S 0030 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYO CCUPERTINO BUILDING-ELECI'RICAI• PERMIT NO
BUu,'INC.DIVISION APPLICATIONIPERMIT vhunvnrvr.-MEcunrvic Ir , �iy�y�{'•2O
- .111UHMING'PROJECTIFIFNITFPATION-•r I
BUILDING ADDRESS: SANITARY NO. APPLICATION SURMI TAI.DATE
1,034)o ' 5Tb a5 AVE7
.It'; Q PHONE: �a(( COM RAC'TOR'�S�NAAMP,: LIC NO', ROI.
/_�� 257-• 70 1 I/GI" LN/17GS. NIC CON l ROI.n
�RCHI'IEC'UTNGINEER: LIC NO, ADDRESS: - ❑
CONTACT: PHONE: - - - f' '_:y... _BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BUX! ELECT PLUMB ,.MECH
LICENSED CONI RACI OR S DICLARAI IONt ) t -- 't
I hereby affmnhtl licensedOrderp f chapter 9(commanchip QIY.p� , ! ( FLECTRICPERMIT:I _ At ','ti11 EP. JOH DESCRIPTION
DMZ wiro Senior 9(NNTIOfD i:mm3af dm Bus ne.sand Pnf sslons Cole,Ina myliceis -
Ian o o PERMIT ISSUANCE RESIDENTIAL
FBF In full tons and all'cm. SFDWh ❑KITCHEN RF.MODIiL
�UU License Class Lic.R APPLIANC17S-RESIDE1,11'IA L' ❑ADDITION ❑PLUMBING RE-PHIE
I-ZW Date Comment
w64 ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
~, en
=if Z I ders mid my plane shall be rased as public redcors PANELS - MODIFICATION
Oz4O UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
5,=<
Li'mard Professional - 201.1000AMIX MPROVEMENT SWIMMING PO(11.S
t4 J OWNER-IIUILDER DECLARATION Qyi;R 1000 AMPS TII REMODI!IJREPAIR ❑DI:MDLL'rIQN
C 6 I berchy affirm that I am exempt Trent the Convadnr's License Law for the
�4�(g'UyU following reason.(Section'/031.5.prier ss and Professions Code-Any ciDOr county SIGNS ELECTRICAL OTHIiR
which requires a permit dr scions ,alter,improve,demolish,Or rated,ad,strnloom
0 prior In its issuance,also requires the applicant for uch pemtit to file a signed smnmmdt SPECIAL,Cl RCUIUMISC.
ohthat he I,licensed pursdamm rhepmnsonsof the Connotoh license law(Chapter 9
G tno,n. COMMERCIAL:
mXCo (co cmgwith Section'WO)the basisnr hlM1reged vsen,Ior:Aamrs Cnionar TEMP.METER OH POLE INST.
4 4 pC Oren he is uenrpl IM1emfrum and the basis fm Inc allugrnl excnsptinn.Any viohnion nr ❑Nf:W ItI,UGIADIIITION ❑131iM(lhl'I'ION
�mN
Section by any applicant a pandit subjects the applicant to a civil Penally of MOWER DEVICES �TENA,yT -ODD SERVICE
X56an,mare than live Lvndoid dollars(5500), IMPROVEMENT
1,as owner olde n,irol employees with woes as emir,sale mm two SWIMMING POOL,FTECTIRA
O ❑ Ps,tr y Ye P Y g Pans" ❑OT41 Ls12
F., will do fework,andtheslructuleistolim iccove ofecelf wdosnot apply to nBusiness
{til'-� and Professions Qde:The Contractor's License Law Jces not apply to an owner of Olfl'LF.T5-SW1'fCf{ES-FI%TURES
3 progeny he builds or ouprnvas thereon,and wlin 1,e1 such work himscltnr thnntgh
fission employees,Provided transient improvements are nal intended or offered for NEW RESIDENTIAL ETECrft SQ IT.
