S 2925 (2) —APPLICANTTO-FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.C1 RICA, P17RMI'r NO.
BUILDING DIVISION APPI,ICATION/PERMIT PLUNIIING-NIECUANICAL
BUILDING PRO,IF,C'1'IDF.N9'IFICSOON'
BUILDINGADURISS: KV SANITARY ND. APPLICATIONS1111MDTAL DATE
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W :R;S NAMES 1' ONNEf /..y CONT CI'OR S NSAAM�E�' -� ^ ^L/hC�NO:
1NL- uV�V a �TJ` P� "t,WR yam. 3IVs NIC COND ROL#
AR�fI1iE I'R[NGNZ AUN(O: ADDRESS:
• • W)• t2?1-1\ $ata+.. 'S1aN �A.tC. RGA\
CONTACII PHONE!: BUILDING PERMI'P INFO
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er „� 1w.1� ` r/ ••f'jny' ❑ Consultant Fees Paid by Applicant(Initial) FILING ELECf PLUMB MECH
lT FC.� J 1, ❑ ❑ ❑
LICENSED CON'rRACIORS DECLAItM ION QTY ELECTRICPERMIT FEE
1 hereby affirm b
dint I nal Ecel„ed bidder Pnwiseno of Chapter 9 b-Founceeatg _ JOB DESCRIPTION
Q)ACZ flu torte and ellen nTof int Businessand Profession,GtJq and toy license is RESIDFNTIA1:
Z w, PERMIT ISSUANCE �'
KGF•
in Dt[-t CSFDWE O KITCHEN REMODEL
QUV License Cy ys�Lic#Cnnlmcmr Ar1ON APPLIANCES-RISIDIiN'DAI- 0ADDITION ❑PLUMBING RE-PIPI3
H z w Dem "F
tnsea�Fse,� ARCHITECT'S DECLARPANELS OMIILTTUN1T El STRUCTURAL
ZOoiZ I trdersmnJ in,planc,hali le-rd.,,.hire recti MODIFICATION
•�Z�O I1P'rO 3IX1AMP5 [IINTERIOR OCHIMNEY REPAIR
W 1-mead Pr.le..in..l 201-100FAMPS IMPROVEMI3N'10SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I(NXIAMPS [I BATH RI?MODEL/ItdPA1R El DEMOLITION
S Q I nerchy of rse that 1 mm exempt front,the Comramor',License I.aw I...the
w,O y V following mason.(Section 7011.5,Buninevs and i'rotua,i.ns Calm.Any city nr cnun,Y SIGNS ELECTRICAL001 HER
IA 3 W h wall,mq.inc a,crush at ennsr.et,late[inmrtve,demolish,nt mpair any adrmture
Rzi0< prior In lis i.v,uancc,alao requires,he applicam for such ltc.it to file a.agiddisalemettt SPECIAL CIRCU IT/M ISC.
f y that he is licensed pmsaanuollte pmvivion,al'the CsmmemY.Licenec Low(Cla,mr 9 _
at�A0 (commencing wills Sallnll]INObolD'Ivl.lona of the lhooeneand Profe"ma,Code)it TEMP MUER OR POLI:11 ST (� COMMERCIAL:
Z. a ,ha,he is exempt Ihercfmm Boil the hose for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
Section 7031.5 by any icaeaMO
nt fora peonk,ad ,the applicant int a eml,dranky of POWER DEVICES
Ixi1^rte applElI'ENAN'1' El FOOD SERVICE
not more than five hundred dollar.,(55110,
FET IMPROVEMENT
' �d iv 1.othew r nf,he,s,,me,nnnyan,Inytedo,o esed uathei(See cnnt,Esiness SWIMMING IKK)L ELECTRIC
Q will dnihe work,ande:The Cnrc is Li ens ornw does nor apply in an,evaer of ❑OTIi IiR
¢1 m and Professions Code:The Comlaab License,db Jncsnotapply inanownerof Of _SWI'rCIICS-PIX'1'UNI!5
C pmony who h.l,,or m..lcd a Bah i,end who docsre a work filed in or Ihmngh
his own employeese pmvldd,hal encs i,npmveelf w are nut i carded nr Nfemd for NEW RCSIDI3NTIAL ELGCFR SQ ler.
a;Jc.IL hnwercr,the building nrimpnrve,rmm itself within one yevro[e.mpletinn.the ' SQ.FT.FLOOR AREA 3/SQ.FT.
ebuilder will have Ise huNan of proving Ihm Ila JiJ not bnlld nr intprnve Ibr pur-
Jes
1 oI'eale.)
n L ,
d owner of Ise property,nm exclusively Pme,etins with licensed comma,,!,a
n t ITh preject, to
D Jrt f NoCadr')tle Canham 1 - - -
.1ho ]am drive t Ip1yI i'p pc(, 'h h 'Ideor'n to theamm d QTY PLUMBING PEItMIT'O
wb tact.I'orsuch pr Ret, ill.con unrfgluc v..Jltrnt moo lhef onlmgnrs
Ciccone PERM11H'ISSl'ANSI!
