94120042 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY �li��' WR N)C4e
CITY OF CUPERTINO ]III MB ISI:-MIlCI I'UCA6 I'IiHMII'NII.
IIUILDIN'O DIVISION APPLICATION/PERMIT PLt1MItiNG�\t ISCIIANICAI.
I41111,IIING 1'xUJY:1;T IDENrIPICnI'ION
BUILUINGADDRESS: SANIFARI'Nll. AI'I'I.ICATIONSUIIMI'1'I'AI.S)AI
OW AWAME:�M PHONE: CONTRACOIS NAMEO:: LIC N
\V/ -Y NIC Cl]NI'kULa
nRCCHITECI'/ENGINIi BO: Y v LIC N(l: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
rY� C/,��3e_C I-f ❑ Consultant Fec,Paid by Applicant(Initial) HLIx' Ii1.liCr PLUM MIiCH
t' `1V� ❑
LICENSED CONTRACTORS DECLARATION QTY CT
ELERIC PERMIT FEE
I hereby affirm Shift I...licensed under provisionsof C11apter 9(commenting JOB DESCRIPTION
M=Zwith Section 7000)of DivixionJnfthe Business and Professions Crde,and my license is RESIDENTIAL:
,05 PERMIT ISSUANCE
f-� in full force unit effect. ❑SFDWL KI'1'Cl1EN REMODEL
QUV Licenve Class Lica APPLIANC17S-BESIDES I IAL ❑ADDITION C1 PLUMBING RE-PIPE
F Z W Dale Cinnamon
mQa ARCHITECT'S DECLARATION ❑MULTI-UNIT' ❑STRUCTURAL.
O too Z 1 undcc.mad my plans shall be used ns P.hire rtcords PANELS MOUII4CAllON
ZO Z�G US' 200 AM I'S ❑INTERIOR ❑ClCI HNINEY REPAIR
F`~W Licensed to lessionm 201-10(ROAMIS [Mpg( ?MhN'r []SWIMMINGPOOIS
(IWNIiR-11111LIlEH DECLARATION OVER 1000AMPS ❑HAI'll kriM(1DIiIJREI'AIR El DEMOLITION
G P'I Q I hemb alllnn that I an cxatipl fro t the Centraaods License Law form.
7pC. cc U hdlbwing rwnnn.(Svroon]131.5,BuoincFs and Pre esuions Code:Any city or county SIGNS I!LEC IRICAL OTI{BR
m w W which regtam,a vo.it to cmutmcl.after,'Improve,demolish: a
or repair any stmmc
OoA Son Ina,i...ac,c.id...reclaims the PPI' ,fimorhva n fl .gnond,tamincut SPECIAL CIRCUfr/MISC.
E' N moth I Ip : II tl p Ith C i' i "1 La (Ckaptcr9
u�aQ� COMMERCIAL-:
WF�O (commencingwih$cU tn9lXXq of U\wnl flhc Rusincxaand l4 f. ns Cnde)Or rC,MP M17 ER POI.Ii INSI'.
d LL ay Lha he is exenlpl Sherefm0 and me basis Lor the alleged exempoon.Any violatinn Of ❑NEW BLDG/ADDITION ❑UIiM01.1'I'I(1N
�mNSection 9(1]1.5 by any applicant for a pencil oihpem the applicant to a civil penalty of POWER DEVICES ❑TIIJANT EI 1-001)SERVICE
an mom than five hundred dollars(851X). IMPROVEMENT
=O F)1,asownnro
edtheppert or my emes ployewith w.gcsas their sole compensation. SW'IMMINUEYCLELFCOOC
C3 OTHER
F will dtIDe work.and the sencome is not intended-offerell for sale Nee 7=,Business
Wand Prnfchsions Colic:The Cuumucnh License Law does not apply Io an owner of ONt.ErS-SWI'rCl11LS-PIX9VHE5
St.3 property who builds or improves therton,and who does such wads himself or through
his own employees,providal that.such improvements are not intended or offered for NEW BEST DENTIAL ELECfR SQ IT. SQ,IT.FLUOR AREA LSQ,rL
sale.If,however,the building or improvement is sold within one year of completion me
neo-builder will have the burden of proving Lha he did not build or improve for par-
�wromTOTAL:
Of the Pmpeny,ton caduzively contracting with licensed rontracbnrs Ito
construct the project(Sec.71bf4.Business and Professions Cade:)The Contractors Li-
scLaw does not apply toanowner of property who builds or improves thematic and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursuant to me Contractor's
License I.ons I PERMIT ISSUANCE
Ianu�exempl tyy�er�Se1C Flat, ar ac^/,a1 Cf his ALTER-DRAIN ar VENT-WATERSEAL VALl1A1'1(1N
' U'
V F
T/ WORKERSCOMPENSATION DE CLARATION HACK PLOW PR(YFECT.I DEVICE /00
1 hereby Al ami under penalty of perjury one of the following declaraWork,,tI Crimper.
