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S 1067 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO 111111rvG-ELECT RICA I. Pli UT NO. BUILDING DIVISION APPLICATION/PERMIT I'LUhfl{ING-MF.CDANICAL 1.i 067 BGILDINII PROJECT IDEN'TIF'ICATION V SANITARY NO. APPLICAHON SUBMITTAL DATE: BUILDING ADDRESS: / O33 G OWNER'S NAME: /� PHONE: CO RA 1' SN AMIi: LIC NO. — NEC CON"I Rot.N CA SOS S ARC[I'I'ECDENGINEER: LIC NO ADDRESS: ❑ S. J. C'ONTACI': PHONE: BUILDING PERMIT INTO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH LICENSED CUM"FACTOR'S DECLARATION QTY ELECTRIC PERMIT' FEE JOB DESCRIPTION 1 he„by affirm that I am licensed under provisions o'Chapter si mummudem, DccZ with Sections of Division 3 of the Ursine.,%and Profev%mrs,Cale.and my license is RESIDENTIAL: WOO PERMIT ISSUANCE F O in full line,and cRectt,� �/� / ❑SPDWL ❑Kit CHEN R1:MODEL. <U~ hiccme Class V`r� 'tics, �yo APPLIANCES-RESIDENTIAL ❑ADDITION ❑I'LOMHING RISPIPF, ,Z al Date Contmetor 6CC ARCHI I'IiCI':S DECLARATION PANELS ❑MUI:I'I-UNIT ❑S'ENUC'1 ~m X, lunderstand my,lura,hall heumd a,puNlerecords MOUIIICAlA'IION OZ14.p- UPT0200AMPS ❑INTERIOR [I CHIMNEY REPAIR I-�FIiI I.me^sed Proc Tonal 201-10(a)AMPS IMPROVEMENT SWIMMING POOLS �•.Ef� OWNER-BUILDER DECLARATION OVER I0MAMPS ❑BATT{REMODEIIREPAIR ❑DEMOLITION C ad Q 1 hereby aRrm that I am exempt from the Contract.,'.,License Law far the XO a V following mason.(Seeman 1031.5.Business and Proas fesamCade:Any city or county SIGNS ELECTRICAL ❑OTHER W 3 a F which requites a permit to consumer.altar,improve,demolish,or relvo any%fracture FSO prior to as issuance,also requites the applicant for such permit o file a signed statement SPECIAL CIRCU IT/M ISC. flythat he is licensed pursuant to the rm.ision.of Commnafs License Law(Chapter 9 COMMERCIAL: WG0 (commencing with Section1(XXp of Division 3,Rare Business and Professions Cmlc)or TI3MI'.MHI'IRORPOLE[NST. a R o y tM1m nc it exempt thercfmm and the M1usis fns Nc alleged cncmptinn.any violminn of ❑NEW I LOWADDITION ❑DEMOLITION W..y notnwrc031 five any ahundred dollars appbam fora fsvinit subjects the applicant son elvll Penalty of MWBR DEVICES ❑'I'FNAN'T [II-OODSERVICE s($300) ycanp, IMPROVI!MhN'1' EZG ❑Lm^wncrk.the are not intended witnwaid for oale(Se .campctnminn, SWIMMING POOL ELECTRIC ❑OTHI?K F- andwill dothe wons ande: a ContunotimcnJed erraw dofafot apply to an towner of I�al�� and ProPossiuns Code:The Contractor's License Law does not apply m an owner of OU'I'LEES-SWI"TCI{ES-FIXTURES y IL 3-. property who builds or improves themou and who does such work himself or through his own employees.provided that such improvements am not intended m offered for NEN'RESIDENTIAL[LECfR SQ FT. sale.IL however the bnadingo,improvemem i%rold within one Ycar of nunplain.,rife SQ.FI'.FLOOR AREA LSU.FT. ser-huildef will have the burden of proving that he did nm Fui1J or intpmve for pur- pnscaLmlcJ. TOTAL: h as owner of the progeny,am exclusively contracting with licensed contractors m em t ct the project(Sec.10,14 1{ ,u and probes l^s Cod ,Tb s- t C :Li- e t I d tapptyt 'fr pry n brim libracon,and QTY PLUMBING PERMIT FEE P A tub connotes f hp 1 t. ocontusions)licensedP II tl C . t /u Cc L' 111RNIII'ISSUANCE I,m cWmpt under Sum. B&ICT th,% .:m At, ER-DRAIN&VENT-WATER(EA) �/ A C)� •Owner Date (� WORKER'$COMI'13NSATION DECLARATION rC FLOW PROTECT.DEVICE Ihereby illlinnundertain.Certifyofparryry oune^f the