S 2182 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OH�CUPIdRTINO BUILDING-ELECTRICAL PE IT NO.
6UII.DINV,DIVISION APPLICNHONIPER• PLUMHING-At1:CHAN 'A6 2182
BUILDING PROJI:CI'1DENI'IFI"THEN
PIU BLUING ADDRESS: SANITARY NO. APPLICATION SUBMUTALLATF
10 S• l�crllt Li uJD F-fir (:517
'WNER'S NAME: PHONE: CONBACfOR:S NAME: LIC NO:
NIC CONTR IL•p ,�
OCHE ECT/ENGINEER: J 'LIC.NO: ADDRESS: ❑
iz m
CONTACT': PHONE:: BUILDING PERMIT INFO
U 1 I �� ❑ Consultant Fees Paid by Applicant(Initial) HL❑DO ELECT PLU❑MH MULCH
ED
LICENSED CONTRACT'OR'S DECLARAI ION QTY ELE(,`TRIC PERMIT 171317
1 hereby ofern that 1 am licensed under provision,of chapter 9(commencing JOB DESCRIPTION
Owith Section 7"Lif Division 3oDue Bminet,a.J Pmfesxlont Code,mal license RESIDENTIAI.:
coO O PERMIT ISSUANCE:
C�� in all,blec ,ClassUnve d,IRCL 0SFDWL O KITCHEN REMODEL
.eUU lacense Class Lia.M
r Zulelsl. Dam Coatroom T
APPLIANCES-RISIDEN[Al. ❑ADDI'TION [_1 PLUMBING RE-PIPE
ARCHITECT'S DECLARAIBON PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Fl,,z
O__14—a lun(tcnlnnJ my plum shall led wed n,pontic records MODIFICATION
UP T02(xIAMPS ZD ❑INTERIOR El CHIMNEY REPAIR
[-4 t:W LittnmJ Professional 201-I(xx)AMPS IMPROVEMENT 0SWIMMING PODS
.4,F,, OWNER-BUILDER DECLARATION OVER I000AMPS El PATH REM EI/REPAIR ❑ EMOLITION
C a' 1 hereby a0'irnt that I um exempt shim the Colnew on',Lilimis,Law for Oa
x�x O d Ufollowing reason.(Sector.]031.5,Business and Protections C:wte:Any oily m county SIGNS ELECTRICAL C3 OTHlilt
W a O
F.
which requires a Permit to comouct,alter,improve,demolish,or repair any structure
sq. fV
prior In lLr iss.smv.11w,requires the applicant r..saehpermit in fileaegnedanmtnnce SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractors License Low
(Chapter v
W tall (comucal,og with Seetion 9000)rf Division 3 offle Business and Profession,Core)nr TEMP.MFER OR MOLE INST.
E E c that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
W^ Section 9031.5 by tory opplicnnt In,apennil subjects thcapplicunf to a civil penalty or POW(?R DEVICES ❑TENANT 0FOOD SERVICE:
m tome than Eve hundred dollen(b5g8.
F_Zi• OTHER EMf:N'T
< 0 Lo the work,the pmpeny,rr myemntendes widtwages...Irrsnlec0mpcmairn, SWIMMING POOL ELECTRIC
pS.m will dr the con,and the iI he aunt is no",Lecteeed L w slo.areata pply In an owner st ❑OTHIift
and property
who b Gs or
p Cnnbhereva Llacn,e Low s such
not apply s if owner rf (IUTLGTS-SWI"1'CIIGS RES
his own who hails,or impmves thereon,and who Docs such wnrk himself m through
his own employees,e provided that such improvements are not intended or offered for NEW RESIUEN'1'IAI.ELI. R SQ
sale,ILhowever thevilte maneonate,of proms itat,add diM1ino rudeornprove lot'he S OORAREA LSQ.FT.
•ElaiWer will Hove the)oaten of Pnwirg Inas he eon nm Hued or Improve lot poli-
�yncortnle.).
q 1.as owner of)he pmpeny,at exclusively contracting with licensed contractors to t
(c aunt the pmjeel(See.7(A4,Business and Professions Code:)no Comracmrs U.
enewe Low decision Opply to unownerol'property who buildxor impmves thereon,and QTY. PLUMBING PFRMIT
who contracts for such projects with a cotnmctons)licensed pursuant othe Commercial's
License Law. PERMIT ISSUANCE.