C/
Ihuvc and will maintain uCcnifientc of Conscni nn self-ireure for Workeis Compcn- DRAIN$-FLOOR.ROOF,AREA,COND. tir 1115 TYPIi CONS'FRUC'Il0
anion,ie prnvit a to by Section 3]mI of the Labor Code,lot the Nrfomtance of the
work lin which this,Kraut o Isamd. FIXTURES-1'ER'TRM'
S I have z 1 di '.t W k ;Coolpenotion Instracce,its required by Section
3700 rt I h C 1 1 tl Tref ' rtM1 kfor wl hth'.p )isissuul. GAS-HASYS'IEM-I INC,4 OUTLETS OCC,GRO UP �AP
N�
My Workers Compensation'lastrancecourricrandl I' Y nib GAS-HA.SYS FILM-OVER 40:A)
Carrico policy No.:
Cliff]IIICAT Ii IIP EXEMPT ION FROM WORKERSGREASIVINUUS I'RI,WASTE INTERCEPTOR
COMPINSA'L'ION INSURANCE BUILDING DIVISION I I H
('Buis section need not be coundemdifthe lrnnil isf ne hundred dollars(511X) GREASE'IBAP
or Icss.l PI.ANCH1iCK Hili
Iceniiythe,in She lefulnmme of the work for which this permit is icmed.I shall SEWER-SANI'T'ARY-S I ORM IIA.200 FE
not employ any penin in any manner so as to Meonm subject1.the Workcrs''Compcn- ENERGY I'ILii
Z scion laws of California.Dae ENEWRr-SIDIiN+FIAL
ATCR WNUISTI iLECIR GRADING FEE
zO Applicant 1
N NOFICETO APPLICAN-1':IL after making this Cenificam of Exemption,you should S1MMIERIiAFING SOILS FHE
hecmne subject to the Workers Compensation provisions of me"For Cade,you must _
forthwith comply with such provisions or this perms shall be deemM revoked. RVICE I\
QPAID n
a
CONST RUCTION LENDING AGENCY PUBS SQ. l� I �. pale Rettipla
V Q IhaeM1y off rm thauhere isattmewaion lending agency for the performuntt of IN
[2. F-' the wmk for which this permit is issued(Sec.3097.Civ.C.) 1 f
OL.eni Name 'OTAL:
C.1 TL:
Lenr's Addmss
de
1 cenify that 1 have mad this application and tlate that the above information is BUILD viz.
f{" 6 TY MECIIANICAI.PERMIT FEE
FrN correct.l agree In comply with all city and county ordinances and state laws relatin Io Q SEISMIC Pr:E
V Z building construction,and herchytnthon'ee represumatives ofthis city to enter upon the ^, —
ab4sonmmioned pmperly lir inspection purposes. PERMIT ISSUANCE C4FeQI�RIc.Ii;P.
(We)agree w save,indemnity and keep harmless the Clty of Cupertino against
Iiabilities,Juicro%andexpenses which may in any way acemeaSuinsl said City ALTER OR ADD'IO MECIL PLUMBING ITEIS
In eonsequcnce of the granting al This permit.
APPL1CAN'I UNOEKS'SANDS AND WILL COMPI,Y WI TH ALL NON-1'OINI' AIR HANDLING ON]'1'('1010.00I CFM) MIiC11ANIG1.Plili
SOURCE REGU A'1'IUNS.
C{66 � AIH HANDLING UNI HOVER IU INIU CFM) CONS'1'ItI1CTl(IN'I'AX
r,naw�,A AP is:nu/(imtmcmr Uum EXHAUS'I'HOOD W/DUCI) HOUSING M lrllGA'llONl7EE
IIA%Ali UOUS MATERIALS DISCLOSURE
WIII She applicant nr future building omupant slam nr handle bamrdous materiul I IEATING IJNI'i'(FII loo'nod it I'C)
uX brncd by the Criterion Municipal Codc,Chim¢r 9.12,and the Heailh and Safety UEATING UNIT'(OVER 100,000 B'L'US
Code.Section 25512(.)'!
C3 YO, Fl No V17NTII.A'I'SON FAN(S INGLE RES1D) PAIS)
Duro Recelpla
Will the applicant nr Iutum building srcuponl use equipment to devices which BOILER OR IFF,0(XI BTU)
'nin hamNous air amtanuinants us defined by the Bay Area Air Quality Management 'I OI'AI.:
District! BOILER-COMP(OVER I00.IXI)BTU)
❑Yes ❑No
I havc¢:W the hamrdws mamd'uls requirttmnts urMer Chu(xer695 nlme Culi- AIR CONpI'I'UNER ISSUANCE DATE
Tania Heald R Safcty Coale,Sections 25505,15533 ad 2550.1 understand ma if the NEW RESIDEWFIAL MECII. SQ.FT.
building Mos m currently have a tenanl,and it is my rtsPmsibility m notify She occupant G aP
of me rtqui frau w icb nicer I pmm m issuance into Cenificam of OcypamCy.
nororieeJ agent
Date TOTAL: ISSUED BY:
OFFICE