Elesd i inn eacmpl a er ec ,li&P C for This reason
ALTER-DRAIN I VONT-WA ER .A OR
1 J 10
U:ne J
1 CR', .O ENSnT1ON DECLARA'T'ION HACK PLOW PROIECI'.UI!VICF, 1
I hereny under penally of pejuD one bind,following declaralionx:
❑I have and will maintain a Cerlificmeof Consent loself-ireare for WorkersCorepcn- DRAINS-FLOOR,ROOF AREA,COND. STORIES I YEE Y ONSTRUCII ON
,aJon.ax pmvideJ kir by Section 3700 of the Labor Code,liar the petl'mme..c of the
wnrk for which,hie permit in issood, FIXTURES-PER TRAIT'
2v
0 1 have and will maintain Worker's Compensation Insumnce,as required by Section
3700of the L.N.,Code.bathe P fl'arme...of the wnrk for which,hisperait i,I, 1, GAS-EA.SYSTEM-I INC.n OUTLETS O(:C,GROUP AI'N
My WorkcYs Coat ,[fen Ids.....c nericr a,uI Polity nu,nbar ore,
C,,rricc Policy No.: GAS-IiA.SYS'T'EM-OVER n(FLA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASIYINDUSTRI.WASTE INTERCEPTOR
BUILDING_DIVISION FTiF_S
('I'hl.eec,innnmd nm be con,pltmdil the Penni,is Gn'ann hundred Jnlium($I Wl GIt1iASli TRAP
nr lesx.) 1'LANCIIECK 121i
1 terrify that in the performance of the work for which this Permit is issued,I shall
not card,may pclann in may nwnn.rsn as,n become xnbject of the W..kerx'One onpmm SEWI!R-SANI'PAItY-$TORN IiA.^_TNI Er.
ENERGY IEE
Z e;,If i Low.,of Cullfoenia.Dole WKT1iR HEATERW/VE I'/ELECT
02 Applicant GRADING PIJ!
z H NOTICE TO APPLICANT,If, her making this Cenilicale of lixem„inn,you shu.Id WAI'I2R SYSTEMII'REATING
ti
a , hcuune,cnial.t the Itadcr'r.Compensation I'maljibervoinavM the Labor,v.kc,yon mu,I SOILS PE13
W Lk Y
l.rlhwilb comply with+nth Pnrvi.lnne ur idle pamtil shall Fedwmd mvokcd. WATER SERVICE
0. A
UO CONSTRUCDONLENDING
ngAGENCY NEW RI3SIUGN'I'JAL I'hMB. 50.F1'. PAID Ilut Rcceip,#
I for
Inch
thanhsernal isuamxhec.3y .Cagoncy fur the penormnnccnf
the work for whirl,IhA per,nn ie iaual(Sm.Jf19].Co.iv.GI
LcnJcr'n Nuntc 1"0'I'Ah:
O U Landers Achim, TOTAL:
'Y'0. 1 renif,ih^I 1 have read this npofeatio i and a,am Lha,Om above inforntatinn i,
hoat
- - I - BUILDING FI'
ta.I new,bt en,^1dy wilt IJI shy Ill.,toothy oNhtances and stmt laws mmung to QTY. MECHANICAL PERMill FEE
'
rz building construction,and hereby authorize representatives of this city to enter.Pon the I ISEISMICFEE
ahnve-mentioned,mperry for in,,cctinn,.,toxo. PERMIT ISSUANCE
(We)agree restive,Iadeninav and keep ha chess the City of Cupertino against ELECI'Ii1C FI!I?
nil I'mhilitin,juJg,nans,Ivstx nnJ cx,cn,c,which,nny in any way ac'tuc against snit City ALTERORADDTOMGCIL
xnpmnce of the gran' gnf this,conic. PLUMBING FILE
APPLICANT 1' D R DS \NU WILL.COMPLY WITH ALL NON-POINT Apt HANDLING UNIT PI'fl III,WO CFM)
SOURG' �L MpCIIANICAL PI3G
AIR HANDLING IINI'I'(OVER 10.000 CFM) CONS IRUCfION TAX
signature oanf - Sl1R f Dale E.XIIAUSTHOOD(W/DUCT) HOGSINGMI'DGATIONFEE
ALAR)OUS MATERIA S DISCLO
\ill the opplic,nt nr GllurcbuilAing occupnm xmrcmhandehazallom mmenal HEATINGUNIT(DO100,000B'1'U)
as deBnd M1y the C320)1 no Municipal Cttde.Chapmr 9.12,and the Ileallh end solely
ale Section 235J2(n11 HEATING UNIT tOV13R IIX),INO 1fPU)
❑Ycs No PAID
VENTILATION FAN(SING 1.13 RI!SIIO7 Ilnlc Itcteipl
W II the a,pliutm or future building occupant use equipment or devices which BOIL ER-COMP IMP OR 100.0X0 BTIH
mit hazacil air ,conlantimer,is delinW by enre
c Bay A ^Air U.allly Mnoo,co ant 'IOAU —
Didna'!
Dyes 0Nn RUILCIt-JR101111(10 B'I'iJ)
1 have real the hnzardot5AIR CONDITIONER
meneB Iequircntenb under Chapter 6.95 nl the G,I I. ISSUANCE DATE
fomi.I Iealth k Sofa Ctz ! qqtt .05.25593 an 2553 1 nndc'a a'ihm if the NEW RESIDENT[Al.MCCH. %17..
b.ddingA ,,c. cosi a fn,.'lltnt it is my' pa a.'hi tym no, the..,a, /T/' v— P
.film fkT vh' , e pnnnnis,Ri � II' enf(krupanry. f
Owmcr rerg t Doc TOTAL: 15SUi!Uits: T-m
OFFICE