S 4216 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL PERMITNO.
CITY DI C DIVISION
NO S 4 216
BUILDING UNISION APPLICATION/PF.RMIT PLUMBING RING-MECHANICAL
BUILDING PROIECI'IUENI'IFICATION
HUILDINGADDRESS: ( SANITARY NO. APPLICATION SUBMITTAL DAT
io400 N . aNTAv � z 8 9 P
OWN° 'S NAME: PIIUNE: CO 'TRACTOR'S NAME: LIC NO'.
1
fJFij' /ENN/C CON'1'ROI,...a���fff
RG 'ER: 'LIC1iOi�S ADDRESS', ID`
_ COINTTA : PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDg] ELECT PLUMB MEC
LICENSED CONTRACI'OR:S OLCLARATION QTY ELECTRIC PERMIT FEE ItJ�
1 hereby af0nn that 1 am license]under previsions of CM1apmr 9(commencing JOB DESCRIPTION
��Z with Section 7000)of Division 3 of the Business and Professions Cale.and my license is R
PERMITISSUANCE
zw� in full tome and ellen. WI. [I KITCHEN REMODEL
QUI" License Class LIC.# APPLIANCES-RESIDENTIAL. ADDITION [I PLUMBING RE-PIPE
N6 plans ad Date�^ —Contractor
❑w :SDECLARATION VAPANELS ❑MULTI-UNIT ❑STRUCTURAL
F w Z nJcrztanJ nsY .null 'c record. MODIFICATION
GP'rD 21XIAMPS
OZEn-a E][NJ CRIOR ❑CHIMNEY REPAIR
r.t3 I=Iq iJ 201-100IAMPS IMPROVEMENT SWIMMING POOLS
WNEWH DER OBCLARATION OVER IIXM)AMUS [IBATH REMODELBtEPAIR Q DEMOLITION
Q 1 hereby a1Rmr that 1 um exempt from the Cnnvacmr's License law for the
X U following reason.(Section 9031.5.Business and Professions Code:Any city m county SIGNS ELECTRICAL El OTHER
ul 3 a
cv~ei which requires a permit to construct,alter,improve,demolish,or repair any situation,situation,F� J prior to its issuance,aHo requites the applicum rorsoch Penni ds Fit easi'mod,a erman SPECIAL Cl RCUGUMISC.
ac � that he is licensed pnrw ire in the provi mo of the Cormi License law[Chapter 9
7'gMC Iamuncreing with Section 01%X11 of Divieinn 3 oft he Business and Prnfeasion.Code)nr TEM P.M LI'ER OR VOLE INS]. COMMERCIAL'
2 q pa g than he is exempt thtmiium and the basis Ea Jin alleged exemption.Any oblation of L3 NEW Ii1.DGlAUUITION ❑DIiMOLI'f10N
iC_W Section 90315 by any applinnn fan permit eubjcele the applicam to it civil penalty of POW HR DEVICES
nt more than live hundred dollars lSSlXp. Kj .:WANT FOODSERVICE
F=QI,as owner oldie norm Inees will,we their compensation. SWIMMING TOOL ELECT RIC OTHER IMPROVEMENT
0 ❑ prose c Yemp y gcs us penes ❑OTHER
(. will dothewore,and then a Conn ot un,intendedoroffered snot apply in an.Boniness
C3 m and profanity
who
molds
or iImp Contnemr's License law ares not apply u,if owner of ` OUTLE-fS-SWITCHES-FIXTURI!S
his own who builds or improves thereon.and who does m n work himself of through
his own employees,provide]the,such improvements am not iyearof pla
or mBereJ for NEW RESIDENTIAL ELECTR SQ Fr.
