S 0393 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING S 0393
BUILDING PROJECT IDENrIFTCA'1'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITI'AI.DATE
C? Vella.
OWNERS NAME: ,M"*_a/ YHONE: CONTRAH"ty1Rh11id Nt NIC CON IROLa
ARCIII'I'IiCf/IiNGINF.ER: LIC NO: AQDR / •(Jf !n r ..+ ❑
CONTACT: v� � PHONr- a79 /.! HU ILDING PERMrr IN170
�W Coruddhanl Fees Paid by Applicant(Initial) BLDG FLECr PLUMB P.11
❑ ❑ ❑
LICENSED CONTRACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm mm 1 am licensed under provisions of Cbupter 9(commencing JOB DESCRIPTION
Oa(Z with Sectir.7(Xa)of Division 3ofthc Business wand'PmfeAssio/m Code.end my license is RESIDENTIAL'
C¢Ips 'n Y�5l�/_ YF.Rh11T ISSUANCE
UF full forccand>tQtq._ a kf� ❑SFUWI. KITCHEN kBMODEI.
QUU license('I' . v!'�/ Lica APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RLPIPl:
NZa D"'° d(�( Contmc ❑NICIJ'6UNIT ❑STRUCTURAL
FQQm ARCI{I HUTS DECLARATION PANIiLS MODIFICATION
O Z.Z l undemmrdmy plans shall he used us puhhenecords
UP TO 2IXIAMVS
❑INTERIOR f_1 CHIMNEY REPAIR
(•-�Fu�1 Licensed Pmfessinnal 2111-IINNIAMPS IMPROVEMENT SWIMMING POOLS
CYC; OWNER-BUILDER DECLARATIONOVER 10X0AMI'S ElBATH REMODEUREPAIR Cl DEMOLITION
C C Q 1 henchy affimm pt l that I acxcmfrom the Cmmoremes License law far the
X 06 U fdhming rearm.(Section]831.5.Business and Profoslona Code:Any city or roomy SIGNS ELECTRICAL )OTHER
W 3 6-h which require,a permit m emistmct,alter,improve,demolish,nor repair any nmetme
prior to is issuance,also requires the applicant for such Permit o file asigned aamment SPECIAL CIRCUIT/MISC.
Shy that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 COMMERCIAL:
WaQOC (commencing with Section](NNI)of Di vision Sof the Business and Professions Code)nr I EM P,M ET ER OR POLE INST.
d d e C thud he is col then( lm and du basis lin he alleged exemption Any violntinn of ❑NEW NLDG/AUDITION El DIiMOI.I'1lON
x1wSeufion 98315 by anyappllcant for a permitschicesthe applicant loacivil penelly of POWER DEVICES ElENANT ❑FOOD SI:RVICE
un moor than live harried dollars ISSIXB, IMPROVEMENT
SD ❑ I.as owner of the property.or my employees with wages as their sole compensation. SWIMMING P(IOI.ELECTRIC
F. left Jo the work.and me structure is not intended oroffemd for sale(Sec.'/814,Busincss ❑OIIILR
6 3 m and Professions Code TTe Contractor's License taw aces not apply In an mvner of OUTLETS-SWI'ICHCS-FIXTURES
property who builds or improves thereon,and who does such work himself or through NEW RESIDENTIAL ELECTR .Q M1 .
his own employees,provided that such improvements M not intended or offvOM for SQ.PI'.FLOOR AREA SISQ.FT.
wle.,,however me building or improvement is told within one year of completion me
erbander will navy me nnrlea err proving mat he ria hat cadre nr improve err pnr- CEI VE
ria rr sown To 1
❑ I,a owner of ct property.umexclusively Professions wire:)MeeCcnmctors i-
construct shoes project(See.oil(an owner
prop Ymwho buions C,o,impr Cnmmemrs Li- p '1997
wl.uwdocanmapply a,ninowncrorpropcny whosedpnrimprove.Connucor, QTY. PhUMRING PERMIT' NOV 2 O IJJ/
who onavns for vucM1 pmjecu wimueontnrcmr(s)licensed pursumtnu the Conuunnr's
License law. PERMITISSUANCE
El lemexemptunder .Sec. .R&I'C lin this naso
ALTER-DRAIN A VENT-WATER IRA) VALUATION
Owner Dam
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I heresy affirm under Penalty of perjury one of me following declaration
n I have and will maintain a Certificate of Coasenuo self-insure for Worker's Compen- DRAINS-FLOOR.ROGFARG,GOND. STORIES 'I'1'19iCONS"I'H FICTION
.a tion,as provided for by Section 3700 Of the Latin Code,for the performance of the
x which this permit is issued FIXTURES-PER TRAP
w I have and will maintain Workers Compensation Insurance,as required by Scene.
