S2652 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I BUILDING.ELEC I RICA PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING..MECHANICAL S 2652
BUILDING PRQIEC'p IDENT'IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
17 6_3 Ly Ce -PWP-- r�o C� 93a/� ,
OWNERS NAME: PHONIi: C NTRACTOR'S NAbII?: LIC NO'
CONT OI.N
•q CHITECUENGINEER: LIC No DRESS) Vv TUCK /� JVI /� ❑
l. A
CONTACT: PBGN'E: BUILDING PERMIT INFO
❑ Consultant Pecs Pahl by Applicant(Initial) BLDG ELECT PLUM MECu
a� v s o ❑ ❑ ❑
LICENSED CONTRACTOR UI CI Aknl'IUN QTY IiLECTRIC PERMIT FEE JOB DCS RIPTION
I broom fl in.,i licensed J p i Chale 9( ring
CZZ athS f 901NB fD 3 tlhc Bus adP fXmin:CuJs..rd yl'ccrmis RESIDEN'T'IAL:
W CC, PERMIT ISSUANCE
z�,F tr full) and c I3� ❑SPOWL ]KITCHEN REMODEL
au, li.c me Lr.# Q APPLIANCES kI SIUIiNTIN. ❑ADD)ETON ❑PLUMBING kIi PIPIT
F Z m Dam Com h,
ARCHITECPS DECLARATION ❑MUI.IIUNIT El STRUCTURAL
F N Z I undersand my pimps shall be used as public records PANELS MODIFICATION
UPTO200Ah1PS
OZ^C (I INTERIOR El CHIMNEY REPAIR
[-r/_)E-M Licensed Professional 201-1000AMPS IMPROVEMENT LJ SWIMMING POOLS
5 x¢ 1 hereby affimr ohm 1 amB elmDEPl roDEthe Compact fs License Law for the OVER IOMAMPg ION ❑HAfH RF.M1tODEf/REPAIR (]DEMOLITION
3�F Ialhrwing reason.(Senion]031.5.Business and Professions Calc:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires permit t construct. It p demolish. p y:structure
ON
h. prin l t alq thppl tf hp di II g its Cement SPECIAL CIRCUI'I'NIISC, (�
bar he m i pursimp,tothep fm e Commi License I (Comaw9
�n00 (cnpminun,sib Scunn9NXpof DAtsi lot the ltu'm.norAlrho: Crdc)a TEMP.ME'IFR OK VOLIT.INST. MM �
a e thin he is exempt lhemfrem and the basis for the alleged ucuipdan.Any violation of NEW E DG/ADDI'EION ❑DEMOLITION
Section 7031.5 by anY opplicxm f ro permit subjects Thu uPpllctnl In u civil penalty of POWER DEVICES ZvIfFril
'I' ❑FOOD SERVICE
not annelhi rise hundredJ IP :(5500). 1. EMENI
ESQ [] 1 fth pr piny ) PIwith wages':O i' n` SWIMMING POOL ELECT RIC
p. will) th k;mdO t t t t dpi b :11 (S 70W BusOEIIIiR
Ww and Profession,Cod, the ConlmCmf4 License Law Joss nor apply m an -net of OUTLETS-SWITCHES FIXTURES
property who hudds or improves thereon,and who docs such work himself of through
his own employers,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECT SQ PT.
sale.If.however.the building or improvement is sold within one year ofcnmpletion.the SQ.PI'.FLOOR AREA LSQ.IT.
cr-builder will haveam burden of parro ingthm he did not build On inrpmr'e for par-
pose ofmle.t.
