S 1599 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING ELEC NIECD NICAICA rE1 IT No
IIUILDING DIVISION APPLICATIONA'ERMIT TING RING.nuIDEN71FIC 1599
-It111L111NG PRO.I F.CI'IDNNTIPICATION '
BUILDING ADDRIiSS: p < �� SAN["LAKY N(i. AITLIC'AAT�IIONNSSOBBBMMII T[A.DATE
C S l V
OWNBIt'SN ME. PHONP,: CONT'RACTOR'S AML LTC NO:
SNEC CONIROLL##�
ARCHI9TCi'/Ii IGINEER: LIC NO: ADDRIiSS: ❑
/ S SK
CONI'ACI': - PHONE: BUILDING PERMIT INFO•: *
I.M / �OD syy �Y� ❑ Consultant Fccs Paid by Applicant(initial) It,Of ELEC' PLUMB Mr:CI
LICENSED CON rRACTOR S II[CIARAI'ION 'i r r -
)TY I 1 LECTRI(,PERMIT FEE:
I n by « uh t l [ [ d p rel pt 91 nm, 'ng C L 'J/Hr JOB DESCRIPTION
O�'L ms I 9otw f0' 3,rme B, a ofeu, ext 1,t I ylenselx RESIDENTIAL:
u co w PERMI -
FF' n f II force ,d B
�F -235339 ❑SI'DWI. ❑KIICIIFN RIMODF.I.
�uu Le nm Class Lie # giILIANCF.$ Rf:MD171'IAI. ❑ADDITION ❑PLUMBIN('RCPIPF,
<W Dute Cnmmcmry�
0. ARClil'ILc9"SDLCLAIL ION ❑MULTI-UNIT' [I Sr
~.' K IunAantmd my pions.hall re umJ as public rttoMs PANELS MODIFICATION
Z O m •, UP TO 21X1 AMPS
OZ�r, ❑IN'T'ERIOR El CHIMNEY REPAIR
F'�'•,2W Licensed Professional 201-10E0AMIS IMPROVEMENT 0SWIMMING POOLS
Qa,ss4 OWNER-BUILD13R DFTLARAI'ION OVI?R InaUAMPS ❑BATH REMODFUREPAIR C1 DEMOLITION
((yy C C Q I hereby m'fim,that I am exempt from the Contrai License Law for the
J(�LV following teaser.Seri 9131.5, iminus,and Professions Code:Any city nr county SKINS 131.ECI RICAL ❑OTHER
W 3 k y which minim,a permit m....I. ,alcor.Improve,demolish,or motor any,Vu mm
vO
FNy; le t it, 1 y ep Cpl ft : nn tl fu g Ia mune) Sprclnl.clltcurlyhusr.,..
�11yy} troth 1 Jp n th n 0th a Connector's L 1' lCl ePmr9
0 (commumxempt therefrom
and of Div xon3 the alleged
evend[n,Any
C,dc)o' TI:MP.MhfEli Olt l'OI,ii INS'I'. COMMERCIAL:
tL aa that he is exempt therefrotn and due basis for the alleged uamptlon.Any violation nl O NIiW IiLDO/ADDITION ❑DEMOhITION
NSection 9031.5 by any upplicnm linopermit suhjeero the applicant o,acivil penaltyof POWER DEVICES ' ANT ❑TODD SERVICE
not more thus fvc hurl..a ($510).
yZ} OIHER IMPROVEMENT
Q ❑Las owner of the progeny.many en,ployecs with wages as theirsole compcnnution, SWIMMING POOL Ii1,liCTItIC
EH c, '01 do lm weak,and thcsmmYnre is not intended omffered for sale(Sec.JMY Boone, ❑O'T'HER
W 3 ao gad professions Code:'Me Convector's License low,does not apply to an owner of OU'I Elf I S_SWI'I CHES-F FPORFS
properly wta bonds or improves thereon,and who dur,such work himi or though A '
his own emp)oyees,provided that such imponenmms for not imended or oB'ercd lir NEW RESIDENTIAL ELL SQ IT
sola ll:holm,,Iliahuildn",,ingrovutncnt'm,old withinnncye'arofcnmpletion,the �q SQ,FT.11OOR AREA $/SQ.FT.
cocia,baflil uhnel,ebamenofpmsing lett redid am buildmimpr..so lm our- ., — WItNI ,. t fl,lrt(D
Lose nraam.). WA 5 !M
I,as owner of the properly,am exclusively common ng with Iiecri contractors to TOIALt
ro t'act the 1entire,(So,.70,14,Business and Protestant,C 1 )I In,CI to"our,'I L I.
erese Love J n tapplYt an fp perty h h Id: 'mon th d QTY' ' PLUMBING PER IT. 1! Flt V` LVI ��"NO
who etmraee torsion leu,wn[I o cot mr(sl I'u uxA pt mon to t he Co vastr, GITY
License Law' PERMIT ISSUANCE
(]
[;no exempt under Sec. .11 h P C I'or this erroun
' Uw'ner Dam ALTER-DRAINar VENT-WATER(,A) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROIECP DIWICE
I hereby affire,under penalty of pedaD one of the munwing dechrelii.s:
❑ Ih:tveand will mainmina Certitcam of Conxnuo self-insure for Wbrkcrx Compen- DRAINS-FLOOR,BOOR AREA,CONT. ;TA IFS 'I'YPECONSTRUCI'ION
,mine,is provided for by Section 371X1 of the IohorCode.for the performance of the
work for which his permit is issued FIXTURES-PER TRAP
I
livened will maintain Work is Coef,camtion Immance,e,required I,,Scott,,.K00 nftha Labor Code,for the perfonnanecof the work for which this minit is issued. GAS-EA.SYS9'HM-I INC.4 OUTLE'LS OCC.CROUP MIN
My Wnrke' Cam s lemi luuraneccurier WW l'oliey nyJRe��N, I.
