S 0523 (4) rBUILDING,ELECTRICAL ^ PERMIT NO. +r
-: CITYOF CUPERTINO ( } 1 "
• t'SQIL'DING DIVISION APPLICA'51k:J ERMIT PLUMBING-MECHANICAL C
n 1 'i•`9.i65. •BUILDIN(}PROJECT,IDE\TIFLCATION�C '0,52
BURRING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
.�' ".'• red IND 95TH :r
1 t
OWNER'S NAME• PHO CONCRACrORE'SNAMUC NO:
CONTROL I'
1F1CHTIELT/ENGINEE ..i• .'r.;:• ;LIC NO: ADDRESS:. p. ..V, .'' + '•+ .t +�'. r \ r'li{?.wi.•
'9' •yl•. c. A .r
'ONTACT: }: ., PHONE,-, l ,, '. ,' _ "�1- ..aUQDING PE_RMITINFO'll
❑ CGoJ,B1 at Fm Paid by App.=t(Cabal) ' B PLUM ='
- •. _/_/7 O�� �B rl IL 9 i-+�Nn .0 k,T._+`s.• < u. 's t , r ,.
LICENSED CONTRACTORS DECIMATION ; 'S T' ' �
1 head y affirm that 1 rm Urcad ode prwblom of QTY v, EJ-EC-[`RIC-PER.\IIT r FEE -. n - c
Chapin 9(mrmne«m{ ..,..J• YJ _� _ _ - —1 JOB DESCRIPTION c
W�00 with Seaiaa]000)of Dtn000JMde Buutmied Rofe.siom Cade.and mY li¢o¢u - - r
F F. in full fact ad offal PERMIT LSSUANCE 3 'r .. t ~•
QF.UZ V U.Class tic:0 AF 0 KITCHEN REMODEL,
N6� Dae an oar ` APPLIANCES�RESIDENTLAL ON r. OPLUMBWGRE-PIPE
7y ARCHfIECR DECLARATION + h1lR.'ll-
F• Z 1 uduaud m L PANEIS F UNTr- '0 STRUCTURAG','p' +
0�� ypWsshall bemdupublc rtcmds a MODIFICATION.
0 Lanscd PmaluO
fe.sil t ZOiTOWA `: MNTEIIORM' OCHIMNEY REPAIR
Y OWNER-BUILDER DECLARATION OSWUIMWGPOOLS•
C6 1 hertbY affirm most I am'ncmpt I.a,,Coerncmr's Ui ma,law f«the OVER 1000 AMPS 0 BATH REM66ELREPAB2 0 DE ol-r 7ON'j•I.
30.0followin{rrawa.(Seubn]OJIS;Buivuad Rduslou Code:AnY city«coat«y SIGNS ELECTRICAL ❑Ol3iF,R e
^0 whafr rtquirt.•pemdl b conswa ala«,impmrc demoliib,«rcpur my auucove _
y prior to its i.,aLm taTuirt.ft applkmt for smh permit 1.files d.,.n,si .,.n, SPECIAL C[RCUIT/MISC t,
th¢ho it licensd punuvum tho pmvi.iau of the Cori aws[Jcaue Law(Chapta9
COO (commencing wiNSatim]0007 of Divbionlof ate Buirev and Profe.lou Cadc)a TEMP,METER OR POLE INST. COMMERCIAL ' '
a o C that he is c ocrift Auelrom ad de u for rhe alk{d.,pion.Any vbluion a - -
B• Saum 703136 - O NEW BLDCdADDMON ODEMOLMON
'^,y by aubjau the applionlmacivilprnalryM POWER DEVICES OTENANT• OFOOD SliR CE
trot mac thm f ve hudred tMWs(55(10). r,1
�?6 D1.a aof the poperty,or my imFoyeea wiib wain ath,,ir¢Ie comp+«.��on, SWIMMING POOL Ft IMPROVEMENT
'
0 will do the work,and the mvemm is not ineddor oRucd lorole Si,c.7614,Baines OOTHER •','
Wsd Pmfus b:.loCoTho Cominscmr.LE.Law docs«t apply to an LETS
owter a _ OUT -SWITCHES-FD(TURES
prapcnry who builds oa improve damn,ad who don such work him¢If or through' ' s .,`fin•'l
his own omployec.•provided this mach Impm evrnu K oot iruedM«wimwl f« ', NEW RESIDENTIAL.ELEC11t SQ F1'._ 'Y.
