S 1431 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'TINO BUITDING-ELECTRICAL PE H No
BUILDING DIVISION APPLICKPIONMERMIT PI•UMRINO-MHCBANICAL 1431
BUILDING PROJECT[TEST IFIG\TION
. .)LNG ADDRESS: SAN[D\RY NO. nPPUCA'I'ION SUBMl'ITAC DATE
Ol,.ao D4 E v7Ei.l Goa 7.-118
O\ ER'S PNME� PHONE: 'ON'1'NA-[OR'S NAM LIC NO:
.q/'__1 ,,p, �- C1 �� �r e�I NIC CON'I'ROLA
14 1
,RCI I'I:C'I'ni:yQlNl:lR:� I.IC rvD: uuF's: Pf7(�[7/Ise 1.7A.��• �uYa QI ❑
CON'1'ACl':!Qft ^�41!'�`J�•'� PHONE: BUILDING PIiRMI'I'INPO
❑ CvnwltaRT Fecs Paid by Applicant(Initial) If_ LOc [its)! 1'LUMR MI!G]l
IACENSED CON'rRA=RR DECLARATION QTY I:LELTRICPFRMl'T FEH JOB DESCRIPTION
hereby uffrin that 1 ten licensed under provisions of Chapter 9(commencing
in Poll force and eRaUivisi:nO nf(hc Ousincss and Pml'ex.lons Code,nod o,license is RESIDENTIAL
OLLO with Seorce and
PIiRME'1'ISSl1ANCli
CLLF t. ❑SI°UWI. ❑KITCHIiN R13.M(1DIih
QUV
License Class Lice APPLIANCES-RESIDENTIAL ❑ADDITION ❑I'I.UMBING RE.PIPE
X66 Dart (.,mnclon
ARC]UTECTS DECLARATION I'AN13LS ❑MULTI"UNIT' ❑S'I'ItUC'I'URAI.
~y 7 I undenland n.y plans shall be used as public ve it, MODIFICATION
�� AMPS 200
1O
UI"
❑IMIIiR1pR ❑CIIIMNIiY REPAIR
Licensed Professional 2(i1-OW)AMPS CHIROVEMENIE]SWIMMING POOI.S
OWNER-BURT)F,R DECLARATIONOVER 110XIAMI'S ElBATH REMODEUIREPAIR ❑DEMOLITION
C e' 1 hereby effirin Nut I Lou nxelon tram Inc Cnnfactor's I.icense Luw for the
1w,'U fulloaimg reason.(Seamon 7011.5.Rosiness and Professions Crile:Any city or county SIGNS ECECTRICAC ❑OTHER
413 LL vFi which require.a pnmit m cunawct,alter,improve,demolish,or repair any xtrudmm
(_��J prior) ( I. requirestheIplic It 'np 'tt II 6 J:T( :c'I SI'CCIAL('IRCUI'IIMISC.
}� that he 1 dp a thep fN C l cl f.1, 1 (Chp(cr9 COMMERCIAL:
W�QO ftnn , hSeu' 7000)'If In' iont nh P , ess dl fe, sCNIOor TEMR.MCTER OR POLIO INST.
(1 d ey tom p((M1cY aFP J 0 h .f 0 II b J excl pl Any violation of ❑NIiW BLDG/ADDITION ' OLI'TI0
�mN Section 7031.5 b,.e licart fora unit subjects the applicant to a civil Penally of POWER DEVICES ❑TIiNANT ❑FOOD SIiRVICH
naI Inure than lion,hundred dollars($51X))" IMPROVEMENT'
�5i 1,as owner nice IF Leroy,,troy auployce,with wugcx os ON!, ole annpenmdolt• SWIMMING 1'001,EIECI'RIC
5N� will Jo Nework.enddicarcmm knot mundalmolfenSII ...lc(Sec.T(XIa.Hadoexs DOPIER
13 m and Proessions Owe:The Comramor'n License Law does not apply n)an owner of OUTLETS-SWITCHES-FIXTURCS
p upcny who builds or improve•,Iherenn,Ind who does such work tio4ell or duougn
hi,,—m cmpb.yeo,providedNm such impmvemenu art not intended or offered fur NEWT RESID v L ELEC!R SQ R.
side.lChowever.the huildmg,r irnpravemetn is told within onc,car of completion,Ne SG.PT. )RARIy\� &SQ.1'I'.
rloilder will have the burden A proving(hat he Jld not build or improve Gtr par- nw A ll��
E]1,assoled. 'I IOTA' NAR
27
❑ I nn p pe ty exclusively contracting with licensed vast m qpl(`
,on.( u1 n i +(S 7044 BusinessII 1 seta) )ro ( facto,:li- �+p
c se 1 J - t apply t I property who builds or hunrovesthOrcon,and EAITER
PLUM G MIT PIiE CITY U
who...mue(e rnrsuch pngcu xln vsct OI Invented n N C mmut is V X J �r
ucelt.e)saws ,RxtPerm this masonERMIT ISSUANCE
E um exempt under See
-DRAIN s@VENT-WATER IEA) VALILVION
Owner Dulc
WORKERS COMPENSAI]ON DECLARATION IIACK PLOW PROTEC'E'.DEVICE
I hereby union under Penalty of perjury one of the following declamtion.
