29667 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY v -
CITYOFCUPERTINO BUILDING:ELECTRICAL. PERMITNO. 6^ ^6
BUILDING DIVI510N APPLICA7'IONIPERMIT PLUMBING..MECHANICAL
BUILDING PROJECT'IDENTIFICATION - 9 J v v
BUILDING ADDRESS:,- SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERS ER loo r N • YAC z�;C q ;
WNER'S NAME: •- - PHONE CONTRAC'FONS NAME: LIC NO:
E,11912,_�� N - L �•^ r i'` NIC CONTROLp
\ggccHITECT/ENGF)TER LIC NO: A R SS: -e S�ktyu ❑
CSR 6r 20000 i��J C WILWW J 9,
,CONTACT: ' PHONE: + BUILDING PERMIT INFO :
` •' -°)' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MP.0
❑. ❑ ❑ .
LICENSED tNSED CON'nRACTORS DECLARATION QTY. ELECTRIC PERMIT FEF: -
LV Z 1 hereby affirm i that I an fthe ed i J provisions oriCork, 9(commencing AOR DESCRIPTION \
wnhS n 7000)tit Division 3 flhc0 sines dProfessions Code and my license .t RESIDENTIAL:
❑O Ix PIiRMII ISSUANCE
n lull f J Ifcct. L11 �a'1
a U� Lccn Cl.v.c Ic.M v ❑SFDITI ', ❑PLUMKITCBNREMODF.h
F W DmcC m cClM - APPLIANCES-RESIDEN'I'IAI. " ❑AUDITION .. ❑PLUMBING RF PINI:
LIP
w 6 TRCHITLCI S DECLARATION
OonK I understand my plans shall be used as public records. PANELS ' ❑MULTI-UNIT ❑MODIFICATIO
_ MODIFICATION
UP TO 2110 AMPS
❑ - DI ❑CHIMNEY REPAIR
Licensed Professional _ 201-IIXNIAMPS IMPROVEMENT MPROVEMENT
IptcS.� OWNER-BUILUIiR DECLARATION OVER HXXI AMPS [-]BATH- - BATH REMODELIRE IR;CDEMOLITION
,c)w I thereby atrium hat l amt pal thContractorsIi L fn Oa
X( L follon6 e' (5 1 ]091 5 8 : a J P'f s. t:C I A Y C IY m nY 'SIGNS[I[,]iCfRICAL r' C OTHER
n1aRraw
which topmost a permit tt lir.improve,Jmla pair any:I clone
prion alisuonce els.req res lre.ppbce lforsuch perion tit flea signed statement SPECIAL CIRCUIT/MISE. r -
�)+ that he is licensed Pursuant to she provision.sof the Commerce'License Law(Chapla9
y'❑O (commencing will,Section 900(1)of Division 3 ofihe Business and Pi.fnomers Code)or TEMP.MITER OR POLE INST. - COMMERCIAL:
than he is Loom pt ahaefmm and the iasis for the alleged r.mat lion.Any violmbm.f ❑NEW BLDG/ADDITION ❑DEMOLITION
sp(, Section 7031.5 by Yapplicantri pc t tr t th no,li l a I ps IIY f POWER DEVICES
W^la "�' •[ TENANT t •".:! FOOD SH VICE
ynot o 'ban five eash.1 d II (55001 - �h -
6 �F I'Ih pop aY Y Ply tl g. a r IeL mpenvf t, SWIMMING POOL ELECI RIC IMPROVEMENT'.
y ❑
will Jo the A d(restructure kmuntended moffieredf rsI (Sec.7044,Business ❑OTHER
W and Professions Collo.The Contractors License law does not apply to an owner of OUTLOS SWITCHES FIXTURES
6 3^ property why funds or improves thereon,and whti does such work himself or through
his own employers,provided that such improvement arc not intended or offered for NEW RC•_SIDENTIAL ELECIR S 11 - n
sale.ILhowever.the buildingorintproveirena is sold wilhinoneyearofcomploom the -, SQ.FT.FLOOR AREA '~ LSQ.for
user,,-milde,will have the burden t p vin g that he did t bu'Id -
'rep ve for par
w nf.
