S 2269 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BU]LDING-ELFCTRICI. Pion)'No. ^ ^
BUILDING DIVISION APPLICKTIONIPERMFT PLUMBING-MKCIIANIUAL Vl L J
BIB LDING PRWRCT I DENI FI CATION
BUILDING ADDRESS: SAN[IARY NO, APPLICAI"ION SUBMI I'1'AI,[)ATI
10S/ Me,�or L g-8v 9E3
OWN'F, ;S NAME: PHONE'
CO RACfORN NAME. LIC NO:
t',k-+Zlna.i 4 J4E•, SIL 2T-�'v4� / r /lD I1••a+bl (--;146)VS NIC LUN TFOL#
•ARCH[TLLT/GNGI :13R: LIC NO: ADDRCSl ❑
U
CUN'1'AC'n PIIONI7. BUILDING PERMIT INTO
r ` ❑ Consultant Fees Paid by Applicant(Initial) BLDG L,CI PLUMB Nil: H
LICENSED CON'IRACE OR'S DCCLARAI]ON Q'TY. ELECTRIC PERMIT FHF
I hehy affirm mal 1 not licensed under Provisions of Chap¢r 9(ctnnmeudag JOI3 DESCRIPTION
rc
L. with Section7N)(H of Division 3 ofthe Blssinecwnd Professions Cale.enJ my license is RESIDENTIAL:
FOp PIiRMH ISSUANCE
In lull mrcc; Ictfecl. ❑SFOWL ❑KITCHEN RFmoDEL
=FUU Llcxnw Clash Lit.# AI'PLIANCIS-RLSNEN'1'IA1, ❑ADDI'T'ION [}IT1fAf i(\ING Rio PIPE;
NGL Da¢ Cnmractar ❑MUIIFI-UNIT El STRUCTURAL
ARCHITECI'S DLCLARAHON PANELS
~.Z I unJcnlnnd In I Ishalt he nand a, blit rmords MODIFICATION
OZp— _ y,:m, Pu Up PO 200AMPS
❑INl'IililOk ❑CHIMNIiV Itla'Alft
u'] Liccmed lkofcssicoal 201-1000AMPS IMPROVEMENT 0SWINIMINGI Focus
y s1E-i OWNIiR-Ia-JUDIR DLCI.ARATION OVER❑%%TAMPS [I BATH REMOUFLIREPAUZ C3 DEMOLITION
C C y I herchy affi ,mat I ant exempt rant the Cmtancmrx Licensee Law liu the
1 a mU fallowin6 nasal.Scction 7831.5.Inosines and Rnfc,aons Gsde Any city or county SIGNS HIXCTRICAL ❑OTI IIiR
3 a F whip nalairto"a Extant to coloomot. II impose,demolish,h Pa y structure / Iho
a'O� Palo,In I " ' 1:,,c,airts,the applicant oh permit toFile a signedstatement MPFCI AL CIRCA I'I'/M ISC.
f�r� mat netslased Panaann,,ata Patvis tttx,,r ml canmcmrs Lcanty l.a (cl apler9
Rommencingwith Section]OgOaf Drvi.sion3afthe Busineoaud Profession%CWe)or 'IFMP.IdHI"IiRORPOLLINS'C. COMMERCIAL
a Xe C IM1nt he is c'earm Ihemfroln and the basis for the ullegcd exemption.An,vinlauon of ❑NEW BLDG/ADDITION ❑DEMOLITION
�..w Section 7031.5 by any applinllu for u pvo,q xofje,Ls me apPlieam I.a dull Penally of POWER DEVICES ❑TENANT ❑FOOD SERVICIz,
not mom than five hundred Jolla,(S500). IMPROVENIFN'I'
_� ❑ mn
I.as owner ofthe ppery.ony employees u i(h wages as their sale cntn,ensation. SWIMMING POOL ELECTRIC ❑OTHIift
will do the work.and the structure is not intended(it offoreJ for sale(Sao.7W4.Business
tL3W' !2
mtd Protvoliti a Code:The Contrncada I3ecme dBs don rot apply , nn owner at Ol1TL11"IS-SWITCHCS-FIX'CURES
Prapcny who bnilJx or improves thsuch a and who rtes such wad Led or or Ntd for
his own cmployecs,PmviJW than such inon, ,olid ado not intended or offered for NEW RILSIDENI'IAI.ELECTR SQ Irl'. SQ.FT.FLUOR AREA LSV.Fr.
