S 2683 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI•PY OF CUPERTINO nuaDING.EUECrRICAI. PER MIT No.
IfUILDINC.DIVISION APPLICATIONILIERMIT rINGROJECI DENT Cc _ S- 2683
' INILDING'I'ROJY:C'I'IUf:N'I'IEICA'rIUN
RRIITDINGADDRf3S: uLvu5 SANITARY I. APPLICAGONSHBMI'I"I'ALDAI'F
Z12 41 'MvWs crAW, OLvp. 441 is e-urar- ii4o c,a. `iso 14. 3 - 2-3 r- 7
OWNER'S NAME: f<ll� , z'rw� PINIi: _ '(OO1 CONIR:S kACfONAME: LIC NO:
NIC CUNTNoh p
ARCHITECf/ENGINHEW LIC NO ADDRESS: ❑
CONTACT: PHONE: dU ILDING PERMITINFO_ '
- �/�D ❑ Consultant Fees Paid by Applicant(Initial) HO 171 P❑ T PI IMF MI❑CH
I.ICFNM D CON PRACIOH 4 DI CI ARATIONCY I FL 'LIC PERMIT� ' I'CE,
I herehy+ffrm th t l f Led J provisions of Ch apter 9(cnnmeneng 0, - _ JOB DESCRIPTION
'1Ma�geZ with Section 7MjotO .
'' J file Hun dl feninns Code L:
and my i, RESIDENTIAL
FOSin full farce und,Tied. PERIOD ISSUANCE
�U~ Li cense Class Tim. ❑SFUWI, [__1 KITCHEN REMODEL,
Q U APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
yW Dam Contractor
CC ARCt{CfIiCTS DECLARATION ❑MULTI-UNIT CSTRUCTURAI.
f.,p Z I'ANEI ti MODIFICXHON
Z O4Z 1undersmnJ my plans shall M1c used:u Puhlic record.
O Z., UI'T021(IAMI'S [I INTERIOR [:1 CHIMNEY REPAIR
`I-y�,Fat LicensW Plorrssiowl OWNER-HUILUIik DECLpRnTION 201-1000AMPS IMPROVEMENT [D SWIMMING POOLS
C I heruM1y xflinn mw 1 am exempt from ilia Cemnmua's License Luw for the OVER FKIOAMPS ❑HATH RF.MODEIARIiPAIR [I DF.MOhI IO
=C)a V following mmnv.(Sermon 7031.5,Bosinees and Promotion,Code Any city meems, SIGNS ELECTRICAL ❑UI'HER
which unpin es a pmmlt to consmmt,cher.'improve,dein oh,or repair any stmenum i 11 -.3
Q print I I I:. 'L.marine,he j,TIl II steh to i1e,ra,acil,trwound, SPECIAL.CIRCUIT/MISC.
for,he I' . d NommanuGhe pri oldhe Cmilmorml,L 1-mv(Clone,9
C dF. (esnman,ingwah S,vrmn]((N1tsl Doritn3 oftheI 'inn d t msCodc)or T1,Mr.ME'fEIt OR P(II,R INS'f. COMMERCIAL:
d oban he is r.rion thcrefrotn and the hunt,fm the alleged eeonption.Any violation of [INEW I31.DG/AUDI1 ION EDDEMOIJ I ION
of m^'� Stainer T1D1.5 by anf applicant for a actual bjecb alm e applicant a civil penalty of POWER DEVICES
O
�� MP ❑FOOD SERVICE
RO'C'
`u, m tore than five hundred Joilt ($500) I
^Z 7+ MPROVPJvIFNT
SQ wiLo the work, the proPicture nyemntended with ffereefralei(Sec.compensation. SWIMMING I' LEI , TRIC
� 2 will do the work.and the ntrvctum i,not intended nnalered far sale(Sec.]INa,Business El OTHER
W, m Lord P olesnions Code:'III,Conionfor's I.icen,c I,aw th—oat apply m an owner A O1TIJElS-SW "-FI XTIJR17
�' property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such inapmvements are not intended or offered for NEW RESIDENT AL EL SQ PT
sale.If,however,(lie building or ltnprevenmm is sold within one year of nn,lotima,the SQ.IT.I LDOR ARRA b/SQ.FT.
wner-bulldcr will have the burden of proving Ed he did not build or improve far par,
poll of.vale.).
1,as owner of the property,Lou exdiamcly coolant on,with tinned nmhamoas m Al.:
cmtstmci aha j Jeet(See.7(44,[last...v vad I'mm ions Cods.)The Comracmrs Li- --
.,Lawdocnot rpFlym rro rc,cf nopeny who build,m'tmprovcmemon.Lord QTY. a pI.UM)fING PERMIT ' I FF.E.r
who contracts for,neh projects with a commands)Iirensenl pursuant mine Commemr's
License l,rw. 11ERMI'F ISSUANCE
❑ I vm exemp under Sac. ,R&P C for lhiarcoun
Owns .-atom ALTER-DRAIN&VENT-WATER LEA) VAI.UATION
ORKI?H'S COMfjrsf jf'N DECI.ARA'I'ION 13ACK FLOW PROTECT.DEVICE
1 hereby affirm under penally or aclj�ly ane d tM following declaretims!
