE: Mille E: CONTRACTOR'S NAME: LICNO'
3 3 L/3 NIC CO ROI,p
I\RCHIT CI'AiN .INFER: LIC NO ADDI�,S ❑ pp
Ys s C 0:3 9 9 /5� .S,.. AJ�o A„4- 0 7
CON'I'ALT: ,�A PHONE: ��w'dn Z G� BUILDING PERMIT INFO
�Y/ta>.f A104 (#9�977- 9/// ❑ Consula
tnt Fees Paid by Applicant(Initial) BLDG Ii ILa—E ' PLUMB Mlicu
I,ICHNSED CONTRACOH:S UIiCLARA'1'ION QTY. ELECTRIC I'FRMIT FEE
I hereby a tint,mm I an Eagan aider pn,vkion,of Chaper a(eon„rearing .1013 DESCRIPTION
FoulDn(cunsxCh..70mpuf Divi Jolt 3mnhe.Ha.incas and Pmrcasions Cane,and my liatteis RESIDEN'T'IAL:
Z PLHb11'f ISSUANCIi
F ntallbracandcll[ �r33�� ❑til'UWI. ❑KITCHEN REMODEL
e-u hi Lic.Convxm APPLIANCES-RESIUIEN'fIA1, ❑ADDHION ❑PLUMBING RIiPlPF
,nQy A CIIITECFS DECLARATION ❑MUhTI-UNIT' El STRUCTURAL
FhZ shall he used as public recoNs PANELS MODIFICATION
OZ UPT0200AMPS ❑IN'RiR10R ❑CIHhINEY REPAIR
F,Z2UI-IgN1Ah1P5 IMPROVIEMENr E]SWIMMING POOLS
CYC;gwif
OWNER-BUILDER DECLARATIONOVER IfN)UAMPS ❑BATII RI:MODEL/RFPAIR DEMOLITION
C:Y a I hereby arum Thm e
al 1 axanp(fromn
m the Coclar'x Limen¢I've Iia the
O S V following reason.(Section AIJI 5Business siness and Pnncasion.Cadc:Any city or rotmly SIGNS ELECTRICAL El OTHIiR
ywhich nampe,a term:(b,emcar a.titer,impmvc,demolish.or mash any ctmmu¢
I—�cQ
'lint to it'i.wanee.aLcnreyuireslhe applicant for such permit ur file a signed statement SPECIAL CI RCUI'FIMISC.
S�y� (hat he in Raved puraa:nn)the provi.%ionsolthe Comracmrx Licen.ee Law(Cha
(lint COMMERCIAI:
WL'0� (unmetancing with Section 7000)(if Division l of pe lba%ine.ssand Pnrfccsions Code) r TEEM H MISTIER OR POLI!INS'n
a m C that he is Tile In Ihcrcfaor and the breis for the alleged exception.Any vinlatio.IT ❑N FWJl1.ONADDITION ❑DEMOhI'1'IpN
'��la' Senlnn7031.5 by any applien,In,aperm.(samj,r,daappIicum br a em1penahyof 2
POWER DEVICES „ANT ❑IT)ODSIiRVICI?
nmunom than live hundred dolham(S5(Xp.
SWIMMING POOL '*RIC M 1'11OVIiMIEN'I'
(] I ' III I-P ny Y pl y wage, tl p ruwla' ❑UI'l lliR
� O
will A ❑ k ' 111 I t' t Jd II Jf ' (S 7(UO lfnds
w
a3— arrdl I Carle;rI c I t sl.i I� does m,t,nplvl or ou'r1lrs Swrr property h bIr,ort p 'The on.vJ h J ch k1 : Iforthe gh
h s n FI ye.:.pmd J th t h imp (. ear I nJ J r ofercd for NEW RLSIDIE r I SQ FT
sale.If.howcve,the building mimpmvementeoAdwohinue ycansf completion.the SV Err.yl'�LOOHRHEA LSV.IrI'.
