S 2565 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RIIILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'IDEWIFiCAT'ION
BUILDING ADDRESS: SANITARY NU. APPLICATION SURMI'PI'AL DAT I!
20460 5�eve n� CreeK B V �- Q
O Pk:51NAn(� ONE: - CONTRAC OR'S NAME: O LIC NO.
- TLfY/VMMir LtW
N/C COR"1'ROL#
ARCII"1'pC'rI (NEE ^- OCD
I ❑ 9M. ) rnap-n ( 2— /
CONTACT. PHONE CMF.q r) ILDINOPERMIT INFO
Eh►``�114 ll �l53Z-531 Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMS MSCy
Z�l A
LICENSED CONI RACTORS DECLARATION QTY GLECfRIC PERMIT FEE
1 hereby union that I am licensed under pra.isionx of chapter 9¢ommeadng JOB DESCRIPTION
SOC with Section700(dofDivisionJo(1he Businessland l'mfeesmns Code,and myfluensc iv pERStI"f ISSUANCE O RESIDENTIAL:
FW. In full foreeand effect AQ 1a2_7_12_6��� ❑SFDWL ❑KITCHEN REMODEL
aUU Licence Class /-fU hic.p 10 APPIJANCES-RESIDEN PIAL [-]ADDITION ❑PLUMBING RE PIPE
h4W [)all— Cummm�ar
F<N ARCHITECI"S DECLARATION - PANELS
❑MULTI-UNIB" ❑STRUCTURAL.
yptt#Z^ II dcfwand.yplans shall ba ancdnspuMarra ords MODIFICA'T'ION
c4- UP T0211(1AMI'S [I INTERIOR El CHIMNEY REPAIR
F�k7W Iaaenscd Po'ca slonll 201-100IIAMPS IMPROVEMENT []SWIMMING POOLS
�k:'q OWNER.BIHLDER DI!CLARATION OVER IIXNIAMIIS ❑BATH RHMODFIJRFI'AIR El DEMOLITION
C C< 1 hereby affirm m.1 am cxcmpt Ira.the Con orcfor's Li¢nse Low fur the
X 3 a V following rcawn.(Sution]031.5.Iiusincs end Professions Cade:Any city nr county SIGNS ELECfRICAI. ❑OTHER
W W yQ which rcgaims a permit lo catnaua,cher,impose,demolish,or repair uny V o amp
OJ
con
prinnnita ixwanm,alsm requires the applicant fur zuch permino fleusignedsuame. SPECIAL CIRCUI'17 :C.
} that he is licensed pursuant to the provisions or the Contactors license Law(Chapter')
al Imc (commencing with Section 7")ofoivision3ofine Businessland Profevsinnv Calc)or TEMP MCI HR OR PHLE lis"" COMMERCIAL:
d ry;o pL that he is exempt therefrom and the basis I'or the alleged exempt an.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W H Section 7011.5 by any applicant fora pcmolsahjuas the applicant m a civil Nu:dty of POWER DEVICES
not marc lh.five hundred dollars($500). I(]IMPROV El FOOD SERVICP.
Y IMPROVEMENT
d O Eo ownarofthe location
knutupende with Brad ros nhei(er.annpcmadatt SWIMMING I'O(11,IihliCfRIC
0 will do lhu wad.,and th Th.Cum is not l Livens of offered f,a,,,apply to an, wnercvs ❑O'I'HI?R
3 and Prtdwsions Code:The Cnnmuctors License Law does nal apply In an owner, O U'TLB'fS-SW1'1'GI(T:R-PI%'U1RBS
Property who builds or improves th,mon.anal who dws such wad himself orc"I",
his awn etnployces,provided that,such hoprovemenl.s are no infendeJ or nlil:reA fur NEW RESIDI!NI'IAL r:LIiCTR SQ PL
sal,IL however.me htildingor impmvemem issnld withinnne y)carof amlpinian the SQ.F'KFLOOR ARRA $/SQ.1T'.
cr-builder will have the burden of proving that he did not build nr impnnc fur par-
poacnfmlc.). � �0ID
I,ax ax her of the property,am exclusively contracting with licensed contusions ,,
months the project(Sec.IDW,Business and Professions Cade:)The Loo rass rorx....
