S 2521 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUI'ERTINO BUILDING.-ELECT RACAL PERMII NO.
BUIL DING UIVItiu)N API'I,ICATION/PERh11T 1'LU\1NIN0:-nll!C11,5NICAi. C C
❑111LDING PROJECT'IDEM TIVICNI'IOIN' J VJ
BUILDINGADDRESS: SANITARY NO, APPLICATION, IiMIpTr\I.LATE
033 D L'IJP�GR�.1�D 2� Z
O\ '1 RS NAME: • I' ONE: CONTRACTOR'S NAME: LIC NO: /
v��i✓f 119 7�`l/3— R o i✓I ~ p/ NIC " T
TIC
�.. CIIITECI'/IiNGINIiI' LIC N(l: ADDRIi.SS: G ��•r_ F-1
7 / J 7
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CONTAC : PUONIi: BUILDING PFRMIT INFO
S7 T T it Z ❑
Consultant Fees Paid By Applicant(Initial) HLA IiL:�, Pl[?I ME
C17-
45-7
CON TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE LJ LJ Ll
1 hereby affirm Run l all,licensed under Provisions of Chnmer 9(.....tied+ems JOB DESCRIPTION
Ws'Z win Sectionllxq)nf DivisionJoftBe lusine„and Pndissions Qde,and my licenm i.. R 1
�Opin PERMIT ISSUANCE
F fall lora aadcxecl. SPU DENTAL: ❑KI'T'CHEN RF.M(101iL
F<�UU 1,i«n,c Cla, Lica ° APPLIANCES-RLSILEN UAL ❑MULE TION ❑PLUMBIN!RE PHIL
NQ1 Ume CnnTracmr ❑M1fQIff1-UNIT ❑S'I'RUCfURAL
ARCHITECTS DLCI. )N PANELS
~vZ Fuad...and,,,,Alam,hail he used an .his,becorJ.s M1tOU11ICAf10N
OZL'E UP TO 200 AMPS CIINTERIOR El CHIMNEY REPAIR
L,,rnod Prafc,Tonal ]111-100AMPS IMPROVEMENT []SWIMMING POOLS
OWNER BUILDER DECLAINI'ION OVER IINXIAMPS ❑BA'1H REMODLIJItEPAIR ❑UENIOLI'I ION
K 5 6 1
hereby a(fmt tM1m 1 am a tarn,from The Cauca, r'.License Law fur the
d(O M U fallowing acus.....(Semi....91131.5,Bulinesa and Paidel,ar,Code:Any city nr county SIGNS 1?LILTRICAT. (]OII{ER
h131+-1- which re4uire.a a permit m conamcl.aper,imPtnve,Jemallsh nr repair any xlruemre
t'u'OI prion, T 1 9 thel such permitt flsignedTt Bend SI'[CIAI,CIRCUITIMISC.
that be wrawdp Iran,I 1 p t the C I -,Li,emc Law'(Chapter 9
X00
(commencing will,Section 11X01 fD �'. 3 1th li _.nndl t :Ld)it TEMP MEFIR OR POLL IN51. IF E IAL:
a 6 c Thu he pt th reftn d tb h ', main, II g J en ld Any - Ern of IiW NLIHi/ADDI'T'ION ❑DIiMOLI'I ION
k^�I'• Serino90315 by ryapplicant1 p nut hJ GI Pphe a anvil penalryal POWER DEVICES EW
❑FOODSERVICE
N T more than five htrndruddollar,(551X).
F=QLa.owncn+f tM1e n - I[]OTHER
0 pn,pey.nrmy(,tannaswi0wred fnr Taic(Se .7044,Busmen, SWIMMING IY>UL ELECTRIC �Q'I'IILR
p.. wind..thew....and Shuavuaaremaa,Liteo,how ddls andappec.II w4,Iiminrn
C'3w pare' f.: Code:improves
L t t Li, how does khim Bora+l (riJlli IS-SWI'EG11l.S I'I%'I'11RL5
In,o nY h h ld. r Imp th and h does:such w k himself If Through
In,own rav'J l Than such'1np t. n..tintended fl' ed tar NEW RI SIUI?N'1'IALI'1 LC'R SQ PI'.
sale,If,however.the building or improvement is%old within one year ofu oplen 1.the SQ.Tri'.IIAUIt AItIiA SISQ.PI'.
owner-huilder will have the burden of proving that M did not build or improve fur put- 3 3 7 I a 0 L
rvn1.as tue.l.
❑ 1,as nxmer of me propenY,am exdTwivdy contracting with licensed amlr'vetnrs it)
IA.:
con.tru<t the Project(Sm.91WJ,Business and Professions CmI1 The i-ormiewrs Li-
ce..scl.aw Ageenma,dyn,unownufot pmPcdy who build.,impfnva thereon,and QTY. PLUMBING PERMIT PF:F.