I,a,..,,if the pmpeny,am motim,seely compacting with licensed cantrecnrrs m TOTAL:
rosea the project(Sec.]WJ.Business and Professions co,10 The Contmemh Li-
scLawdoesnotapplytoanownerofpropertywhobuildsorimprovesthereon.and QTY. PLUMBING PERMIT FEE
who conlnwts for such pnrjecn with a mnnectar(s)licensed pursuant it)the Contradni z
License Law. PERMIT ISSUANCE
I can esOmint under Sec. .B&P C for this reason
ALTER-DRAIN A,VI?N'I-WATER IEA) VALUATION
Owner Beatpp
WORKERS COMPENSATION DELI \RAI ION (SACK PLOW PRDII.C'I DEVICE L" Vj
II I'di BullrC rulpoYPLJ y III II y l f -i
� Ihrise a dell fo rty na,fiou 37W al the Labor
Cod,t eh rwurkc'XICof the
DRAINS-I FLOOR.lif rOl'NtEA,CON 1), - S'I'OIi11iS 'TYPECONS'I'K11C1'ION
Manan,rte.marded far by Section 3)W of the Lubnr Cada for the I`cUonnantt nl the -
k to, I'1 1':pmminal is issued FIXTURES 1'IiK PINI'
' Inane i willannicamW k ,C lerimfian 1 :mma,p.to.ricculmdhy9 tion
".G"i,ifilm iamorCusle,f tb performeariveofthe workf wh h the pooh is issued. GAS EA.SYSTEM.]INC 4Oil'[LETS OCC.GROUP S/ 'NO
MyWn tmpnsa an In: aro and PolicynumberGAS EA.SYST EM OVER 4(EA) V
Cnmcc; Pnl s>Nn.. I �
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASY%INDUSTRLWASTEIN'TI; CEPTOR l'
COMPENSATION INSURANCE BUILDING DIVISION FF.F_S
(Bois waionneednot hewmpIppJ iDhe p.it is foronc hundred dollan(SIM) GREASETRAI'
or)mss.) 1'L\NCII[CK FEIi
I ertifYthet othe performanceofthe wo,kfarwhi,h thispenna is issued.Isha11 SEWER-SANITARY-S'B)RM EA.200 FT
not employ any on.in any manner so as to fee cnme subject to the Workers'Compen- ENERGY F[E
Z Xmmu Lars of California.Dam WATER HEATER WNENTCLECI'H
zApplicant GRADING FIAT
fn NOTICE 10 N'PLICAN'E If,after making this Cenlficam of lisenrption,you should WATER sysrp M/IREAIING SOILS 1411?
Hbecome subject to the Workers Compensation proviXinna oI the Lahur Code,you must
wIbrthmith canprly with men pravinions.,,his permitshall he d.cnmd mvokcd. WRIER SERVICE
Q
CONS"TRUCI'ION LENDING AGENCY NEW RESIUEN'I'IAI.I'I,MIL SQ.FT. PAID
U O 1 "oelyallimr thethere is acotnmucfmn lendingageney lin'the Pefonnanre of Date Keceiptq
I. - tlieev k for which this prune is issued(Ser.3097.Civ.CJ
OU Lender's Name '1 OTAL:
} I-) Lender's Address TOI
y I ccnifY that I have read this applicminn and state ohm the pho-infunumian is BUILDING hili
F-' tq counter Ingres m comply with all city and county ordiammcs and state laws rcmtingm QTY. MECHANICAL PERMIT FEE
U Z building continuation,and hereby authorize representatives of this city it)enter upon the
SIiISMIC FEE
abovomentiared propaeny for inspection Purposes. PERMIT ISSUANC12 El.ItCTRIGF 1?
(We)agree to save,indemnify and krep hamt s,the City of Cupertino against
I abilitics,)udgricmx.cos end expensewhich may in an)'way mecum against said City ALTER OR ADD TO MECII. I'LUhININ P'r
in Cmnxcqucncc of the morin^ us permiL
AS -IC UN .<$' AND PI. WITH ALL NON-POINT AIR){AND)"ENO UNI'1'(TO IB.OIM CIIANICr
SOURCE ' .WN S.
C AIR HANDLING UNI'T(OVER I FM) - CO . R Cl )NTAS
Sig amre of Applican Conroctor I DOBI EXHAUSTT1 OOD(W/DUCT) TIO St' .MIT IAI'[ON FEE
HAZARDOUS MATERIALS DISCLOSURE? nen rs n QOI I t
Will me'prplc t future building nXmr ' JI fo
cepctu 2 lIJ n.trou,ial HEAPING UNI'I('TO O,But Or IYIF'If( \
;is(I'll I by the Cup i MuuuJ,,I Cade Chapter 1)1 2-rod,he I I t hh and S Jcty
Coda,Scahatr 25532(x)'! HEATING UNI'I'()VI?It 1000)(0U)
C3 yes No VEN'ULALONFAN(SINGIJ! 3. IA Dme Rxer pt#
Will he upplicnm nr[owrc buildin%rmeupunt uxr equimumu or devise,which BOILER-COME'OIIPOR 190,000 BT )
curious air em m ¢nritmnas defined by the Bay Area Air Quality Management
crunt inL:
Dlgrin' 1_Slre/ BOILLIt-COMP(OVI?K 100,000 BTU)
Yes
I have mad the hmvJrms mmerials requiamems under,Chapter 6.95 of Joe Cali- AIR CONDITIONER ISSUANCE DATE /�
(omit,health A Safety Cade Sections 25505.5533 and 2553.1.I mrdenand that if the NEN'REMDEaNT1AL MFCH. SQ.FT •✓7 C D y'
buiWingdlneno¢unently havcatenant.thanis my rcspmsihilirymnotify the«cupam L� '(
of the orprom or ' d� st be met Prm,to ismano,of a Ccnif nl(kr _7/
Ovoiror autharized 'em TOTAL ISSUED BY: `
OFFICE