S 2792 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BOB.DINc-ELECT RICAL PERMITNO.
BUILDING DIVISION APPLICATIONTERMIT TING PROJECT
IDENTIFICATION
Q 2792 7 9 2
' IWILDINOI'ROJN:CTIDL:N'1'IPIL'ATION O I
BUILDING ADDRESS: SANITARY NO. APPIACA'I']ON SIIBMI'I'Al,UA TN
Z ser v;"r4D ate' . cc-Oz-R i..�o C� 95 o it/
OWNER'S NAME: PHONE. COLTRAGTOR'S NAME: LIC NO
I-14914 V-4119 "e':;Wc ,-90-51Z 17 /C ar NlJ3✓f[.v/"M ,Z jr— NIC C+++111ONTROL#
ARCH I'I'IiCT ;NGIN HER: LICNO'. ADDRESS 1ll
❑ ��j
' G- �,cK o c pisd-c 14/C3v
CONI'ACI': PHONE: CUA /—Jp /9 SS D 'Al' BUILDING PERNIITINFO
_S/� ❑ Consultant Paid by Applicant(Initial) BLDG ELECT/ PLUMB h1E❑CH
ELM
II.ICENSI?IICONTRAC'Irllt'SDECI.ARATR)N QTY. ELECTRIC PERMIT FEE
1 hereby arum mm 1 am fian.ee tmJer pnwiamn,air cnapmr 9(con,menemg JOB DESCRIPTION
"Z with Seainn]Of10)ofDivision3ol the Businos and l'mfe..ion.,Gide.and my license is HESIDF.NTIAL:
WO, PERMIT ISSUANCE?
F to is full furor and effect 'Y//�/tL ❑SFDWL ❑KITCHEN REMODEL,
VU License Lic.p APPLIANCES-RESIOC TIAL []AUDITION i0 PLUMBING RE-PIPIT
FZuc nate comraam,RNE[ON .D�✓fde�►'Ji'7
HCH ARCHIE EC'1'S UECLAItA'r1ON PANELS ❑MUL'1'hUNIT ❑SI'kUCI'UkAh
m Z 1 understand my plans shall be used os public records MODIFICATION
02`=`0 HP10200AMPS'
❑IMPROVk (3S CHIMNEY MINGREPAIR
FOOL
1-�F'ul Licensed lknfnsional 201-I(NX)AMPS IMPROVEMENT (3 SWIMMING POOLS
E
OWNER-BUILDER DECLARATION
OVER IIH0AMP5 [I BATH REMODEIIREPAIR ❑D13MQLITIGN
G 1 hereby ofllnn ehnt I exempt(rant the Con¢.aor'S License Law far he
O y U frllowin•tali.....(Settlor]031 5,Husinre,and Profession,Cade:An t I ❑01 HER
g v v r' v SIGNS E.I ECrHlcnl.
y which - p m , t l p - d I'sh P Y.rurmm
aO
prim e e I q th spPFaz tl bPermit rl .g W.mmmrnt SPECIAL CIRNI'I'IMISC.
E } 'Fah licensedpumu nu top fth Contractors u - to (Chapter 9
m_DO Icon 6 th5 t 700(p fD nt ftM1 B II f C Ic)ar '1'IiMILMEI'F.R Ok I'OLF.INST. COMMERCIAL:
G. m 'het hes car npe ehetefr m,n 1 the bass for the alleged ext Es m.Any small n tor Q NEW BLDG/ADDITION E]DEMOLITION
x SeGinn]0315 by any 1ptplicunl fora Caron'subjects Emopplic.nl lna civil Pumlly of POWER DEVICES
y ❑'1',NAN'1' [DF
,N
oa marc Than live hundred dollars($5001.
Ih1PROV1iMIiNT
=6 [-]I,asowner kl theand
pm pent',mmyemntendedwithwred for one(See
c0mpensutlon, SWIMMING POOI.IiI.liC 1'HIC
G will do[lie Nme.and the he Crm is not intended Law dos not apply totan,owner
of
� ) IeR
d'F-o
W ao and Pn,.ts norm Cale:The Commcmre License Law dors not apply himself owner of OIl'I'LfTS-SW'ITCI113-10XTURI!S
�'_ Property who Fuels.or imprd that or,h..:md who dues such work that ,of ehnogn
sal awn employees.Cntvia ti that each rural I,solid within are not Ilncnsnl nr nlrcrcI,far NEW It ESIDEMI'IAI.EhECTk SQ Pf.
..este', addle, r,Ihe huildre har lntpmvenonl sat hed ,, uild rofcpirmic for lane Q.EI'.I?LO(Ayy41t ��� PI'.
net-bniWer will have the harden of proving Ihm he did not buil)nr Improve far Pnr- r P 1
pose of scram).