sale.If,howcon,he nuiWing or improvement is sold wiehin one year of con, ion,the SQ.Ff.F �RARBAEISQ
nbui Orr will have the burden of proving that he did not build or improve for par- E
❑h as owner of the Pmpeny,hat exclusively mmvuding who Eecnred mnlmelom to it
msvuct the project(See.9114,Business and Professions Cade:)The Contractor:Li-
c w awdoes not apply toanownerofpropertywho build%orimproves themn.and QTY PLUMBING PERMIT FEE ;r Jul- 1919 39
Ut
who contracts for such projects with a commemr(s)Itcen.wd pursuant to the Contractors u
License law -RMITYSUANCE
0 1 am exempt under Sec. .B se P C for this reason
L -DRAIN&VENT-WATER(EA) VALUAT[ON
lwner Date B
WORKCR'S COMPENSATION DECLARATION IAC LOW PROTECT.DEVICE �J—
I hereby ul'llrm under penalty of periury nuc of the following dedamennr
Ihaveand will mainlainaCenifcateofCensvnuoselFinsurc for Workers Cnmpctr DRAINS- )OR.ROOF,AREA,C NU. STORIES 'I'YVF CONSTRUCT IOP
cation,to provided for by Section 3]110 of the[Ago,Qdc,for the performance of the )
wo for which Nis puma is issued MTRAP \.3
A N
I have and will maintain Workers Compensation Insurance,as required by Section
ofthe Labor Code,ba the pcommence ofthe work for which this permit is issued. C.JQ S up
My
AVN�3
My Worker's ComIgninnan Insurance carver and Policy number arc:
Caricr: Policy No.: VN fCA) d
CHRI'IPICU 17 OF EXEMPTION FROM WORKERS' AS'I'I.IN'I'IiRCEPf(
COPFNSA'I'ION INSURANCE BUILDING DIVISION FRCS
(Ihiswetion need not be completed it[lie penttol is for hundred dollars IS l W)
nr Imc.7 VLANCHIECK FEE
I certify that in the amformanceofla,work for which me,permit is ismed.[,hall -STO .200!1'.not employ any person in any mannerm as ms become subject to the Workeri Compcn- ENERGY FEE 2 Q
ZIZ nation laws of Calarpro .Date WATER HEATER WNFM/ELECTR GRADING
O Applicant Iqd
.N. NOTICE TO APPLICANT:If,after making this Cereifeate of Exemption,you should WATER SYSTEMGFREATING
a , become subject m the Worker, mpe
's Cunxation provision%of the Labor Gyle.you inti, SOILS FEE
W bmhwith comply with xueh provisions or this permit shall be deemed ur,aked. WATER SERVICE
n' CONSTRUCTION LENDING AGENCY NEW RI!ti1DEYr[AL PLMH. SQ.FT. PAID Doe Receipt#
U0 thereby affirm Red there is a constmnion lending agency for the performance of
H. I"' the work for which this permit is issued(Sec.3097,Co.C.) f I.OTAI
C U Lcndcr's Name
TOTAL:
bender's Address
r S I certify that I have read this application and state that the above information is BUILDINGEEi
.Ha h comp,.I agree u,comply with oll uy and county ordinances and stale hewn relating to QTY. MECHANICAL PERMIT FBE SEISMIC 311
U Z huilding cmn,nnunin i.and hereby man... ereprenenwlivea ol',hi"i'ym ane,upon the
uhava-memionedproperty Lorinxpeaimnmapow, PERMIT ISSUANCE P.LECTRICf'E SD
(We)agree In save,indemnify and keep harndess the City of Cupertion against
Iiabili,ies.judgmmix.v,stsandespenwswhich may many way acemeagairm said City ACT ER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDER WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM) MECHANICAL.FEE
SOURCE. EGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
.tgnuuuc of Appt . mmcnx
nom EXHAUST 1 IOOD(W/DUCK HOUSING MITIGATION FEE
DIII15 ERIALs DISCLOSURE
Will the applicant or Wmre beakingoccupumeblfem handle memolom material HEAPING UNIT(TO 100,000 13 1 U)
as deintal by the Cupertino Municipal Coda Chapter 9.12 and the Health and Safety
Cale.Section 2553200? HEATING UNIT(OVER 110,000 B'IU)
•
C)Yes 'Wo VEND[LAT10N FAN(SINGLE RESID) PAID
Doc Receipt p
Will the air contaminants
m future defined by the[l y A equipment or devices which BOILER-COMP QHP OR 1 03,000 BTU)
mit hmallous air antantit future building
by the Hay Arca Air equipment
or
devices
mem TOTAL.
District? BOILER-COMP(OVER Iko'kaI if I J)
E]Y.
I have real Be lmvardous materials rm under Chapter 6.95 of lac Cali AIR CONDITIONER ISSUANCE DATE
�nircme 7 2� 7, P
forma Health&Safety Code Sections 255(15.25533 and 25534.1 understand mm if the NEW RESIDENTIAL MECH. SQ.Fr.
buildingd snot curcnJynavenem .my renponsibiliy to notify ehe occupant
of them , ntc which mus "mance of a Certificate or(X upalKy
woe •d r D, c TOTAL: ISSUED BY7�2 :
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL PERMITNO.
