S 2723 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMITPI.mHDNG-MECHANICAL �+ nZryQ
BUILDING PRO.IECI'ID5M1'IF'ICVI'ION ' O G L 3
BUILDING ADDRESS: `aI �^ � ^ SANITARY NO. APPLICATION SUBMI l9AI.DATE
2 5Teyvv`!I 6'n �W o_ L 3—
OWNER'S `�9
IA01"t1c PHONE: l lN`A(.I�(1kf NIS MSE. ��� �y�(9 'L NIC /�//, CONTROL
k`
R I CTIL'C EER; LIC NO'. 13� ADDRESS:
AnIC � FV�L- ❑ I 2-
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CONTACT: PHONE: k ILDING PERMIT INFO
(,/,,Il
jo ,,)Ar 9/D'6
I q _ ❑ Consultant Pees,Paid by Applicant(Initial) BLDGLF,(:1'_ I{ NO MICH
l
LICENSED D CONTRACT OR S DECI-ARATION I// QTY. ELECT RIC PERMIT
1 hereby aRr t,d a I 1 R.ensee d p ns of chapter v(vamma hag '+ JOB DESCRIPTION
O�Z with Sea nn]001 of 1y i tithe Bus .: nJ1 fessions Cod,,9n try tic w RPSIDENTIAL
Ia10c, - PERMIT NSU, �qf
�IyF n full force III cftc � ❑S19lNL ❑KITCHEN REMODEL.
QUU Liwna Lich is APPLIANCES-RF.SIDEN'I'I Al. ❑ADDITION [I PLUMBING NE-PIPE
H ly Ilam Ca
Foy ITCH SDE Al-ION Lo ate]� e PANELS ❑M111.T1-UNIT ❑STRUCrMODIFI NI IO
Z O vfl7 1 unJeraanJ my +- .,all he nM'm rds CHIMNEY
Ill"I'02fNlAMPS
02'-'0 ❑IN'I'PRIOR CHIMNIiY klil'Allt
4 W hocusWP .sinna 201-1000AMPS IMPROVF.MEN'1' SWIMMING POOLS
J GWNEk-BUILDER DECLARAl'[ON
C J I hereby altiml that 1 am exempt from the Contra....'.Licence I.aw for the OVER INX)AMPS ❑BATA REMODF.UREPAIR ❑DEMOLITION
LOW infesin
X &arch,.(Section t I . Business and Ihnfe,.ions Gds Any city or mumY SIGNS ELECTRICAL
M HER
wM1 h pa,mrs,a pnim,l construct ide, no,one.groodid,or mica, yoficune
�.� pr: t o1...ps,pipene ii,pliemn11 ll II g d"uniancia SPECIAL CIRCUIT/MISC.
} did lie licensed pn thep of Contractor Is I (Chapter 9
(co y itIS I 7000) fD 1 III Il :' II 'CJn)nr LIMP.MI.IIR OR POLLENS, COMh1ER IA
d o 0 Ih:t s circuit,Ihv ul nand In.bas's f Ibe III exempt r+ Any v'nlw'nn or ❑NEW RLDO/ADDITION L IlF.M01.1'I'ION
W^so Section 7031.5 by any applicant for apennil subjects the applicanuo a civil penalty of 11OWI7R DEVICES IiNANT ❑FOOD SERVICE
not mom than five hundred dollars(S50)).
F Z Y IMPROVEMENT
XC emsnwnendthe pmpeny,ormyetnpinycczwithxagesac Their site nimpensaion, SWIMMING YUOLELECIRIC
=F.L' will Jn the work,and the etmaure isnm lmenJeJ orniteredfo...]a(Se..]IIW,Business ❑OTIIF.R
W 3 m and Profession.,Code:The Commetnrs Licence law dues not apply to an owner of VI'LETS-SWI'I CHLI FIXTURES
pmpeny who build.nr impnrven Ihern+n,nnJ who does snch work ma...f nr Ihnmgh
hixwL ampinyeas,pin.ided thin such uprostancol,arc not immndeJ nr oltroed for NEW RHSIDH 1.131.1?C'l'lr
vatic lhaw glLcbuilJil+g or lnpm and to wJJ wllLin
I.(he SQ.FP FLOOR AREA R/SQ.FI'.
er-hmIder will trrve the burden of pmving Ihat he did not build or improve lir pur-
1,asso
0 owner
dcontracting
I,as owner of the property,um exuvivdY .ting with licensed amry m nnrac 'AI O
consumer the pn)ject(See,701 Business and Professions Code:)The Contractors Li
cense law does not apply to an owner of progeny who builds or improves lhemon,and QTY.,. - PL U NG t MIT FEE
who contracts for such projects with a contracmgcl licensed pursuant o me Commemes
l.lecnw Low. PERMIT ISSUANCE
❑ I am 9xemptnnder See. .B&PC In,thio realm .
