S 2810 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BURRING-CUECTRICAU PERMIT NO.
BUILDING DIVISION APPLICKI'ION/1"ERMIT PLUMBING-MECHANICAU O L O 1 A O 9 O
•r IJI111.OING PROJECT IDEN'I'IF'ICNFION' t, O
BUILDING ADDRESS: SANITARY NO. APPl.ICAI'ION SUBMITIAI.DNI li
10651 SiOKEs �7�1UE . /���
OWNER:SN all)�pl /� CO A�1' 'S NP15,/' 11 , FI`/ N/(; C()NTROI.p
ARCHITECDENG NEER: I.IC NO: ADIMQSIF.( D IL�JI!���.�/N(Op Ir _ L ❑
CONTACF. PHONE: f/ (� �(�(N�1 J .,, BUILDING PGRMITINFO: h
❑ Cunsullaol FOcs Paid by Applicant(Initial) BLDG F.LIIC'IPLIIMII ME—CII/
-D?Z Z ❑ ❑ ❑ lX
IICI LD CONTRACTORS DILIARATION Q`t,y I LLGCTRIC PERMIT, t FEE `
Ihereby affirm thanar licensed d p fCbaper9r
(ro me g _ JOB DESCRIPTION
paZ with Section 7000)rflovis int thellmm :rndl rlcsr Code.and tip l'cen. 1 RESIDENTIAL'
uI O p PERMIT ISSUANCE
F u,f, it full force and ckoee-ao Q�ilIk ❑$FDWL ❑KITCHEN REMOUEI.
asZW Do,- Class Como , 'r APPMANCES—RUSIUIiN IIAI. ❑ADDITION ❑I'I.UMB1NG RI PIP1i
H G L Dore ConlDIICL
ARCHITECTS DECLARATION ❑AfULTI-UNIT ❑STNUCTURAI.
p.,ph PARI?l.5 MODIFICATION
Z p N L understand my plane whit))be used as public a'ueoms
pZ—p UP TO 200 AMPS ❑INTRRIOR ❑CIIIh1Nl?Y klil'AIR
�4.F.LL1 U'roed l'rofeasiomal ?000XIAMPS IMPROVEMENT E]SWIMMING POOLS
�Y2; OWNI?k-IJUILDFR DECLARATION OVER IIXNIAMPS ❑HA'fll kEMUDEIJitEPAllt ❑UI?MDLIfIQN
Cay' I hereby alRrm that I am exempt from he Coal...or',For c Law for The
p 0.V f»loo Io•b meso..(Sema..7031,5,Haxlmcea I I I'rofowxlnn,Codc.An T t OUTLIER
iqq�5( Y city i or conn Y SIGNS IeLI?LTI11CA1.
u+31+,y ori requiresissuance,pe construct. her p - demotion, repair any vwaure-
<
pnprort r T ia1. y ' erapplicantf chpermit t fl 'g statement
dSI'F.CIAh ITI
CIRCUMISC.
did he I cert.alto l ur uam ill That provisions aITT C bacto, U,ca,c I.L.IChapmr9
WCQD lannmencing willr Semina 7IX10)of Divi,inn 3nflM1a Business and ProfessionsCwlc)nr TEMP.METER OR Irc)LE INS COMMERCIAL'
d p`,o C That he i.exempt Iherelmnr anti The trook for the alleged exenrptien, JohAny Jos n of - ❑KEW RLONADDITION El IJEMOLI'f10N
W..y
Section by any appllcall for a permit subjects the applicant to u civil penalty of POWER DEVICES
not more then rive hundred dollars(551X1). ❑TENANT El FOOD SI?RVICIi
1,; Y IMI'NOVEMENT
d wiLoownerofthe pe%bactre is
intended wiNendfoaTheircee anopensaaon, SWIMMING PUPILELI!CTRIC
CYC will dothe sica,endNmmsmure is nm intended La c US.,
apply no afire, it ❑O'rl11?k
a~w
UI I.I'S—S W Il CICS—FI%'NRES
[al ti
and Prnfe who
h Code:The Co s theta,Liceron Law s aac nor apply In on owner ul ITL
L properly who builds nr improves Ihervun,and who dues nucb work himself nr Nrnuyh
his awn empioyccv,provided Ihat such impmvcmems are our in'n nr nlfercd for NEW RESIDENT'1'IAI.I71.ECTR SQ FT
sale,If.hnsce,the building or inrpmvemenl is weld within enc yaenal ermplOian.the' SQ.PI'.[TOUR AREA 95Q.FT.
pnae,builder rill have the burden of proving Ilmt he did oar build or improve for pur-
•of sole.).
❑ I.as owner of the prnpeny,um m,Advively comrnaing with licensed contract... a TTf YIAI. _
const t(he prolosea Ise 70,14.B .' d Protesdars C de)Ill,Contractor's L - ,. �•,��-• ��
er , I J I pplyt r rproperty l n ll:or improves eerco e QTY ., PLUMRINC I hfjMIT -FEE
who ammctwfn.act,grojesics wi0tacommurr(s)he....it purmnnno the Con rad rs
License Law. PERMIT'ISSUANCE
❑ I am axempT under See. ,B N I'C for ki eL..on
Owner Dam AUTER—DRAIN B VENT—WATER(HA) 111 VQ21 1
W'ORKER'S COMPHNSA'I'ION DECLARATION HACK FLOW PROTEC 1'.DEVICE �1V
I hereby o0imt uad,,wdedly of perjury one of the following declmations.