❑ Ihuve mW will tnaintainnCe+lif¢ant nfCnn,cnl lu self-innum liar WorAcr'a Cnntpen- DRAINS-FLOOR,ILOOP,AREA.COND. STORIES CONS DEUCE
iwron,an provided for by Section 37M of the LrMar Code,for the performance of he D
work for which this p::mait is issued. FIXTURES-PER TRAP
1'havc I it will inaintnln Worker s Contpemudon Imu,are-,a,mquimJ by Section
3700ofthe Lahr Cada forahe Pelbrmznccofe work forwhich this Permit is issued GAS-HA.SYSTEM-1 INC.4 OUTI-HIS OCC.GROUP
My Worker',Co mpcnwtion Imu....r,amr,and Policy nandesr are
Carrier: Pnl'my No.: GAS-PA.SYSTEM"OVER 4(CAL
CERTIFICATE OP EXEMPTION FROM WORKERS' GRF;AS: IlSTA4.WlIY :'TOR O
COMI'IiNSA'I'I(lN INSURANCE? BHILpiNG DIVISION FEES
Gbisseninn need not be complelW if(Im namoia is formic hnndmil dollvrs($1 W) --
It's') GRF.AS T 1' U Ir
PLANCHECK FEE
I cmvily ilia in thaperf nnue,aidhewmis llmwhldido,permit lnissued.IO2,11 SGWEIt I'TARY-S'1'OItM F.A.2011 PI'.
not employ any person in any manner ser as m bacntne subject to the Workers'Compeer- pp ENERGY HE
Q Z, wino Lnwsnf Cnlifomia.Data WAT17R 'FRV/aI�NT/IjIli R GRADING THE Applicant .
ti
.N. NOTICE'CO APPLICANT:If,cher making this Certilwate of Exemption,you should WpTEH "I'EMRREATINC
loohbecomea ,oral to it Worker's Compensation anord has of the ell Code,you must SOILS FEE
fimhwith tnmaly with,uch pnwislnnsortbispermit shall he tire ell revakeJ. WATEIi.R ECR
0
CONS'CRIICTION].ENDING AGCNCY NEW ItE•IWiNWIRf:'E'1]NN. SQ,FT. PAID Dom Itccetpl#
U 0 I hereby allum that dam Ina construction lending agency for the rerfonnance of
F the work for which this permit is issued(Sec.3099.Civ.C.)Nunn O
u' Lendar's TOTAL:
0 09 Lent r' Address
'TO'I'A r R1111.IlING P
Iccr,ifymen I have marldfl, ppl t I J unichater,abovenomination is
liar,
currect.I agree to comply w th all city Laid county ordinances and staleaws relatiogto QTY., •` dECHAN[CAL PERMIT I•EE
L) Z buildng eonslmctim,andhereby majorim reproccrearivesofilascmatter upam the IDE
SEISMIC F
svcmen.nest p,.Perry tf"n,cc aaparpnsenPERMIT ISSUANCE
ee
-(We)agrto save.indmanify end keep lorries,the Clly of Cupen'mu age{nn CI.PCI RIC F,,
ti
liabilities,judgment,.cntvndcapemes vAchnmy m irry way ucaveagaimisaid City ALTER OR ADD TO MECH.
evltwneeol the go Linger R in..anon PLUMBING FE: �
incur e
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(1011,009 CPM) h1ECHANICALF
SOURCE RF"GULATIONS.
AIR I IANDLING UNI'T(OVER 11,110(1 CPM) COIN STRIIC'DON'CAX
.ignaturcof/iTurcare nta ' Data EXHAl1ST HOOD(W/DUCE) H(II151NO MI'I'[CATION FEE
HA%AI OILS MAI'ERIAIS 1lISCl.OSURE
Will maidilicomor.,a.buildingoccu.amsmrenrhmdleh...Non,material HEATING UNIT G'0101000 IT CU)
o alefinerl by the Cnpenino Mian,dd Code,Chapter It 12,and the H,Alrb and Safety
Code.Section 25532(a)'! ,�/ HEAI ING UNI'I(OVER 100,00)B'1'U)
Yes LY'no VEN I'I LATION FANS INGI,U REST I)) PAID
Will the applicant or future building sent nt use a nem or devices which
Date Receipt#
PP 8 pr quips 80111tH-COMPGfIP OR IIp.000 RTU)
emit hveanlnus air containment,to defined by the Bvy Arev Air Quality Management Z. O
Distric,!
0Yes I ROLLER-COME(OVER IINI,Iy)(11{'I'LIE
I hate mad the hmson-maehd,e is trader Choler R 95 of the Cali" A IR CONDI'I'IONFIR ISSUANCE DA-117
825533 a Chad
in
Health&Safety fide.Sections,IN,i I, ey and 2s53i.I mmalonnalinady,h that if the NEW HF.SIDIiNTIAh MECH. SV.Fn
ofthingdreare emrcnhy hovebi it ttnnttl inmymapwtnCloifide oifythenecorl.
o(Ihe�:awntnwhlebinams Mn ¢ain,nenee nfu C,nilicvm ofOeeup:mcy.
Ow ruin nrimd agent Datc 'IGIAL: ISSUED E, Y"
OFFICE