'131t-DRAIN&VI1N'I'- "I (EA) 1A
hoer One 1:1
WORKER'S COM PENrjun,on DECLARATION IIA FLOW PRO[ DEVICE
1 herebyunionmat ander penalty to ofCon one of the following dedamtinn
lalhmt and will maintain eCion37Mof the Labor
CwIr odemurtter Werkeracempen- DRAIN. FLOOR.R(R)I'.AItISA,COND. STORIF_S TYPE CONSTRUCTION
urian,as hick his
for by Semina issued. oRhe LuMr Cade,far the I+crhmnunce of the 2 /•
ark far which lois pinainWorker IB%'1'IIRES- -R TRAP _(1
1 have and will nmine+in Worker's Cnnq,nle:uian Inwronce,u.myuimJ by Station
J]o0 oft
Labor Code.lot the provenience onM1n work for which Phi,pefii(i,issued. GAS-HA.SYSTE ZINC.4 OU,LET OCC OUP N
Glnierr sC{+�K suYuul .wrance caoricranA Policy�uutpe�aph / O GAS '1t4(HAT IGg,
l Policy No.: C )6 O
CERDFICAFF.OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASE/INDIISTRI.WAS1 IERCEPTOR
BUILDING DIVISION F_F.F.S_
(Thissection neral not he completed iOhc pcmtit is for one hundred dollars(SIM) GRI3ASE TRAP
,it less.) P C tH
I cenifythm'm the perferseacenf the such for which this permit i.,towed,l shall SI3W13R-SANITARY S'IORM EA. LFT.
nal employany pctae,in anymanner sone..heroine xobjestbi the Workers.Cmnlmn- 13N IIk-q :L+
z ,urian Laws of Culllulniu.Dun WAI'IiR SVS' M/I R13AI1 IiLI!C'IY2
7� � Applicant WA'IHIi IIFAU..l /VI3NI GRADING PBE
G (meq NONCE TO APPLICANT:IL otter making Ibix Cenifeme of Exemption,you should' NG SUMS PIiE
a ? hesome subject .,he worker's Compemati in pmooiar,of the Labs,.Code.you must
forthwith emnply with such powkiwa,or this pennn shall be deemed revoked W'AI ER ikVICE
s, 0
� z CONSTRUCTION LENDING AGENCY SMRESIDEM'IALPISIB. SQ.ET PAID
U 0 l herehyaffian that is a construction lending agency for admittance I, Date Receipt p '
I he ends for which 11,,,I Is issued(Sec.91Y➢,Civ.C.)
Lende.s Name CA
O U Lender,Adde.e T(YI'AL:
} W 1 cenifY then I have read This application and gale that the above union'motion i. - B1411y I THE �.
FZ) eo.rca.lag on+ply witholl any and,omr,opmennee,and one luta relating In Q'FY MECHANICAL PERMIT FEE
Uz, building ca wen nn.xnJ herthy authnrim mprexmmivesal this citymcn¢rupan me :Shtl PEE 3
above-an inncJ mpenyforinspeaionpuHswc,' PERMITISSUANCE
( q ugr m save,indemnify and keep hamdas the City of Cupertino against 1..E kIC FEE 3
Ilobilio ,judgl nts,.osuand expenses11,.dOcy intay'way testae uguiu,Isaid City ALI'FR OR ADD TO MECH. e1'1
'm,c ZIA
dlhn gn'nling (this pcmlit. f`/ '.1. Ii1NG PEE
APPLICNDEI(STA S AND WI/LI.COMPLY 1'1'11 AL1.NUN-POINT AIR HANDLING UNI'I(I'O 111,001 CTM)
LAe ge iCIIANICAI.I-EE 21 /_`/, �� AIR HANDLING UNIT(OVER 10.000 CFM) IONS'IRUCFION TAX
lieam 'ommcmr Date EXHAUST HOOD UNIDUCU {O USING MITIGATION ME
I IAZARDOUS MATERIALS DISCLOSURE
Will the opplicam or future hoild,oc.,eme smreor handle haelndeasmmened HEATING UNIT(11)110.00 BTU)
un defined by the Cupertino Municipal Gds,Chapter 9.12,and the Beellh and Safely
Code,Section 25592(a)! �� HEALING UNIT(OVER 1110,000 BTU)
❑Vee . I/INa VEN'T'ILATION AN(SINGLI3]III SID) I'All)
Dn,a Rao,in It
Will the appli,em or famre building occupant uoe equipment nr devices whim
L"c"
s air amo nin r.as defined fi the Bay Area Air Quality M.a.rwo oto H(IILER-COhIP!3111'OR W!NMI HTIJ)
i.iL� BOILER-COME OVER 101,1X0 BTU1
Alk CONDITIONER
II / d I `I. y I: de CI pt ( 5 fthc Cnli IS$UANCL'IJATE
& 'I IyCJ S ( 25511525511 J255iy.1 1 Ill, ftM1c NEWRESIDENTIALMECH. SQ,FI'.
Iyl t I r}}��yI `n I'lyl Tyd xnpan,
cute soh JI mac l urngyQti�ra can fuse l:ncyle—
hmJ age.. Dole ( ISSUED BY:
OFFICE