who commew for such pmjeeu with aurmoi or(.)licensed pursuant to the Contractors
License Law. 1'IiRM1l'ISSILWCIi
I lntexemptunder Sea .11 h PC tanhix,war
ALTIiR-DRAINI VBNT 'ER(EA) VALUATION
Owner Date
WORKI'R'I COMPENSAIION DCCLAItA'I ION HACK PLOW PItOTI?CI'.IIEVICE q '^
I rebuts,affnn under penally al'perjury one offlue following Jttlmationa lJ YJ
�I havcnnd will lnninllinnCenitictnunft}maenunself-insum for Worker's Cnlopen- DRAINS-FLOOR,ROOF.AREA.Co STORIES 'TYPE CONSTRUCTION
Barron.as provided fur by Section 3700 of the I.oMa Code,fur the perlimnmac III the
work for which This Permit is i...ed, FIXTURES-PER TRAP
I h:we and will au....con Worker's Compmrsatior Insurance,its required by Section
3100ofthe lxMr Code.for the perfirnmnce of the work l in which this Permit le issued. GAS-EA.SYSTEM-I INCAOMLII'S OCC(IRODP STN
My W.d CA�c,v crorticralley N .nd nu .���QQ GAS-EASYS"FENbOVER 4 EPA)
III,Cantle'
T
Valley No. �-II�kV
CERI1F :A]E 01'EXEMPTION FRAM WORKERS' GREASI%INUIISTRI.WASTE INI'ERL'ETTOR
COMPENSATION INSURANCE BUILDING])]VISION PENN
Ola, cnonnnd 11111 he,onpdeerl if the Turbid is for one hundred dollars($11X) GR HA,SIT TRAP
or lcs.J I'hANC L' hili cJ
Ittnily that in lM1e ltcdormnncenl The rank for whichthispermili.issued.Lhall SEWER-SANITARY-SI ORM EA,200 FT.
nal employ uny pesos Ia unm
y nu ..cr s.as In became d m
ae enbjcthe Workers'Co+npe
a .., ENI? .V B
,Z cation lmws of Califan ia.Dale WATERHEATERWAIEN'EIi1.LCR
z0 Applicant GR DI'il9ili
= NONCE'IOAPPI.ICAN'1:11.alieranakinglhls CcrtiGcatcn1'17.xmI I1aa.yea should WATER SYS'I'I!M/I'REGFING S IFE
't-' Monte sonic',,m the W'orker's Compensation provisions of The Labor Com.you must
forthwith rolnply with ouch provisinm ortbis permit shall M deemed revoked, WATER SERVICE
PAT
4. CONS'TROUT[ON LENDING AGENCY NEW RESIDIiNT1AL PLMIL SQ.TT lime ReccipTa
U0 1 hereby affirm that there is it caustm,ann lending agency for the pernn anew,of
The work Rn whicht.......li(is Issued Nvc.31191.Ci¢C) qf I O
Q U Ganders Name
} W lander, re
Add ,,, xml.Dlac
G 1 cenily that I have read th'd application and tlnou Ind the above ima nuu
eion
FNn,rtem.l agree mcnlxplY with 111 city and county ordinances and smm lawn tenting n. QTY. MECHANICAL PERMIT FEE SEISM ' Eli
U Zi Iuild'mgcunaunnion,and hereby authoriac repre,cntatives of this city to enter upon the
pmwcancatinncd Property lit inspection......•us. pit ISSUANCE ELP 'I' iii Z
IN'd..glee In save,inrcmmfy am keep uI an the City of a pairs..again..
Iiahilitics.juJgmm�ls,c.sw and expense,which may In uny way ucenm ngainxt said City AIA'ER OR ADD TO Mh:Cfl. GLUM 1 "0131?
n.aquan ranting ul this permit.
A",
I'P1.1Cv I'UNU 5TANDS ANI)w'ILI.COMPLY WITH ALL NON POINT AIR HANDLING UNI'1'fTO U.000CFM) NIECE] ICALF U
SO,IURC RP "DNS.
AIR I{ANIILINGUNI'1'MOVER III,IXNICPMI CONS'rNL "I'11lN IA%
Sigt IAPPIicm EXHAUSTITOODIW/WCI') HOUSINGNIHIGKTIONIIiIi L
I IAZARDEOUS MAT. IALS DISCLOSURE. f
Will ther,plinmt or fuwre heildmg arupam Blore or hanJlehvardous anmerial HEATING UNIT(TO 100.000 BTU)
us Grund by the Cupertino Municipal Code.Chapter,9.12.and dm Ilcahh and Set,,, HP.A'1'ING ONE(OVER UIgINI01i'I'U)
Code.Section 25532MM? oJ
U Ven �d 1No VEN'I'I DATION FA N IS INOLE REST D) PAID
IJwc Rtteipt M
r Will,he appliCamnrin,..hu,Idlas......not equipment or devices which BOILER-COMP QHP OR IIIO IOIt
,nit harardoux at,cunwntinum,m defined Iy the Pay Area Air Quality Management D .
Owner! RUILBR-COMP(OVER 100.000 It U) -
Yes
nao Thchvzrdouznmtrand,n ..trod,,Chant,G95 of the Cali- AIR C(lNlli'1'IONIiR SSl1ANCE DATE
1 avc
ymrenunt
tannin cash ie of w Code.Satinn.'_5505.3533 and 3534.1 nWersund that ilthc NEW RESIDENTIN.MECII. SQ.FT. `'�- -2
C
nankin•dna' of ndyb:rv. . E.MraI,,, ,yrn,sub,aruylnno,yTMoc.,on ( L
or 16 +Mehl It Mme PrionII cot t$Icrd5cale "..cap
Ow T Gaul..rind. - 1 om T L' ISSUEDBy: �' O
OFFICE