Carrier:�'`� 'Y Policy Na:.GJ�'�ij pmpt GAS-EA.SYSTEM"OVER 4(EA)
C:RTIF CATE OF EXEMPTION FROM WORKERS' GkEASI%INUUSTRL WASTF.IN'IERCIiI'T(lR
COMPENSATION INSURANCEBU_IL_DING DIVISION P ES _
(TIisseaionnced sol beeompined if We p[rmil is(Drone bundral dollure($IlX)) GREASE!TRAP
nr.lo,sd PLANCIIIiCK IEE
I,Iycertify t meaut in any no c,,n(We work for which this permit. m'N,l,prm SEWER-IsANiT'ARY-S DORM HA,21X1 FL
not employ any pennn in tory mnnner,u as to become enbjut m the WoderJ Gnnpem ENERGY AEF'.
Csmim Lmv,.f Cafifomia.lhte WATER HEATER W/VIiNI'/CLF"CTR GRADING FEE
z Q Applicant
rN.0
NOTICE 10 APPLICAND If,alter making this Certilicam of[xemptinn,you should WATER Sl'S'IEMTREATING
ti
(~ ' hemtne.vuhun
jecthe Weaker',Cnmpenxmn
iun pmvlsins nCore,Labor ndc,"unmet SOILS THE
forthwith mil ovah.mchproviccur,car this permit shall is deemed revoked WATER SERVICE
a0
CONSTRUCTION actionLENDING AGENCY NliSl'RESIDENTIAL I'LAfit. SQ.PI'. PAID
U� D:nc Receipt
iherebyofiirm,hnl ori,
is sd(See 30 Icnding agency fur the perlbt.ntanccnf
W � the wok for wM1leb his permit is issued(Sec.309],Cis.C.)
Lender's Name rt Yl'AL
V Lender's AdAtnxs -'DOTAL:
- BUILDING FliE
� y 1 nlYthtlh Jlh' applicationand b information - { -.r„r : f�a
v1 cu LIon t ply TM1 II ty n p n d,tt I g QlC .MECIJANICAI PIiRMIT. t fF.E
�.) Z buildingas nnruc( n andlctebya tent: p x e .0 nl M,elyu onto po he SEISMIC IF.E
above-emntiened property for inspection Purposea.n' t
(We)agree m.,ma indenmify and keep harmless We City of Cupertino against I'ERMI'f ISSUANCE ELECTRIC FIAT
bahilllics„mistreats,costs and expenses which tray in any wayacctae against said City AITER OR ADDTO MECH.
in consequence of the granting of this permit. PLUMBING PCF.
APPLICANT UNDERSTANDS AND WII.I.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT cry IB,BIXD CFM)
MECHANICAL Fiai
SOURCER C'iLAT10N5. //•.
�CC&C S���qQ AIR HANDLING UNIT(OVF.R 10,000CFM) CONSTRUCT ION TAX
mmrc of App icanl/Co actor ❑um EXHAUST HOOD(WMUCT) � 1 IOUSENG MI'I'IGATION FEE
fiA RDOOS MATERIAE S DISCLOSURE
Will tire applicant or funic buddingo,cap:col,taro nr hondle ho,anlua.n,amnm 1117A1INGUNI"I'ITOI(p,I0k)BTU)
esdefined by the Cupertino Municipa[Calc Chapter 9.12,and the ikmllh and Safety
Code.Semian 155320x1^. HEATING UNIT(OVER 100,0BO RTU)
Yes �Nn
VIiNTILATION PAN(SINGLE RESIDE PATI] Date Racits#
Will the applicant or future budding occugan,use equipment or devices which
pn homrdous air terminated,as diby the tiny Area Air Qualify Munogmncnl ISOII.Ek-COMA'(31{I'OR 11X),100❑'fU) TOTAL:
0„Viel
E]Yu BOILER-COMP(OVER 100,000 BTU)
AIR CONDITIONER .1
\\I have read the harallous mu,vrials reyuimnentn under Chupmr h.95 ni the Coli- ISSUANCE DATE
fomlu Rcnith A,Samly Cnde,Sections 25505.25533 and 25534.1 and onced That If the NEW kESIDP.N'1'IAI.MECH. SQ.IT
building:luesnalcurmnt[y have a mount,Wal it i,my resp rouninym notifytheew"panl
nftb' uwM1ith nun be met rortolxxuanco of,Cenil:cam of Occupuoy
umhud,od agma Ihm 'DOTAL: ISSUED BY:
OFFICE