S 1693 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull,mrvc-ELEC1 RAL PE
Ir No
BUILDING DIVISION APPLICATIONAPERMIT PLONDIING-MFCHRCM
ANICAL J 1693,
BUILDING PRp.IRC1 IDEN'I'IF'ICA'I'[ON
BUILDING ADDRESS,. SANITARY NU. AITI.ICGI]ON SUBMITTAL DAT
ir✓12 MWGL V9r�6 -7- i
p ' N,ME � ONE. CONT'RACTOR'S NAME: LIC NF).
q�7{ N/C Jf({ CONT ll
ARC 1113-1/IiNGINlihlj: LIC'ryll'. V UU ADDRESS: ❑ V 932-
F�Grf1' /NI
CONTACTPHONE: i/�(7 ILDING PP tMl l'INFO
V W �. L�fM/d-°�t, B'Po� '6`T��X6 ❑ Consultant Fees Paid by Applicant(initial) BLIH' ELI!CI' P17MECH
LICENSED CON'I'RAC'I OR S DI3CLARAI ION Q'pY. ELECTRIC PERMIT PETE
hereby afrm than 1 am accused andc,to int„(or chapter 4(,I'm JOE DESCRIPTION
7�_ with Section 7a0p.(Division 3 of the Business I,,d Pmfes,innx Coda and my hecnx is D RFS(DIENTIAL:
PIERMI'I ISSUANCE
in full force..,[eRect. ❑SFDWL ❑KII'CHIEN REMODEL
QUU License Ctnss hien API'IJANCIS—RESIDIENT TAI. o U ION ❑PLUMBINGRE-PIP
W Dow—, IT
F Z .(scan
,,ir ❑MOhTI-UNIT ❑$T'Hl1CTURAI.
i ARCHITIECI'S DECLARATION PANELS MODIFICATION
"L O f Z l undcmwnd m}plate shall M1e used uc pnblle rccorJs
OZy4,- UP TO NO AMPS ❑INI HRIOR ❑GIIIMNEY REPAIR
W Licensed Professional 2111-IIIMI Ah"PS IMPROVEMENT (]SWIAIAIINGPOOIS
OWNER BUILDER DECLARATION OV ER(IMO AM1IPS ❑BATH REKIODEIIREPi ❑DEMOEJ'I'[ON
IY d 1 hereby affirm that I a.l client, the Com uctor'n License Law for the
FW,O ererm W U ❑OTIIIER
L (allowing reason.(Scab..7031.5.Business and 1'mfe sinnx Code',Any city or county SIGNS IJ.f:CI'RICAL
3 Wy when rcquirtn a po-mit a,co ll"all,ahea Improve,dTra kh,o,mpai,any smtn..v
^,N"Od pnnno lss iswarm,also require the applican,fui pi I,,f lea signed xmten,enl SPE IAI.CIRCUIT/MNC.
ALLY' mat he is licensed p...annoihe pmvl.uonsofnhe Gmeacmr,hicvnnc law mp¢r4
u1�C0 (commencing with Section 70g)of Division 3 ofthe Rnsinessand Pnde..I TEMP.hII!1'lift OR MILF:(NST. COMMERCIAI:
I 1 e C that he is etcmp,therefrom and the basis for the alleged exemption.An tela r ❑NEW BLDG/ADDITION ❑DEMOLITION
W M.vi Section 90.31 S by any applicant for a Permit subjects the applicant a,u d penally ar POWER DEVICES ❑TENANT' ❑P(II)D SERV ICE
nal more than five hundred dollars($500). IMI'ROVEMEN'I
ZO 7I,c,Evo of the properFr,my empluyec,lot wage.ax Incl' urn, digin, ING POOL ELECT RIC
p. willdathe work.rnd,warnemre is not intended or offered for sale .70,14.13—on— -7 ❑O'IlI13R
6 3 m and 1'ml onto Carle:The Contractor's License IW
w'cook,not a a —he LG S CHIS—IIXI"URFS
property won builds or improves thereon,and who doe,such work If
his own cntt provided that such improvements arc not intended or to II TI !'R, SQ Fr,
sale.It,however.the building or improvetnem is sold wdhin one yeandeomplon, dt SQ.FC FLOOR AREA $/SQ.14.