CITY DI C DIVISION
NO S 4 216
BUILDING UNISION APPLICATION/PF.RMIT PLUMBING RING-MECHANICAL
BUILDING PROIECI'IUENI'IFICATION
HUILDINGADDRESS: ( SANITARY NO. APPLICATION SUBMITTAL DAT
io400 N . aNTAv � z 8 9 P
OWN° 'S NAME: PIIUNE: CO 'TRACTOR'S NAME: LIC NO'.
1
fJFij' /ENN/C CON'1'ROI,...a���fff
RG 'ER: 'LIC1iOi�S ADDRESS', ID`
_ COINTTA : PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDg] ELECT PLUMB MEC
LICENSED CONTRACI'OR:S OLCLARATION QTY ELECTRIC PERMIT FEE ItJ�
1 hereby af0nn that 1 am license]under previsions of CM1apmr 9(commencing JOB DESCRIPTION
��Z with Section 7000)of Division 3 of the Business and Professions Cale.and my license is R
PERMITISSUANCE
zw� in full tome and ellen. WI. [I KITCHEN REMODEL
QUI" License Class LIC.# APPLIANCES-RESIDENTIAL. ADDITION [I PLUMBING RE-PIPE
N6 plans ad Date�^ —Contractor
❑w :SDECLARATION VAPANELS ❑MULTI-UNIT ❑STRUCTURAL
F w Z nJcrztanJ nsY .null 'c record. MODIFICATION
GP'rD 21XIAMPS
OZEn-a E][NJ CRIOR ❑CHIMNEY REPAIR
r.t3 I=Iq iJ 201-100IAMPS IMPROVEMENT SWIMMING POOLS
WNEWH DER OBCLARATION OVER IIXM)AMUS [IBATH REMODELBtEPAIR Q DEMOLITION
Q 1 hereby a1Rmr that 1 um exempt from the Cnnvacmr's License law for the
X U following reason.(Section 9031.5.Business and Professions Code:Any city m county SIGNS ELECTRICAL El OTHER
ul 3 a
cv~ei which requires a permit to construct,alter,improve,demolish,or repair any situation,situation,F� J prior to its issuance,aHo requites the applicum rorsoch Penni ds Fit easi'mod,a erman SPECIAL Cl RCUGUMISC.
ac � that he is licensed pnrw ire in the provi mo of the Cormi License law[Chapter 9
7'gMC Iamuncreing with Section 01%X11 of Divieinn 3 oft he Business and Prnfeasion.Code)nr TEM P.M LI'ER OR VOLE INS]. COMMERCIAL'
2 q pa g than he is exempt thtmiium and the basis Ea Jin alleged exemption.Any oblation of L3 NEW Ii1.DGlAUUITION ❑DIiMOLI'f10N
iC_W Section 90315 by any applinnn fan permit eubjcele the applicam to it civil penalty of POW HR DEVICES
nt more than live hundred dollars lSSlXp. Kj .:WANT FOODSERVICE
F=QI,as owner oldie norm Inees will,we their compensation. SWIMMING TOOL ELECT RIC OTHER IMPROVEMENT
0 ❑ prose c Yemp y gcs us penes ❑OTHER
(. will dothewore,and then a Conn ot un,intendedoroffered snot apply in an.Boniness
C3 m and profanity
who
molds
or iImp Contnemr's License law ares not apply u,if owner of ` OUTLE-fS-SWITCHES-FIXTURI!S
his own who builds or improves thereon.and who does m n work himself of through
his own employees,provide]the,such improvements am not iyearof pla
or mBereJ for NEW RESIDENTIAL ELECTR SQ Fr.