IhaveandwillmainlainuCerfifevluul Cnnwum oself-inwarefn.Wakl-Conrpen- DRAINS—Ff.f)OR,RUOP,nREA.COND. STORIES 'TYPE CO L-1'ION
amioa us provided far by Section 391X0 df the Lalua Cold,Rn the pofimna a of the _ t")1�
ar
k lin which This permit is issued. IT%TURES—PER T RAP [.r
I>(i have and will Ied,f r Worker's Qamlmmvti w rkfor hi aw him.pra by Sen Oon
/5700 bribe laWMrr Grdc.for the performance of Ore work for which Ibis pcnnit is ixsrmJ. GAS—IiA.SYSTEM-I INC..OUTLETS OCC GROUP AI'N
My Worker' npentra Ion Inv1I m e niurnrJ Polley m
Carder, i'nliey Ne: GAS-1;A.5YS'I'I?M-OV F.R a IEA)
CERTIICATIi OF EXEMPTION FROM N'ORKF:RS' r
COMPENSATION INSURANCE GREASIDINDHS'FRI.WASTIi INI I RCEPIOR BIJR.UINO DIVISION I➢ili5
Fibisseaion need nal ire cnmplmeJ ifthe pedantic isfornnehundred Jnllar,S10O GREASETRAP
or leas.) I'LANCIIECK PEE
I recopythat in the performancvofthe work hit which hispo,mil iwlnned.I shall SEWER—SANITARY—STURM RA.200 FI'.
not m h
employ any person in any manner so as carme anbjecl to We Wolet,'Camper- ENERGY FEC
,z, sntion laws orlih
Carm '.D
bec WATER FEAT FIR W/VEN'VIiI.FC1R
z Applicant GRADING FIT?
h NOTICE TO AI'PLICAMI':If,nlmr ,ranking this Cc0i0cam nI Exempuan, mishould WATER SYSI'EM/fREATING
become subject m the Werke,Crmpememion,mv,kions of the LuhmCodc,you must SOILS FEE
11I ti
forthwith comply with such provisions tirlhis Lot shall be deemed resoled. WATER SERVICE
aQ
7 z CONSme I,ar UNve;imp LENDING AGENCY NEW RESIUIiN'fIALI'Lh114. SQ.PI'. PAID Doe spit#
L) IherebyaRmuhot there lsvvunswetinn lending agency for the pvrfonnance oC
theIs I for which This psorala i...ed(Set.300)7.CivC.)
0l— Lenders Name Torn L:
V Lcneer'.v Address TOTAL:
� y I rrfrTn111 d11application.,III ,;I,,Ion the ad information „ , .. r_ BUIFDINGFFF ..
V1
comes, I J,rcc la,om,ly with'u city and comayonfitemov,and. law,.1f bra QTY, MECHANICALPF.RMIT FEF.
V Z builti 'T t g land I ly thry
TI l :r.euT'vl.' t 's� mc Iwuprnhe SEISMIC PEE
r abo' ncntoned properlyose..for inspection purpPIRNI1'I'ISSUANCE 3
(We)agme m save,indemnify and keep harmless the City of Cupertino againstELEC RIC HE
Ilabilitie,,judgnren.......t,.ad expense,which may in any way.c...c against said City ALTER OR ADD TO M KCI I.
I'LUMHING PER computcomputationaflhcgmmir,orthia pcmon. -
APPLICANTUNDERSTANDSANDWHA.COMPLY WITH ALL NON-POINT AIR I IANDUNG UNIT(TO 10,000 CIMJ O
SOURCE REGIILAI'IONS. - MECI IANICAI.I'lili
AIR
UNG
NIT
I )r ��7-79y EXHAUST HOC (WIDU71) IO.(XXI CPFD I:ONS'ING MI ONTA%
Sr6na rco ApphcaHAZAR O Date IiXHAIJSI'ip>nDIW/DUCIT IIOUSINO MI'1lGA'I'IUN hili
IIAZAIti1fN15 MATT? IAL$UISCLOSl1RH
Will The applicant or furore building uccupam pore nr boom..hazanlons mwcdal IIGA'I'ING UNIT('I O IIX4000 BTU)
it,defined by The Cupertino Municipal Cade.Chvpmc 9.12,and The Evil and Safety
Code.Sabo..25532(x)? HEATING UNIT(OVER 100,000 MITT
Yes [1111 Nn
E] VEM'l1.ATION FAN(SINGLE RESIp) PAID p:ne Recaiptx
0011 the applicant or future building oc'cupam use druipmcnf o devices which
emit hmando s air conmminn is as defined by the Hay Area Air Quality Nlanagmnao BORER—COMP CHP OR I00.00(1 BTU) 17,
District' BOILER—CQMP(OVER I TIH,000 If I'll)
I have rend the hmmdaus m:apn1.1,re n under Chaser 6,05 of the Culi- AIR CONDITIONER ISSUANCE DATE
collimate.' P
Inmia Health,des h Sn[ety Calc,Secdnm]55115.25533 and 25531 I ends..cod ace if Jin NEW RISIDICNTIAI.M[CI1. SQ.1'1'. r—r ^�
M1uilJing Jmes noT cuneney hove a tLrunn,maT IT is my arcponribillry ea amity Iburneupvm /
ofthe uwhichnr tpnn miswunceofa Cmaiemeof )ear
Owner nr aurhonzcJ agent UaI 'fOT [SNUFF,by
OFFICE