` poal 7
❑1 f th property 1u.lusty ntmsl g with dcontractors tit
T 'Al, -
- const a theproject(Sec ]014 Business enJ P (e. n:Coda)ThC 1 t slot Q Of /s/T' 11 99 6
reares,Lawoe
dstm apply m an ownerof property who builds,, reproves thereon,enJ Tl'. PLUMBING PI2RMIT lz '7
whocommcumilaxh projects vithitemitatemor)licensedpursuamm the Contmanr's Uri L(jf•"
License Use PERMIT ISSUANCE _ Ci1QyV
Ej lam exempt under Sea ,i3 dtPCfdnhis redspn .n -
Owner - • Dt - - AI.TER- DRAW&VENT-WAI ER(EA), VALUATION ^
WORKER S COMPENSATION DECLARATION BACKII.OW PROTECT DEVICE. -
•IherchyuMo.under pecally.(penuryrte o din,followingd 1 t
�0 IhmeanJwFl nwrmaina Ceadcam of Co. tet-If .umf W k r C mcen DRAINS FLOOR.ROOF,AREA COND. STORIES E
ECONSTRUCI'ION
sa.on,as Provided for by Section 3401 of the Labor Code,for the cello-mance of the
work for which this permit Ts issued. PENT RES-PER TRAP
❑I have and will maintain Worker's Compensation Imsumnco,as require)by Section - _
3900of the LmhorC.Ay for th.performance of rho work for which lblspenoll is lssueol, GAS-RA,SYSTEM-1 OCC.OU'I'1.1?'fS WC.CHOUI' LAPN
- Myier:Worker's tiny Insurance carrier and Policy mmrherurc:' _ "
•
Carrier: s� �u.A� Tolley No.: GAS-13A.SYSTEM OVER4[EA) „
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE J GREASEYINDUSTRL WASTE INTERCEPTOR(Thissemina need not be completed ifthe ceraia is future hundred dallier,(S Elf) BUILDING DIVIEES
or less.) ' GREASF:TRAP - PLANCHECK FP.E'
Iceaifytha intheperformuncenl lhrwark fnrwhich this permit isissucJ;Lshal
SEWER-SANITARY-STORM EA.2001"E.
nlnempl.y.eycernen in cony on
e. abrot i ha Workers'Cmohom- - ENERGY PEE -
,Z moon laws of California.Date /VF.M'AiL1iLTR
z O Applicant WATER HEATER W
- -- _ GRADING FEE
` NOTICE TO APPLICANT:IL a0er making this Certificate of Hoempaion,you should WATER SYSTEM/IRF-ATING
f,
become subject to the Wok Compensation previsions of the Labor Cade,you must SOILS FEE
forthwith comply with such previsions or this Permit shall be deemed revoked. WATfR SERVICE
Z) ZsU0 ,,CONSTRUCTION m LENDING AGENCY NEW I<CSIUI:NIIAL PLMIi. SQ1i',
' Ihmeby ul Urm flim there tcuconswclion letahn,ir,rucy lot the perfmmm�m of Dam'" Rewiptk
W F the work for which this permit is issncd(Sec.3097,Civ:C.), -
0 U Lenders Name - TOTAL:
1<nders Address TOTAL:
H0. I really that F have read this application and sure that the above information is BUILDING FEE
N . QTY. MECHANICAL PERMIT FEP
U huildingcomfominn,and herchy amhlrizc rrprecentmivcs of this city aoentcr upon Ilia SEISMIC FEE
above-mentioned prolsAy for inspection pusposds.- . s - pERMI'E ISSUANCE
(We).'rice m save;indemnify and ml
keep hilesv'ihe City of Cupertino"gain's ELFCTRIC FEE
Iiabilities,judgmcnts:colts and expenses which may in any way accrue against said City 3 ALTERORADDTOMECIL
inO -
nsequence of the gmndng of Ihis pennil. PLUMBING FEE-
,• APPLICANTUNDERSTANDS AND WILT , PLY WITH ALL NON-POINT pIR 1{ANDLING UNIT('TU IO,fX1pCFM) ^ �k
SOUR E LATIO MECHANICAL FET? * V
AIR HANDLING UNIT(OVER I0Tf 0 CPM)
zt" CONS'rRUCTIONTAX 5
Slgnn of want _oniracmr Dme EXHAUST HOOD(W/DUCI) HOOKING MITIGAI'IUN FEE
AZARDOUS MAIERFALS DISCLOSURE '
WilFtheapplicanl in future building oecupanasme,tor handle harallous material HEATING UNIT TO INMXXI BTU)
as defined by the Cupertino Muni I Craft.Chapter 9.12,and the Health and Safety -
Code,Section 25532(a7? / - HEATING UNIT(OVER 100000 BTU)
Yes Jtq'4•'C' - - PAI I)
- VF.NTILA'I"ION FAN(SING I.E RESIU) Dmc . -" ReceiplN .•
Will the nppliwtiI or future building rompma uee.gmpmenl or devices which, BOILER'_COMP(3HP OR I W),000 BTU)
'mit District?
us air comaiitinans ax delmeJ M1y she Bay Area Air Quality Mnnagonem TOTAL,
District? '=Y.(`"// .
❑Yei - BOILER—COMP(OVER I(q,I101)BTU)
I have rcetl thehazardous s AIR CONDITIONER
requirements an 1551pie 695 of ifthe .ISSUANCE DATE
fore i Health lth no Safety CW Sevier,-oa 255(15 25511 115514.1 d t d that ifthe
I - NEW RESIDENTIAL MUCH. SQ FI'.
htild'ngd t curiously oln it. II y bl)fi rally Ila
of the req memo wh ch usl M met pr nn e rift Cen t f O cdputcy `
Owne th.naerlogenl Dane >T \ ISSUEDBY:
OFFICE