hollowing dorker'lons: f IaUY L 0Ihave and will mammin oCenifcam of C.nscnuosdf-insum fur Workc/%Gtmp,n- DR IsLLI(IH,ROOFARIiA.GOND. STONIES )Tl'I'Ii CONS"TRUCI'ION cation,us provided for by Section 311X0of the labour Csde,for the pefromance of the w^rkfnrwhichrhkpmmiti,issued. F OR TRAP I have and will maintain Waders Cmapeasation Insurance,as required by Section C� ? (X)of the LaMx Cade,!.,rife perfonnuna.!rife work forwhich this permit is inuW. STEX .40U'ELETS OCC.GROUP AI'N My Work' GC alICCOMPENSAIM cr:md Policy nt�bac vg. �� sunnm t !JL. Gnricr; P.Ilcy No.: GAS-1 S r' OVER4(13A) 1410N 17ROM WORKERS' ' >N INSURANCE GRI3ASE/INUl15 LWASTE IN"TEHCIi19UR BUILDING DIVISION P131iS (This wsorm need not be cnmplened How permit is benne hundred killer,($[(as) GREASETRAY PLANCHECK FEE or Icas.l Loy my person in the p,rfomumcmaw, s ork becmew bjesi to permitsissued,'Comm- SI3WEH-SANITARY-STORM EA.Np IT. not employ any Peso^^in any manner m as m become subjn't m the Workers'Cnmpcn- ENERGY ItiE oZ .,,tion lax.of Calimmia.Date WATER HEATER W/VENT/ELECTR GRADING 193E O Applicant Z y NOI'ICl3 TO APPLICANT:If,after making this Certificate of Exemption,you should W'ATIiR SYti TI3M/IREATING SOIhs THE F-' b,mnm subject oo the Worker's Cninpcmatioto provisions of the Lol.n Cade,you 111-11 a forthwith comply with such provisions^nhic permit shall be deemed revoked. WATER SERVICE DJ Q 6. CONS'[RUCTION LENDING AGENCY NEW RESIDI3N'IIAL PLMtl, SQ.IrIL ['AID ])a'. Rccmpl I hereby affirm that them'isaconstrvmiot lending agency Carol,,peut'nnname of M WFthe work for wh)chrhis permir is ism.it(Se,.3091.Civ.C.) TUI'A ' U Under's Name IMAL: } Isndcis Addm%s ARICITI: 1 131i Q. 1 sonify that I have read this application and mmc that the above inhmnmlon i., Fh cancer.l agree m comply with all city and county madames and state laws reining u' QTY. MECHANICAL PERMIT FEF. TE V Z building construction.and hcmby tountre rePEcenmfives of this city to enter upon the aMwcmentioned pmpeny for inspection pulpa%es. PERMIT ISSUA NCH 11313(Wc)agree m save,indemnify and keep mardess the Cityul'Cupertino againstliabilities,judgment%,costs and expenses which may in any Is yaccmcaguin.asuidCity ALTI2R OR ADD TO MECIL ".FAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIH IIANULING UNIT(TU 10,1X10 CPM) A.-'13SOURCE GUI IONS.is /D/4#7 EIKHAUST LING HODUNIT(OVBR In.IM)CPM) DONIignatureof Ap 'a.'— DmeEXHAUST HOOU(W/DUCT) MI'I'IGATI FEE AZARUOUS MATERIALS DISCLOSURE Will rife app mans err fmure huiming cecupant score^r handle h...wims natural tIEAfING UNIT CTO IOp.tXX)BTU7 as defined by the Cupertino Municipal Ctdc,Chapter 9.12,and the Health and Safety III3ATING UNIT LOVER 100,000 BTU) Cole,Schon 25532(m^ El yo, n VENT ILA IION FAN(SINGLE REST) PAID /� Dntc R,,eipt to Will loc applicwn or future building occupant use equipimmal or devices which BOILER-COMP CIHP OR 100,000 If'IU) emit harardnus air senutnti tants u.,defined by the Bay Area Air Qualify Management 'TOTAL: IuIldml HOH,FR-COMP(OVER I W.(NX)B U) Yes sk, I have read fee fia�ardmwoto,Se materials255 requirements undo Chapter(?95 of the Call- AIR CONDITIONER ISSUANCE DATE RtmiaHealth&$armyCalc Sne..%2fildi is 533 anyandmibili1 In man,the that ifthe NEW RESIDP.NI'IAI.MECH. SQ.17. buildingdoes not is have,cnanuhoto isanyof a ibilitym notify the rwapam of the uw ' mut me1pnamissuance nfa'e�fic�sf Oecu �)me TOTAL: ISSUED BY: Own rot auNone F o OFFICE