❑Ilrrvc unJ will:nu:nluin nCcnlEnn,nt CnnnmwuticlGinwmfnr Wu.kcr's Cnngmn- DRAINS-JTOOR,ROOF.AREA,COND. SI'ORINS "I'YPF;CONSTRUCHON
sa(ion,as provided for by Section 3701 of the Labor Calc,for the pedomtance of the
work lot which this terms is issued. ETXTURES-PER TRAP
0 1 havc and will modulo Worse',Contpcn.ull,n Insurance,m re,...ed by S.ctlon
370d.fthe laMdGsdc.for the pedonummenof th.work liar whiclnhi.permit is i...ed. GAS-IiA.SYSTf:M-I INC.40U'H.ETS OCC.GROCI, APN
My Work r'p(' plso In cc c. - itPo]*eye �9 GAS-HA.SYS'1'f:M OVIiNO([A)
Currier FX �I I ro Policy Nu.:
] rh 1' PMFI'[ON FROM WORKERS' GREASUINDUSTRL WASTE ENITiRCEJTGR
C.f1h1PENSATEON INSURANCE BUILDING DIVISION FEES _
(This sectionneed nul be ennmlcmd d tine peril is hit one hounds)dollars($110) ORCASE'IRAI'
I'LANCHECK FEE
or box)I
lay any that in the pertormance the Necanu which
iethis permitisissued,
ou shall SEiWF.R-SANI'rnRY-S'I ORh11SA.21X11'1'.
nm employ any pant unyn nnvr.oaxn'Irecumc.ennjceuu the WnAord Cnn:pcn ENIiRGY PHE
min :n
Z smum Lad SwvCalifornia.Dot. WATERHA'I ER W/VENT'/EIAgMR GRADING IEE
Z O Applicant
NO]CII'[(I APPITCAN'T:11.attern:ukinglnixCeriliumeof l?xentplinn,you xhuldd WA'l 17R SYS]FM/l'REAL INC, SOILS FUJI
C> neanne.object to the Worker's Compensation provision.of man Code.you nom
Ildthsultum..ly with such prov:uoIt,orthis pr uni,>hall he deemedrmoked. WATER SERVICE
1 PAID
' Z CONSI'RUM[ON LENDING AGENCY NEW RE.SIDEN'I'JAL PLMEt. SQ.I7I'. Date I X
U 0 l nerchy atinn thalhem is a cons(metion lending agency for the p ofornionce of
D. . the work for which(his permit is testasd(Sc,,o 3097,Civ.C) 'TOTAL:
C) U Uenders Name 'I'OTA L:
r U ).cinch Address _ HIAIDING 1171;
6. E certify Ihnl I have read this applicmion and sunt Ihn(tbe above information:s
F' J, wrrccL Eagrce to co.off,with all city and county oNiumcc,and.nm laws elmingm QTY MECHANICAL PIiRMIT FEE SEISMIC FEE
U Z 1, t in,construction,unit hereby authornc representatives of this city to enter upon the
uhuvo-mcmi,ned properly ka inspection Lou paws. peRMI'I ISSUANCE ELIiC'IRIC LIFE
(We)ogres Rs save,indemnify odd keep hmm ee,the City of Cupertino against
liahll'nic.,judgmema costs and expenses which may in anyway accrue against said City ALTER OR ADD'TO MECH. At
FEE
c,mryucnce el"the•'nnI hix Penni).
AI'I'L ,r N UND )'ANI AND WILL.COhll'LY WITH AL1,NON-POINT AIR HANDLING UNIT('1010,IXXI CLING h11iCIlANICAL Piai
in
Cil R iUl T NS,
9 AIR HANDLING UNIT(OVER III,IIIX)CIM) CONS'CHUC'D(1N'I'AX
Signuwrc of Appl :mUCunvanor D c EXHAUST FOOD(WB)UCII BOUSINGMITIGAIlON 191E
HAZARDOUS MAT'RIALS DINCLOSIJR:
Will the applicant or Iumre building occupant slum or handle ba.aldous material I IEATINC,ON I '('r0 1pit.(XXI BIL,
;is defined by the Cupenin,Municipal Gale.Chapter 9.12,and the health and Safety HEATING UNI"f(OVER IPXLlNX11iTU)
Code.Section 2553260!
p Yes Fl No VIINTIIATION PAN(SING LE RES ID) PAID
Dmc Raeiple
Will the applicantroom,
or building o'cupmn use nfuipnmm o devices which BOH.I;R-COSI'(3111'OR 110. 0 LOTH)
coal In...does air containment,as defined by the Bay Arca Air Quality Management (0X 'ITl'I'
[)',mdeR BOILER-CQnIP(OVIIR I W.000 BTU)
L3 Yes Fl No a
AIR CONDITIONER ISSUANCE DATE
Ih:ne read the n Code,
mm,255 requirements underChapternit ai or Inc Cali
uildi Elcalln n Snlc(v Gde,ea'li,ns 255115,2551)snit %ibili 1 un.nvtand Incl it out NEW I11iS1UIiN'I'IAl.MliCll. SQ.Irl'.
of hengdlcsnot ,voicy have atenant.Nmit ismyo,or.Certiycanotifythe Iucup:lm
,r he retplire edl.wm,nmu.Irte)net nri,rn iso nee nr cenm,amnro,alF ser.
Owdet or authorvN.,cm Dam TO I A I.: ISSUED BY:
OFFICE