sale.If,howcon,he nuiWing or improvement is sold wiehin one year of con, ion,the SQ.Ff.F �RARBAEISQ
nbui Orr will have the burden of proving that he did not build or improve for par- E
❑h as owner of the Pmpeny,hat exclusively mmvuding who Eecnred mnlmelom to it
msvuct the project(See.9114,Business and Professions Cade:)The Contractor:Li-
c w awdoes not apply toanownerofpropertywho build%orimproves themn.and QTY PLUMBING PERMIT FEE ;r Jul- 1919 39
Ut
who contracts for such projects with a commemr(s)Itcen.wd pursuant to the Contractors u
License law -RMITYSUANCE
0 1 am exempt under Sec. .B se P C for this reason
L -DRAIN&VENT-WATER(EA) VALUAT[ON
lwner Date B
WORKCR'S COMPENSATION DECLARATION IAC LOW PROTECT.DEVICE �J—
I hereby ul'llrm under penalty of periury nuc of the following dedamennr
Ihaveand will mainlainaCenifcateofCensvnuoselFinsurc for Workers Cnmpctr DRAINS- )OR.ROOF,AREA,C NU. STORIES 'I'YVF CONSTRUCT IOP
cation,to provided for by Section 3]110 of the[Ago,Qdc,for the performance of the )
wo for which Nis puma is issued MTRAP \.3
A N
I have and will maintain Workers Compensation Insurance,as required by Section
ofthe Labor Code,ba the pcommence ofthe work for which this permit is issued. C.JQ S up
My
AVN�3
My Worker's ComIgninnan Insurance carver and Policy number arc:
Caricr: Policy No.: VN fCA) d
CHRI'IPICU 17 OF EXEMPTION FROM WORKERS' AS'I'I.IN'I'IiRCEPf(
COPFNSA'I'ION INSURANCE BUILDING DIVISION FRCS
(Ihiswetion need not be completed it[lie penttol is for hundred dollars IS l W)
nr Imc.7 VLANCHIECK FEE
I certify that in the amformanceofla,work for which me,permit is ismed.[,hall -STO .200!1'.not employ any person in any mannerm as ms become subject to the Workeri Compcn- ENERGY FEE 2 Q
ZIZ nation laws of Calarpro .Date WATER HEATER WNFM/ELECTR GRADING
O Applicant Iqd
.N. NOTICE TO APPLICANT:If,after making this Cereifeate of Exemption,you should WATER SYSTEMGFREATING
a , become subject m the Worker, mpe
's Cunxation provision%of the Labor Gyle.you inti, SOILS FEE
W bmhwith comply with xueh provisions or this permit shall be deemed ur,aked. WATER SERVICE
n' CONSTRUCTION LENDING AGENCY NEW RI!ti1DEYr[AL PLMH. SQ.FT. PAID Doe Receipt#
U0 thereby affirm Red there is a constmnion lending agency for the performance of
H. I"' the work for which this permit is issued(Sec.3097,Co.C.) f I.OTAI
C U Lcndcr's Name
TOTAL:
bender's Address
r S I certify that I have read this application and state that the above information is BUILDINGEEi
.Ha h comp,.I agree u,comply with oll uy and county ordinances and stale hewn relating to QTY. MECHANICAL PERMIT FBE SEISMIC 311
U Z huilding cmn,nnunin i.and hereby man... ereprenenwlivea ol',hi"i'ym ane,upon the
uhava-memionedproperty Lorinxpeaimnmapow, PERMIT ISSUANCE P.LECTRICf'E SD
(We)agree In save,indemnify and keep harndess the City of Cupertion against
Iiabili,ies.judgmmix.v,stsandespenwswhich may many way acemeagairm said City ACT ER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDER WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM) MECHANICAL.FEE
SOURCE. EGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
.tgnuuuc of Appt . mmcnx
nom EXHAUST 1 IOOD(W/DUCK HOUSING MITIGATION FEE
DIII15 ERIALs DISCLOSURE
Will the applicant or Wmre beakingoccupumeblfem handle memolom material HEAPING UNIT(TO 100,000 13 1 U)
as deintal by the Cupertino Municipal Coda Chapter 9.12 and the Health and Safety
Cale.Section 2553200? HEATING UNIT(OVER 110,000 B'IU)
•
C)Yes 'Wo VEND[LAT10N FAN(SINGLE RESID) PAID
Doc Receipt p
Will the air contaminants
m future defined by the[l y A equipment or devices which BOILER-COMP QHP OR 1 03,000 BTU)
mit hmallous air antantit future building
by the Hay Arca Air equipment
or
devices
mem TOTAL.
District? BOILER-COMP(OVER Iko'kaI if I J)
E]Y.
I have real Be lmvardous materials rm under Chapter 6.95 of lac Cali AIR CONDITIONER ISSUANCE DATE
�nircme 7 2� 7, P
forma Health&Safety Code Sections 255(15.25533 and 25534.1 understand mm if the NEW RESIDENTIAL MECH. SQ.Fr.
buildingd snot curcnJynavenem .my renponsibiliy to notify ehe occupant
of them , ntc which mus "mance of a Certificate or(X upalKy
woe •d r D, c TOTAL: ISSUED BY7�2 :
OFFICE