rl 1,ro,mmer of are Sec.property.a ane si and Protracting CoM1 licensed eommenns m T,\L:
construct La theesjoa(ser.]rani Business and tly who bei Gdrit The cnmmmors IA. `'
w Law does mit apply Iran ownernf ps"...s war mord ins improves thereon,Iced QTY. U 7 PERMIT FP,E B
who Parmlrna r r.nd,rmjert.ween n rs,mmam(,)Ewnsm in sound m me crmmaa:n
License Law. PIiHMI'I'ISSUAN
0 lemeumptuodcr .Sec. ,H&1'Crmtbismason
Owner Dam ALTIiH-DRAIN Veil. -WATER IIiA) y� VALUATION
WORK IiR'S COMPF.NSA'I'ION DF.CLAHA'I'IfIN HACK PLOW PR(YI'ECI'. )EVICIi / D
I humhy affmn natter pamhy of,crjnry#tooth,folk wing dcalamfmn,, 6
❑I have and will malnwion Cunifirm, In two,mndfprime III,W..ket"Competo- DRAINS-FLOOR.ROOF AREA,CON D. STORIES 'TYPE CONST R UCTION
,much,as provided for by Section 3700 of the Labor Cede,for the performance of rhe
work for which daw Permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Cenrpeasmion Insurance,as required by Section
3700 of he Labor Code,lirbepcdramarecof the work for ishieh'hls Permit is issue), CAS-1A.SYST17.M.1 NC.4ODUJIFS OCC.GROUP APN
My Worku's Compensation hiss once carrier and Policy manner am:
Gmicr'. I'nllcy No.: GAS-ITA.SYSTCMd)VER 4(GA)
CERTHICAI Ii OP EXEMM ION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRI.WASTE INGIERCEPIOk
BUILDING DIVISION FEBS
[rd,sorptionami nd le contpleped ifencp.it is Europe bandied dollms($100)
or less.) CNIiASIi TRAP 1'LANCHF.CK PF;Ii
Ieeniry(hat ln'ho Nrioreanceofthe work forwhich thispennie is issucd,lstood SEWER-SANI'T'ARY-STORM EA.200M
no'employ any Person in way manner so as m Mconlo subjun m Oto Workers'Cmnpen- 1?NENCY PEE
ZZ ,oda#]-;I.,or C.Iifomia.Date WINE'ER BEATER WIVENTIELECTH
O Applfram GRADING FEE
h
NOTICE 10 APPLICANT:11:after arcking this Ce tificem of Escmplaam you should WATER SYSTEM?REATING
heroine subject tothe Worker's Compensation provisions of I.For Code.younmse SOILS PEE
LklG fntthwitb cmnply with such provisions or this lwrnti'shall be deented revoked. Wn'1'17R SERVICL' or
0.
CONhere isCI'ION LENIllNG AGENCY NEN'RESIDENTIAE,I'LMB. SQ.IT. PAID
Z Da Reccipe#
L)0 lhereby eEfirlb, earns isIcd(Sec.07.Clending agency leuetre perfomr:mtt of
the work far which'hi,pemrit is issued(Sec.LMl].Ci,C.) O
0 (--' Lender's Name 'Fr 'N
V Landers Address TOTAL:
Q. 1 readily that 1 have read this opplicmin I and state Thal Inc abnve inronnuliall is 111111.1 ,FEE
.F. VJ crrrwt.Im,rcmcamply wlm 111 city and ennalordinenees lord Into laws rdmlngm QTY MECIIANICAI-PFRMI'T FEE
L) Z building cinsioceion,and hereby authotim relmescntahvea ofthis city to eater upon the SI71SN CFEE
above mentioned property far imEaretlon purposes. r
(We)ago.,.save,indemnify and keep hemdese the Ci'yof Cupertino against I'ERM1II'1'ISSUANCIi E1114. IC PEE
liabilities,judgment,costs and expenses which mey in any x'uy nccmepguinst and City AI]'I'RORADD'TO MECH
in acque¢vofhe gninfr,III(his'111111, PLUMB0FEH
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING USE I'(TO 10.000 CFM)
SOURCE REGULATIONS. MIiC11ANICAI.IT?li
33/ AIR HANDLING ON]'T(OVER 10,0100 CPM) CONSTRUCTION TAX
n lice# �imroctnr Datc EXHAUST HOOD IWIDUCT)
pLNtD S MATERIALS ISCLOSURii HOUSING MI'1lGA'I'ION FEE
Will Icapplicant rare build;ngonu t strrear handle hvlNo.s mal,nal HEATING UNI'1'0011111O0 BTU)
as defined by the Cupertino XZipal CnJ ,mpmr 9.12,and the Ilcahh end Safely
Case.���S25532m)] HP.ArING UNIT(OVER 10001(k)BTU)
e, ❑No
VENTILATION FAN SINGLE RF.SIII) PAID Date Receipt#
Will the uppliant(ir lltuae building occutu0 use equipment or devices which BOILI?It-COMI'(3111'OR III(I,WOII'I'U)
amie boznaloa..air commnlnams as defined by eha Bay Area Air Quality Munngcnwnn
Drunk'
i]No BOILER-COMP(OVER 100,00)]OLD
I]{i'cs e.
V
l have read the Fur rJnus materials mryircncnt,
tunder Chapter MAIR CONDITIONEkrfi.95 the Call- ISSUANCE DA OO
Find.Honda&SafetyCode,Sell a,25505,255331nd 25534.1.ndcomodehat it to NEW RESIDEN"FIAT.MC:CH. SQ ET, /1
nuilJiny daK nal eurzenl y Fav e:unan4 that it i.nay arry mmilily In#miry then"a"inal
or Os re .....are -hem,11met 'non Lxronce nfn CepJjc �,f recent, 7
Owner or amrson, J [)all SSUED BY:
OFFICE