I ant exempt under Sec. ,E&PC Gu this rcu.nn
ALTER-DRAIN&VENT-WATER EA) VALUATION
x Doc
WORK R'S COMPENSAr DECLARATION HACK FLOW PROTECT.DEVICE
I hareby affirm under penally of penury ratio [in following deelamrom:
OR Ileveand will maintain a Cenificamrf Caused,loself-intoe for Worker's Compen- DRAINS-FLOOR,BLUE AREA,COND. $T'ORIES TYPE CONSTRUCTION
.ration,as provided far by Section 370d).1 the Irby Cade f n the performance of flue
work for which this permit is issued. FIXTURES-FEET RAP
0 1 have rad will naiatim Worker's C'oniper smain In....mr,ns required by Secure,
3700cwthe LabalCedc.fmlheperformancenfthc walk for which mixpcnnit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Polley No.: GAS-EA.SYST1:M"OVER J RoG
CEKI'IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASP%1
BUILDING DIVISION(LES
('(Tis section need not he completed if the permit is for one hundred Anllars ES 100) GRGASB'f P
nr lees.) PfANCH1eCK FEE
I certifytbaliathepoinninanceol'the work far which this permit isi.sseed.L shall SEWER-S. r RY-S'TURM M.200 IT
not employ any Person in any manner so as to)emnr
)emote subject the Workers'Compete ENERGY FEE
Oz .,.torn Laws of Colonia.Data WATER HIu W ,F. R4 MU
zQ Applicant
w/x-• GRADING FEE
y
NOTICE 1-0 APPLICANT It.niter making this Ccnidmm nl Exemption.you should WATER SYS /I BEATING
f^ become subject m the Workers Compensaion provisions of the Labor Code,you must SOILS PEI:
W _s forthwith comply with such provisions or this pennil shall be(teemed revnk,J. WATER SER 1
Q
7z CONST RUCTION LENDING AGENCY NEW RE.SID SQ.PP. PAID
V O I hereby affirm ther there isocomreaction lcndingagency for the perfrrmancc of Date Receiptp
the wnrk lin which this pooh is ane!(See 3197,Civ.C.)
Q h Lender',Name TOTAL:
L) Tenders Address TOTAL:
>s UJ 1 certify th d I have reel this application and state that the above information is BUILDING FEE
�." rA comecl.I agree it)cmliply with all city and county ordinances antl state laws relating to QTY. MECIIANICAI,PERMIT FEE
U Z building construction,and heady corruption representatives of this city to enter upon the SEISMIC FIT..
aboveatemimed propcny for inspection purposes.
(We)agree to save,indemnify and keep hem Iles the City of Cu,mum against PERMIT ISSUANCE: ELECTRIC FEE
Iiahilllic.,juJgmems.costo antl expensoe which may in any way ucerve ngaina said City ALTERORADD'IOMECII.
in asequence of the senting of this permit PLUMBING FEE
APPLICANT UNDERSLWDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To 10,000 CPM)
SOI�IICIi RIiGULA'rl0 MECHANICAL PTai
\��j� AIR HANDLING UNIT(OVER 10,0910 CFM) CONS]'RUCT]ON'I'AX
Signmure ofAppli.- fiCommctor Dae EXHAUST GOOD(W/DUCO HOUSING MITIGATION BLE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or l"inure building rccepunt store or handle humnlru,material HEATING UNIT T 0 100,000 BTU)
as defillrl by the Cupertino Municipal Code,Chapter,9.12,and the Health and Safety
Code,Section 25532(00 HEATING UNIT(OVER 100,000 BTU)
0Yes ❑No VENULA'f10N PAN(SINGLE RF.SID) PAID
Date allin
Will are applicant or future deflu d occupant use equipment or devices which BOILER-COME'(3HP OR 100,000 B'I'G)
oil hvnNnu.air armaminun0 us Adined by the Huy Arca Air Qualify Managetncm
Oct <I?