de -Witw wthe WO bLn inofpmentia hedwdam Willdorim mpkfoo - SQ.FT.FLOORAAI:A ;SrsQ.FT,t•
owner-�daw0l tum ale hidden olpmving this he d'dn«Wildar impuve f«ps- � + .. . �5 ;•
u oww of tit propenry,w eubvi.elY contractionwiN licrned cmuacwrs hat 1 f• •�,
t the mi ic,(Sa 7W.Bumex ad Prof aii..Code.)The CoomacmY U
I.law doe not apply romowom o(property who builds or tmpm.a thu,nmo, QTY `" LLh10IhC PERAII'f'+a t" d:,`FE. E P' - +s
who corl2ca for such Mjmis with a cmaam«(s)Itcw¢d pnsumt to the Cono-um/s r •�'}Y• — d`fes-- -��.- y�.1 0
Dil cmplu B C l PERMIT ISSUANCE
_ ALTER-DRAW hVFM-WA EA)
pw 'T _ N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. 'I �r
l hucbyaWrm udapctWty of perjury on of the following dalamions:
)Iluvi end will nuimain aCaufilauof Conantro¢U-iuurt f«W«tet.Campcm DRANJS=FLOOR R00 'COND. LEE
r '
.cion.n pmvdd for by Srcuoo 3]00 a the lab«Cola,f«de performance M the •570 TYPE CQYSTRUCTIO
!or which this pernut u umerl. - t FLXIl1RES-PER TRAP r
❑1 Tuve ad will maintain Worths Compmvrlon Inmance,as rtquirtd by Seuion
3](p of the labor Code,f«the pefmmure of Ne xvk(ar which this permit 1.inud. "' OAS-EA.SYSTUM-I -
MyWorkeri CampenI..ntion l .olu rtad number am;nuare: OCCGROUP��' AIN
Carr n: Policy No.: GAS-EA-
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASMNDUSIRL WASTE UTTER a _
(This d.noon! bcmmpWd ilthopimit b formehudrtddallan(Slip) „S,- •'RUT ` 1'.wN Tf!IS"n
«least CREASE TRAP �•
1 certify ilul in the pMormarn of dr work for which this pcnrh is Iuo kTshall PLANCHEC
motploy my pcwuuer
to in my maou to bccone suu bject the Women'Compm- SEWER-SANITARY-STORM EA.200 FT. ENERGY Ia
Z eminion law.of CaTrfomiu,Date
O WATER HEATER WI VFNTIELECTR
O
Z Applicant GRADING FEE
NOTICE TO APPLICANT:If,afar making this Cenificu aof Exemption,you mould WATER SYSTEM SATING
a '^ became subject to the Worker.Campcnauon pmvlslou of the Libor Cock.You must SOUS FTE
fmhwith comply with a«h povurou«Nu pctmit stall be deenN rtvokd.
WATER SERVICE
0. 0
7z CONSTRUCTION LFNANG AGENCY NEW RESIDENTIAL PLMB.
SQ n PAM
U O 1hin,by affirm that them is at a cotion leding agency for the p,rfononce of
rhe work for wh this pemut u iawad(Sa.3091.Civ.C.) '
O tudefs Name
U.1I<ndeY AM.
lL I certify that I have¢ad this appliorioe anal"a that tie above infolmadon u - G
V) c«recLlagmerocomplywi6"6tyadcaunty«dinauc.mdnuelawsmlNngro _•,QTY, - ..\IFCHANICALPER\SIT' ''-rl"',•1"FEF.'..::
U z Wildin{mutsucdon,ad hertby mNron¢rtp¢untvivo of 0u cityroent«upon tie p"u 5� .h. . SELSMI
above-(Wo)it dpw nor«iupztlonpurpaev
(Wo)agree ro ova iMcmrufy std kap hay in m the City of Cupmino agniut PERMIT ISSUANCE ELECTRI
IiabiBualdgmmu,cmuad eapeue which maywmy wyacweatalmr oid G7 ALTER OR ADD TO MECK
u c«uegoerce of de gassing of this peemic PLUMB WG
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10A00 CFM)
SOURCE REGULATIONS, MECHANIC
AIRHANDLINGUNIT(OVERIO.D00CFTT) CONSTRUCTION TAX
Stgn.o°eof ApphuotlCoeu¢ror Date EXHAUST HOOD(WMUCO HOUSING MITIGATION
MATERIALS DISCLOSURE
will the applicmtorfunue building occupmt stone or hudle bacurml material HEATING UNIT TOI(N,000 BTU)
u dented by the Cupertino Municipal Cade,Chapror 9.13,ad the Hnith ad Wu,
Codi.Sedon 25532(.)1 HEATING UNIT(OVER 1(0,000 BTU) ar
❑Yn F1 No
VENTILATION FAN(S INGLE RESID) PAW
Will me applies«futvrt building occultismh,,B u¢ryuiir Quality
Mma,which
Dae Raeipt#
mit harnrdou ev contaminants a defi«d by tM Bay Ara Air Quality Mumgement BOLLER-COMP(JHP OR IOO.fpO BTU)
jistrutl TOTAL:
❑Yu ❑No ROLLER-COMP(OVER 100.000 BTU)
I have and tk hiardous nmteraii rtauimmcno ode Clutter 6,93 of the Cali- AIR CONDITIONER [SSUANCE DATE
fomia Hmlth&Safety Code,Sauom 255(15,25533 and 255J4.1 udentard Na if ate NEW RESIDENTIAL MECH. SQ.FT.
Who ,don ois mmmdy Tuve a . dwoismycii a.Ciilirymr,,a Ne a«vpar.
qoeof he t�uirvrenu which rtxv Wrte.priortoinuva ofaC 'A...ofO¢vpa«y. 1 pp
Owren oreurMntd ages Dau TOT ISSIJFD BY:
OFFICE