cr-bmldcr will have the to iter of proving than Ira did ten build nr Improve lin pIIt
�I.no 2 f3 La �
c ,none properY,sin exduxivdy enmmning who Iimnu•J commcmrn n,
ct the project See.7140.Business and 11..rasions Coleco The Conu.ctors 1.1-
suWwdocs not apply to an owner of property who hadds or improves thereon.and QTY. PLU N FEE
won comment for cash pm)mtN ori lh it rams......)licensed p.cwmn home Contractor. s�
U'r,oc Luw. P11 SSUANCI! ttlb
AEI
Q I nexempt node ,H Ye I'C far Ihiv m:unn
a 1iR— look N'I'— ' 1
1erm Date 0 VALUATION
N'ORKISR:S COMPENSATION DECLARATION PACK FLOW P ( .DIEVICE 2 D O
I howl,oc am,m under pcnnhy of perjury nuc of the 4Nawing Worker's Co
(] Ihave mad willmaintainaCenlficmcof Cnmenuosclf-insure fur Worker's Compete DRAINS—II OOR! )�.ARIi OND. 5'IGft1Ii. IT CONSfRUCIIIII
wenn,as Provide,[for by Section 3701 al the LuNh Gia,far the penrmmnee or the
work far which This pairir is i,oted FIXTURES—1" 'NAI'
❑1 have and will maintain Wnkers Compensation Insurance,as terminal by Section
3701 at the Who Code fnnhe performance oft he work for whichnhis permit,,i....III. GAS—IEA.SYST; IIs a UI'LLTrS OCCGROUP APN
My Worker's Cantpenw,ion Insurance cre icr and Pat icy number are:
Cartier: Polley Nu.: GAS—IEA.SYSTEM OVI_ ) ,A \
CERTII4CA'I'1;()It EXEMIT ION FROM WORKERS'
COMPENSATION INSURANCE GRIEASIVINOUSTR WAS ' ERCI!I'fOk 1 LDI ,Ul I. N _
(This.wnlnn need not he careplc,ed if the proud is for one hundred dollars($100) GREASE TRAP
or lens) PI.ANCI IEC � \\V
I ctai yo,that in the perfrrnanccof the work for which this Penni,is issued.l shall SIEWER—SANITARY—STON M PA.2110 Fr.
//55
not employ any person in any manner m a,m lmcome aubjen a,the Workers'Campers. ENERGY FEH
Z .atom Low_,of California.Irne WAI'1!R IIIEATER olocip [112L
C) 2 Appliaum [CI'N CItAUING I *E VI
NOTICE'II)APPLICAN I''.IL;if ler nmking this Cennicme of H,mra .ion,you should WATER SYSTEMG KFAI'[NG
I'-' ? heat,z.bj., ,,,he Wndcr,C( tKii,ntion provisions of the Labor Code,you.,it,( 5011 ti(IEE
tomb%im comply with such provisions or this permit shall M deemed revoked. WATER SERVICE
Q
a CONS"I'RUCT]ON LENDING AGENCY NEW RESIDENTIAL PLMB. SV.I'1'. PAID Dam Rcccipt a
I Iter by a floe than mere is a anxtmtlien Irn,[infm
g agency ore perli,nnuncc ul
LL P: he work for which In,pefnill is i...cd(Sec.3097,Civ.C.)
O Lender,Name 11.\L ^ TOl'A1,:
I<ndve,ABd,ms : 1v
I certify than 1 have mistook application and>mm IT the above information is it
B LING FEE O
Fon correct.logre,to comply withall city and county nommncen and wa'ane laws mlating QTY. MECHANICAL PERMIT ITE SEISMIC PI:'
building oommanian,trod bcrchy uumnrirs rcprcscnunivcs nr tui,ehywemcrnoonme
above-mentioned property f or hmliton p io eve,a PERM I'1'ISSUANCEIELECfIiIC I
ZO
1 WO agme m save,iodmiandy and keep hmndess the City nr Cupertino against
li.bilitins.judgmcn,s,rose xnJ eapcnscx whish may in any way accede against said City AIZER OR ADD'TO MIECH. PLUS INf - E
in ctmxquence of the grurning of this permit.
APPLICANT'UNDFRS"rANDS AND WILL COMPLY WI T'I1 ALL NON-POINT AIR HANDLING UNR(IO 10.00I-FnD MI: 'AL FTI(
SOURCE RFGULATIONS.
AIR HANDLING UNI'I'(OVER Igf011CITY) CON S' tUC'I'ION'IAX
Signature of Applicant/Commmnr Date (EXHAUST TOLD FW/DUC) HOUS GMITIGAT)ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant%ow or handle.mallow,material HEAPING UNIT ITO 100.000 BTU)
as definW by the Caherire Municipal Coda,Chapter 9.12,and the Herb and Safety
Code Stolrn2553200? THAI ISO UNIT(OVER I01.INg)BTU(
0 YEN No PAID
VI7N'I'l1.AT1ONPAN(S1NGI.ERESIDI Dan, Reaiplto
Will me applicant or suture bu lding oceapa t use equipment or dm'ices which BOILFR—COMP(31111 OR 100.000 BTU)
I Pi emit hmardous air connotations as defined by the Bay Area Air Quality Management TOT .
Coronet? ITOILIER—COMY(OVIER IIXL(XIO BTU7
❑Yes El No I tl
I have read the i I-Inaeialxre ,n under Chane,SE)Sof the Cud. Alto CONDI'I'ION1EIt ISSUANCE DATE
25533a
h,mla building does
En Safety ine Calc,Sections n 25hat i 25533 and 25534.1 it)not of man it nhc NEW HI!SIDENTIAI.MIEC11. SV.FL
of hhapumorm urmmly have be met.Iiornixmy uanesof a Ciilitymnmiffecupwapant
4r the regairmenu whim nm4 be met prior m issuance bra cmuiam nraaPany. 111
Owncn .....W agent Ilei yl'AL: ISSIIEDBY:
OFFICE