D Yes ON. BOILIiR-COMP(OVER 1(0!1X10 RTU)
I hill,rend l belsoanlnn,ameeialxf he Cidi- AIR CONDITIONER ISSUANCE DATE
romia Ilealtlr&Sdmy Cole,Sections 25505,25533 and 25534,I understandthat if the NEW RESIDENTIAL Ni SQ.14. O
building docs not currently have a tenant.that it is my wsponsihility to notify the occupant
of Ne equimances which must be met prior to issuance ofa Creature of Occupancy.
Owner lir aufhoritod agent Date TOTAL: ISSUGDBY: `' —
OFFICE
W
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s
e..'ADDITIO' PERMITnEq
'Y .lIIJ I LOI NO PROJECT,I DENT]FI
CATION
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LIG HTING;FIXTURES�,
:,,�,e'APPLIANCE
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FANELs7�,:- :A
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SIGNS
SiGNEITKANS.7"
. ...... '.14SPECIALICIRCUIT I.:
EMP METER ORTOLE,INS.-I
.AT I,
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L�,,'r TORSj-'V*j! �','t�y,,�CZSEEFEESCH. ......
SERVICE
At A L�
sy ;LU OTY! I.-.1PLUMBING P
ISSUANCE DATE.'
ERMIT4," FEE"; BLDG
ELECT.
AlTER:pR?MI4 89YEkNT-,WATER'IEA
• -Z'uo�
BACKIFLOW.PFIOTECT-.,DEVICE
fYyu'LL
DRAlJYEi:FUOGR,�RO0F;AREA,COND 7, -T
K
PER TRAP',.'
IZ
GAS:,EA.S)�STEMz.I INC:40TLM
I 6�1
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INDUSTRIAL WASTE'INTER
TER.
WN.SPRINKLERS� :,YJNC
�j
�,A�YN,SPRtN5LERS.:QVER,5,(EA�.I
41�
SEVVER-SANITARY-
STORM�,EA:!200ft/C..
WATER HEATER j. fil
WATER,SYSTE Z`1:111w;
WA EQUIP:
WATER
:z ',l !'TQTAis� I-'
QTY.
MECHANICAL PERMIT V.-lt
-�FEF
w
`F
ALTER:OR'XDDT0 MECH 7 ;P,
APPLIANCE?,! 4!
'J, AIR HANDL'INGLJNIT'(TOidpObr-FK)�:
AIR HANDLING UNIT(OVER IOXOC.F.M.): .�
_lTiX�HAUSTH606(WlTWDIlCT)%'
HEATING UNIT,(TO.1100,0
00 Bjeu.)
HEATING UNIT(OVER 100
VENTILATIONlFAW(iINGLEj-,,_
P,13H.P.'o,100,000B.T.U,1°
. ' SOI C EWCOM P 10-1,100,000 BTU)SE E F EE SCH
o i��
E1 ° �TOTAL 7"
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j Elle Ddit view [nsert Fgmet gacwds 'Loots yyndow tlelp � J
6®�t�� r� Hyl ' Gni Zi�, I ,. .X I - I
Input Permit Number: s2182
PERMIT#: ARCHITECT: VALUATION: 57.
APN: 34216067 LICENSE# ISSDATE: 9/14/90
SITUS STREET: FOOTHILL SUBDATE: 9/14 PLCHKDONE:
SITUS NO#: 10535 TYPE: RSE LATE CODE:
AVE,CT.ST RD: BL BLE CODE:
N,SC.W S DESCRIPTI ELELT ENGDEPT:
NOY', PLANDEPT:
CITY: CU PLCHKREQ: LMA
ZIP: 95014 CATEGORY: CTRFIRE',
LOT# D DATEDUE: SANDIST:
ID: Comme¢ial HLTHDEPT:
STRCTENG:
OWNER: ERNER GER TRUDEA ! LA¢9###: TOTAL,
OWNER 105359 FOOTHILL BL CEsnpflp: INSPHOLD:
ADDRESS: CN.a fllln:
CITY,STREPEH NIE: CUPERTINO CA 95 Residential �I
RNeRpllp:
CONTRACTOR: 689138 TRUCTION RE-ea#Ilp:
LILA: 609138 RUSaIXpIIIX: Semch by Address
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