ow enM1uildef will have the burden of proving that he did not build or improve for par- P it
"enfsule.). T w'Y D
1,as owner of the praperr,am exclusively contracting with licensed contractor'.to IE
comtmct the pmjcct(Sec.]THY Business and Pore,mons Code:)The Comracerr's Li-
relive
i-
s ve Law does net apply to an owner of property a lar build%or impmvc%mercon.and QTY” PLUMBING PFRMIT FEE /� 7
whocontmclsresuch projects sithacantrarmar,)licensed Punoantoth,Contractors QVJ ', - 7 /9
Licence Law. S ,It ft 1'C l u tit's rcacon PERMIT ISSUANCE f ��w✓�
- p an er,em
ALTER—DRAIN&YEN(—Wal HR(EA) 'ION
Dale
OMPFNSATION DHCLAI NI ION BACK ROW PRUIIEC[ DEVICE O
I hereby all!ern unnerle Sahyofp Jury one or the following dechmniuns-
(] IMweanJwill nainmina Ccnlreueo(Genese((test(-:teem Ert WuAc,,Cn upon- DRAINS—I'LOOR,ROOI(AREA.COND" STORKS 'I'YI'ECONSTIt I1Cf10
sedan,us provided ha by Section 37(X)of the Ishan Cade,for the perlonnance or the
work for which fhiX Ircrnrit is I....I. PIX'1'URIS—PlElt'I'ItN'
I have and will nmimain Worker's CompensaJnn Insurance,un required by Section
?>([loflhe Lahm Cwte.fanhe performance of the work for which lbs permit it i...eT GAS—IEA.SYS]17M.1 INC.J OUT LETS OCC GROUP AI'N
My Worker x Compeivanlnn(romance artier and Pill,,nunrhm are:
Cartier: Policy No.: GAS—CA.SYSTIEM"GVIiR J ILEAL
CIT RI'IFICATE OP EXEMPTION[:ROM WORKERS GREASE%1 N DISTRL WASTE IN 117 RCEPfUH
COMPENSATION INSURANCE tllll G DIVISION ILLS
TBi%section need not be completed if(he Permit is for one hundred dellen lSlEU) GREASETRAI' 30
nr las.) I'hANCI A �E'
I verify thatimhe perfmmanceoOhe work fm wbichshi,Permit is issued,khat( SEWER-SANITARY-STORM IEA.200 FE
an airplay any r mryma Mtnrma,itus to cnme subjec ,,the Wnife 'Copper- IiNIiR
pea101!
( O Z aaion Laws of California.DasWATER MEATIER W'/OGYI'n:I.F:CTR GRADING '
Z O Applicant
NUI ICH FO APPLICAN'F.If,at ler'making Ihic Certificate of IlecmPti m.you should WATER SYSIIEmn R17NI'INC, SOILS I'I'"
F` hccomp xuM1jccl lu(he.WnrAur'n Compcnsetian provisions of the hoMe Crate,you mwd
� � lirthwithaonrply wish such Prnvicion.c onbis permit nlmll he Jcenedrevoked. WATERSIERVICH
PAID
.DZ CONSI'RUCIION LIENDINGAGENCY NEWRESIDIENI'IA,I'I.MH. SQ Ff, etc Receipt#
U O
I hr ehy all that here ie a ,am
mnction Lem ng agency for the purfonmam of
I era work for which llu nmol(Sec 3097,CIv.C.)
OH Lender's N:nnc ��n2 T(YI'AL. <
L.) Loder',AJJrcac 'OTAL:
I cenity that I have read this appliemlon and sere that the above information I% I{IIL.DIN IEEE
Z) correct.I agree to comply with all city and county onlinatees and care lows relating m QTY. MECf1ANICAI.PF,RMIT FEE SEISMIC PE'
V Z builiingconamation.and hereby authorize representatives of do,casy Rr clnerurym the
abrrvoacrat ned prolemy for inspection purposes. PERMI I'ISSUANCE ELECTRIC 19:i
(Wel agree to save,indemnify and keep hani less(he City or Cupertino again%
Iiabilitic%judgnentc,costs and expenses which may in anyway accrue against said City ALTER OR ADDTO M ECIL IE.UMRING Fl:' OO
in n.alluencc of to grunting of this pemit.
APPLE ` STANDS AND WILT.COMPLY WE III At.[.NON-1'UIN'1' AIR HANDLING UNIT(10 IBIXXI CFM) MECHANICA1,I lilt 0
IT
Ii
. RI:GUI.ATI S /
AIR HANDLING IINI'I'(OVIeR 10,000CFM) CONS'IXUCfIUN Tn%
Signamrcn Dale EXIIAUSTIt000(WA)UCI) I IUIISINGMITIGABONIF[
IIAZARDOUS MAI'ERIAIS DISCLOSURIE
Will the applicant or fmmre hmIdlngomupanfch..porhannlchacaall mmenial HI?AfINGINI'I'(iORXLfXX)BIU)
m doh Stan by Ibc Cnpcninn Municipal C,vle.Chapter m.12,anA(he.Ilenith and Snlny
Cade,Section 255320J„ � IIL'A'I'ING USE'I'(UVMIt I(N),t)(N)li'1'U)
1]Ym VEN'I'ELATION PAN tSPRILIE RESID) PAID
Uum RccciplF
Will[tic applicant or funic building occupant use nluipmmn ver thvicec which BOILER—CVMIIDIIPOR 1000)( ID-0
earl hazardous air COMIcamant as defined by the Bay'Arca Air Quality Management A
JA
Di"T BOILF,R—COMP(OVER 1(p eco fi ru)
❑Ycx CID r—
AIR CONDITIONER I¢ OANrE�E:
I laic mel the h mS c mans d5 rcquileneme under Chattel b?5 of the Cali- .Yi`
Immix Ileahh ra Safety layCame,Section .cast 25533 and 2553+"I uI mulf1 n that if the NEµ'RISIDENTIAI.MCCII. SQ,fT
building docs nm<umn0y M1avc a mount,that it is my merymcihility er nnufy the u,cupam ,
of the requirement which must hn met prior to issumce of a Ceniticn¢of Occupancy. `�) O� _
owner,,,authorized agent Dae T L: ISSUED BY: e+ c-'t A - To
OFFICE