cause Law does not apply loan owner of property who builds or improves thercon.vnd QTY PFHMBTNG PERMIT FEE
who contains for such projects with a canuactons)licensed pursuant lo the Coonawrs
License Law. PERMIT ISSUANCE
I arta cxcmpt under Sec. .B k P C hn This reason
Owner Date ALTER- RAINAVIiN'I'-VINI'PROBA) mal-"' 0 O
WORKER'S COMPHISSA'I'ION DECLARATION BAC ('ROI' f.FEVICF. L�!'/"'L7•
1 hereby affirm under penalty of leaqury one of the following declarations:
• I1haveandwill mainmin aCenigam of Conscm to self-insure fur Warker'.v Cum,.- DRAINS-FL l IDP.-iiREA.COND. STORIES l'YPE CONSTRUCT ION
salon,as provided for by Section 3700 of the Late,Code,far the performance of the O
work far which this permil is issued FIXTURES-I'.k'I'
❑ 1 have and will maintain Workers Coml'enw0on Inmance,as required by Section
}](0ofthe LaMnCale,fertile perinnnanceofthe work fur whichthis pa'mlit is issued. GAS-FA.SVS'I1!A NC.JOUTLEfS �fOCC GROUP 7/. /e 6
My Wor Co. n EOoa huarn a __JJ and Policy f�/��� SO 7
Currier: !�Jrl'nl icy No.:� rV GAS-EA.SVS'1'lih4(IVr:RJ(F:A) J
CF,RTIFICAI'I OF EXI?MI'l'ION FROM WORKERS'
COMPFNSAI'ION INSURANCE GREASEJINDUS"1'Itl.WASTE INTERCEPTOI<
BUILDING IIIVISIO_N FES
fTM1lx section need mol bcenngiloal 11 aha pannit iufin ronc hundrcA lotto.[$11111) GREASE'I'ItAP
or less.) PLAN 3CK H!E
la'rtify,irnom rely.tnancenl'Ihework furwhich this permit ix lnsucJ.l.sull SHWIil2-SANI'T'ARY-$1'OIiM EA.21N1 F1'.
nal cnlpny uny Icann In rely manner xn vn m become nubjea to We Wnrkcrd Cungwry HN F ! O
z .cation l.awsof California.Date C
ZApplicant WATER 111!A'I'Ek W/VIiNI'/ELECTR GAA NICE
N NOTICE TO APPLICANT.If. far making this Cenificoc of Exemption,your should WATER SYSTEMO REAJ ING
F ;
Fee n.a object to the Workers Companautlon provisions of the Labor Code,you most S01111/`C
fonhwim comply with such provisions,"this pcnnilshall be deemed revoked WATER SERVICE
a �
UO CONSTRUCTION[.ENDING AGENCY NEW RF:SIUIiN'1'[Ali ILMI{, $V.Trp PAID Dune Race,#
1 hereby affirm mounds Is s ed(See.30 I7,Ci, agency fur the lwdnrmuneenf
W Lu work lin which this pcmlit is issued(Sa.3fIH],Civ.CJ
l-� LoNur's Numc
C.) 1 nl" Address, 1�^
'� W 1 certify thw I have read this applicunion and.state mal the shove ii liunction is BUL ;P'. 9 iv
F!0./1 most.(ugrcemcomply with all city and county nnlinunm.c and.oath laws retuning nm QTY. MF-CIIANICAL PERMIT FILE
U ,� hnildingcnnswmimn,and hereby emhmriza represemmives of this city venter urynnbe SETS I iii!
aMrve mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamlless me City of Cupenino against �7 E TRIC ITF.
Imbilities,judgmem oos and expenses xhich may in uny way accm<against said Cit LTER OR ADD TO MI:CH. (� PLUMBING PEE
in conseque egmmin ofild"ulit.
APP! . T lo'DERS'f DS AND Wll ,f )MPLY WITH ALL NON-POIM' AIR HANDLING UNII'CIO 10,00(CFM)
S .RCE F J ON ECHANICAL`F
�/ � �� AIR HANDLING IINI'I'(OVER loflol CFM) 'ONSTRUC'Rosl AN
Siganwa or ApplicAUCnntm]dnr Data EXHAUST HOOD(W/DI171) HOUSING MirrIGAHON ITC
HAZARDOUS MA'I'BRIALS DISCLOSURE
Will the applicant orfuora buddinglwcupunn smreorhandlehaznNnas tInlunal HEATING UNI'1'0('0100,000(111'U)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Ilenhh and Safety
Cole,Section 25532(a)1 HEATING UNIT(OVER 100,00 BTU)
Dyes Fl No VENTILATION PAN(SINGLE RF.SID) PAID
Ham Receipt p
Will the applicant or(ware hnilding raccupaR A equipment or Moria which BOILER-COMP OHP OR IoBdNO BTU)
emit hazardous air ronaminanlS to AehncJ by me Itny Arca Air Qualify Managcmem T L
DisaicR BOLLHR-COMP(OVER 1010.0(0 BTU)
'
Yes EJ NII
regmranen p AIR CONDI"(LONER
Ib end h od 1 rt eats t der Chapter rb)5 Ith Cil- ISSUANCE DATE
fun LIC IOt.V SeCty Calc ti n'255(15255�a 25534.
1 i dulynl 11 lon fila
NEW RESIDEN'1'I Al.MECIL SQ,FI',
bt it l' y1 Oyl n tnl I) .' jl� 7
al / 1 S m � IAV (]� Y
Owlcroruumorize age C/Das / L ISSUED BY:
I OFFICE