.to pertonnanneco
f the work for,Inch thi,,entitk olOrd. GAS-IiA.SYS'TEM-I INC.4OUrLISI'S (ICC.GROUP APN
3"I(N)of the labs Co de /1
My Wnrk (�IJI Iain yuy9lpcynhrund Policy nm�beGlt�1OM CAS-IiA.SYS'I'IiMs)VER4(EA)
Cinrier. I V� I'nllcy No: C/007 'I
CERTIFICA'IEOI:EXI?MYTIONI:ROMWORKERS' GREASI%INDUST RL WASTE INTIiRCEPTOH
COMPENJA'IION INSURANCE IIUILDING DIVISION Itl31iS
fnd,,wuo.mvJnnt hecompkteJ ifine permit is for enc nundmlJnllun($11X8 GREASE'I'RAI'
or less.) I'LANCIIECK LEG
I conify mat none pefformaneeofmc work for whichthis pronto is is sued.I,mII SEWER-SANITARY-STORM EA.2f0 FT.
not employ,any person in any manner m as to become subject the Workers'Crmpen- ENERGY FI:E
Z sution laws of Califomet.Date WATER HEATER WNENTIELECTIR GRADWG PEE
APPlicam
NOTICE'TO APPLICANT:IL after nmking this Certificate of Exemption,you should WA'I IiR SYSI'EM/TREATING SOILS THE
a ; become subject to the Workers ContpcnssJor provisions of the Lubn Code.You must
0. Q lorm abcomply with sa.It pow,,irnsrr thin perms shall be deemed revoked. WATER SERVICE
7Z CONSI RUCTION LENDING AGENCY NEW RIiSIDENI'IAh PCMB.
SQ,ITT PAID
I M1creM1y eff mathnt there isocnnstmution"anng agency Ionise perfonnerecol ante Rvccipap
W 0 the work fin which this peon u Insucd(See 3899,CO.C) TO I_
Q lenders Nume TOTAL:
r {ULl Lenders Address WIAX
EE
li I cenify,that 1 have real this upplicaumn and state that the above information is
f' N c rect.l agree mcomply who all city and ttmnty ordinances and stare laws retains to QTY. MECHANICAL PERMIT FEE E
U Z building consaucnon.and hereby authorize representatives oftnls city reenter upon me
above.mentioned property,for inspection purposes. P17RMI F ISSUANCE EE
(We)agree m save,indenmi fy and keep harmless the City at Cupenino against
liabilities,judgments,ensu and ex�mmu which may in any way same against said City ALT12R OR ADD TO MECH. IEE
In cnmcgnenw of the granting of this scoria.
AI'I'LICAN'r UNDERSTANDS AND WILL COMPLY WITH ALL NUN-POINT AIR HANDLING Gist r(To IB,O(H)CI'M) AL RE
SOURCE REGULATIONS.
AIR HANDLING ON]'1'(OVER 100)0 CFM) I'ION'I'AX
Signature mf Apdicant/CmTmzm, one EXHAUST HOLD(W/DUCT) ITIGATION FEE
HAY.ARDOUS MATERIALS DISCLOSURE
Willthc applicam.,form handing neirparnome r handle hm.Nuus materialHEATING UNIT(TO 100.000 BTU) GV
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Ilealth and Sa vAy BEATING UNIT(OVER H0L000 BTU)
Code,Section 25532009
E]ye, Nn VI?NTILA'I'[IN FAN(SINGLE RESID) PAID
Date Receipt p
Will lM1c applicant rte future building mceul a r use equipment nr devices which µOILER-COMP(MHP OR IN),(XN1 B'TO)Aft
` mit hmurJnnssir,nduoaa,asnsdrlinnl by the Buy Amu Air Quality Munugemen( 'Itll'AI.: C/
Driaan, ROR,EIi-COMI'(OVER 100,0001ITU)
❑Vex
AIR CONnTI'u)NIiR ISSUANCE DA'I'li
1 have mad the O.MCode. a mamri 55 x5.25533 an v2SS .I and nta of the Call- —
firmi.Healon&fSafinyearn Code.Sections t.that.25533 and n3514.1 to ncntath that if me NEW RCSIDENTIAL MECH. SQ.TT.
building dm na curtrntlY havea¢nanL that it is my responsibility to notify the occupant r
mOto ytx;hich mu m prions issuance of s Certify, L eu cy ,\
a(/L_• ` Uatc 'TOTAL: ISSURDBY:
caner aumomed agem
OFFICE