sale.It.however,the building or Improvement is sold within yea <umpletiun.the SLIP"
QFT. :A S/SQ.h1'
owner builder wllba the bunion fpm tgthat l Ida Ionebuldr of p v f P,.,.,- _ �'/
Fos f le) TOTAL: M� 27
1 f the property exclusively contracting lh I can. J t o -m �1 Dry_
comarnalIh ronjectS 7044 Buitimi I itP !:a C,,.a.,I aC t t 1 . .' I - . 1 r, •j fIFW/•yY�
ran. I d marryt an fp Peny ro n le turner eJ 'PTY, _ r PLUMBING ILRMIT + I�f PBC
whoa tract f such projects ithacodtmetons)licensed pursuant t the Contractor's -- - '` s tt ��CUF+ AND
License I... PERMIT ISSUANCE X47{ 4�
❑ i ren exempt under Ser. .li&P C for this reason _
ALTER-DRAIN&VENT'-WA'I'F LISA) VALUATION
Owner Date i -
WORKER'S COMPRN$A'l'ION DECLARNI'[ON HACK PLOW PROI liCT.DEVICE
( I hereby alarm under parody of perjury one of the following declarations:
\ ❑I have and will maintain a Cenificme of Consenun self-insare for Warkers Compen- DRAINS-FLOOR.ROOF AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided forhy Section 3900 of the Labor Code,lot the perhanranw of the _ ,
work far which this peak is ismer. - FIXTURES-PER'rRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section -
3)011x1'the LahnrCcic,kit he performnnccofIlm work far which thispandit is issued. GAS-EA.SYSTEM-I INC.4 OUTTEAS OCC.GROUP APN
My Woreces Compensmion Irovmnce camier and Policy mother are:
Caren: Policy Nn: GAS-EA.SYSTEM OVER 4(PAT
CERTIFICATE.OI'EXEMPTION FROM WORKERSGREASIPINDUS1In.WASTE:INTERCEPTOR
COMPENSATION INSURANCE lit tI.DING DI VISION FEES
(Thissttlionnnvl not odcimplmeJ ifthe Permit is foronc huMmddollan(SIW) CREASE[RAP - - -
or lccsJ PLANCHECK FEIi c
I certify tborm the peroammuccut the work for which this permit in issued,Ishall SI?WER-SANITARY-SBt)RMEA.2WIel'.
not employ any person in any manner so as to become subject to the Workers'Compen I ENERGY ITE
,Z Nation Laws of Cvlibrmir.Date. WATER 1117ATER WIVENf/ELECTR
GRADING P
Z Applicant ) - FEE
NOTICE TO APPLICANT:If.after making this Cenificme of Exemption,you should N'A'I'ER SYSTRIFTREATING
F [t5or become object .,he Workers Compensation pookions of the Labor"e,ynu all SOILS PEE
la4a L.I forthwith comply with such prni'minna or Ibis pcona,hall hadcemedrevoked, WATER SERVICE
0
0,
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MH. SQ.FT. PAID
V MIhercby afUrm that lherc i.vaconMmdion lend'tagagemey home pedomwns.of Dam Receipt
the wmk for which this permit is issued(Sec.3097,Co.CJ
,O F 'TG'1'AL:
Deader's Name
r Lcnderc Address - TOTAL:
Q., I unify that l have read this application and nhon That the abase mountain.n Is t .. r ,• t 1 li❑ILDING FEE
F L nines,i agree to comply with all city and county ordinances and stale laws mlmingm QTY. r , MECIIANICALPERMIT t FEE riIr'
VZ building constriction,and hereby authorize representatives if this city to enter upon the
- s SEISk1IC1TE
ahova-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(Wc)agree m xavo.;ndcmnify and keep Imnnless nhc City of Cupeninn against Ii1.1?CI'I<IC FEF.
ALTER OR ADD TO MECH.
liabilities,judgments,casts and expenses which may in any way accrue against against said City
in consequcncc Of the gnmtin,i t'this Fannin PLUMBING PEE
APPT.ICAN'I' NDERSTANDS AND WILL COMPLY N'ITH ATI.NON-POINT AIR HANDLING UNIT('TO 10.010 CFM) MECHANICAL THE
SOURCE .G CATIONS.
AIR HANDLING UNLTQ)VER I Ijooa CFMIAq
CONSTRUCTION TAX
Signature pplicanUC tractor Date EXHAUST HOOD(W/DUCO HOUSING MITIGATION THE
I IAZARDOIIS MATT RIALS DISCI.OSLIRE
Will the applicant or future building occupant store(1r handle hazardous notarial II EATING UN I'T O 100,0100 BTU)
as def ned by the Cupemino Municipal Code.Chapter 9.12,and the Icalnh and Safety
Code,Section 2553200! 11HATING UNIT(OVER RNk11HO TO
❑Yes ❑No VENTILATION FAN(SINOLE RESID) PAID
Data Receipl0
Will the applicant or Toon.building occepaOr use equipment 0,"0...which BOILER-COMP(UTP OR I W,(ND BTUI
emit hazmnlons air cunmminams as refined by the tiny Area Air Quul fly Management "I'OI'Ai,:
District' 13011.ER-COME(OVER I W."BTU)
❑Yes [:1 No
I have read the hazrdous materials ramimments under Chapter 6,95 of the Cali- AIR CON In CONT;IT ISSUANCE DATE
former Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MUCH. SQ.FT
huilJingJws unl currently havmueaan,that in is my respamibility m ratify the ncapont ' /.
of the wriairemrs enwhich most la met prim m issuance mfr Cenancy
njcam Of Occup . w _ 'fir/
Owner or authurizedagenn Datc TOTAL' ISSUED Try.
OFFICE