sale.If,bowcvw tho ve the g arm inn,naveof,rmm�l ,old h wilhln;n,year a(nmtplc(inn,dbe
ncnbuilder,will huvc Ina bnldmt of proving that held nal huilA ur ingtovc Iia pur-
f:I ) TOTA h:
E]
� I . f et S pent exclusively NIh I sa contractions m /
ct n i 10 P 'IIS 7044 Business J P a .C )Th le aamo,1-
on
i-
1,w coconut II Ivt fp p n 1 b IId: I II�mt and QTY. PLUM[31NG Pf?IiMIT PEE
who contracts to,such project,sold,a contractors)licensd pairomoral lothe Counter-'s
Lnonae law. PERMIT ISSUANCE
E] I all,sxntpl,nd,.See .B&P C Ga lair rc:uon
Owner Dale EGREASFRL
AIN#VENT-WATER[P.A) SFORILS VALUA'I'ION
0Q
WORK17R'S COMPENSATION DECLARATION PROTECT.DEVICE
I hereby ofirnt ander Peffid y of perjury one tithe fidlowing(belamlions:
❑Ihave unit will maintain a Certificate of Comm a,,self insure for Worker's ComPom OOR.ROOF,ARBA.CON[). '1'VI'E CUNS'I'RUC'I'IUI
w...k far
as hick his
for by Section A(X)of the IaMr Cede,for the pcdonnance of the
work have and
so lis uume is ixwcd. PI[R TRAP jfOca..C.,
I]I have writ rill nivinmin Waders Coltq,emainn Inxurvnce,ns requireA by geelion
3900oflhc labn Cede.far the pofannanttoOhc work for which this peril a issued. YSTEM-I INC. OEM1-171'S OCC.GROUP AI'N
My Wnrk "Co.c roti Int mace ansa Policy num :
Curricl-.� rPolicy RO:MOR !1� USr,ALwo ,I4(EA)
Clik���'1'll'1000'A'I Ii OP GX' [PITON hRO��I��Pjj(xf RiRS' US'FRL W'ASTII INTIiRCFPTOR
COMPENSA ION INSURANCE BUILDING DIVISION PERS _
(lltissc,lumneadool be compkLN iOacpcnnil is foromelmndooddallars(S100) GREASIi'FRAP
I'LANCI[ECK Hili
l certify mal in the PCHitntanecnl the work our which Thislermil isissued,rimper SEWER-SANI'T'ARY-S'1 ORM IiA,21#1 FT.
not employ any pennn in any nwnner so as to become subject et the Waderi Compcn- IiN'1?ItGY PEIi
z notion Law<nf Califumia.Uatc ` WATCH I IFATFR W'NENTMLECfR Q Q GRADING Pf3E
zAp"I"c l
= NOTICH TO APPLICANT:If.Mier making this Cnnifiemo of Uxennin n,you should WWI FR SYS I EMG RFA'I'ING SOILS Flit:
(•^ become .bjmno the Workers Compenwdion Provisions of the Labor Code.you must
{a H lim,w'ith.amply with such prookianxnr this permit shall be Jecmcdrevokcd. ATER SLRVICT
y PAID
CQNSIRUM[ON LENDING AGENCY NEW RESIDEN I'IAL PLMIL SQ.PI'' Dam Receipt Of
V Q Iherebyufffin thll,nae isamn,ma.bm lendinga6eney farymn
nhe rfomcc of
13s F the wad Nor which This Pcnml is issued ISw.31197,Co.C.) J
TO'PAh:
(.ender:,Name
TOTALV Lenders AdJrcs.
} a BUILDING Flli
1,unify that I have read Isis applicafion and Nam that the above information is
.�. fq curet.1 again no umT1,will,all city and county ardinatic—ntd slate laws relating Io QTY. MECI IANICAL PERMIT FEE SEISMIC FEE
V z building ama,ma ion.and herchy umbarieca no, allivesof this city(ocnter urym the
above mentioned pmpeny for insl a Linn purlttxes. FERMI'['ISSUANCH ELECTRIC FEE
(WO agree to save,indmnnify and keep hannicos the City of Cupertino ugaina
iabilillcr.judg...... costs and calwnses which may in any way ammo agoloo sail City ALI'FR OR AGO 10 MUCII. PLUMBING FFF
I. arwilt enec of the g..Iin,of this PcrB. ,-,
APPLICANT Us RSI'A 'DSAND ILL (IMPLY WITH ALL NON-POINT AIR HANDLING UNIT('IO BLOB)CFM) MECHANICAL PEE
'OURCH REO 'ION" !r] ply
�/ AII4 HANDLING DNII'(OVIR 10,000 CFM)
SEXHAUST H(RU W/DUCT( MITI(AION F .
I IA9JADOIIS MXGzRIAI S DISCLOSURE
Willds,appllcma in fnotm bulldingoccupon(store nr trundle hvutJouslnuon.1 HFAI INC,UNI'1'(10 obtua)BTU)
ac def nal by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(0).! HEATING UNIT(OVER 100,000 BTU) SEP
p ye, 0 N VENTILATION PAN(SINGI-F RHSlI PAID IAv -i1 #
Will the applicant or future building mcapunl use NuiPment or device,which BOILER-COMP(3HPOR 100AX)B.1'UI
mit hyoid...air smanuna its as Joined by dw Be,Arca Air Quality'MOnugemetn TIIIAL:
DoraolP BOILIiIt-COMP(OVFR 11 10,00011'1 G]
C]yes E]No
huvcread thetraeanlonsntmcrialsrc Is talc,Cha 0:r6.95ofthe Cali- AIR CUNOITIONER ISSUANCE DATE
yusfin Pic p
fomin llcalth&Suf c(y Code,S,nion,25505,25533 and 25$}4.1 ondetnnnd that if the NEW RBSIUEN'I IAL MI!CIL SQ 1711 }/s
building torn not s which huvcI tenant,that it is fin,ua rn Oda Cl111y to notify me occupant
of the reyvircmenu whin,mal he mel Prior m iwuunee Oda Canificsto at Occupancy. --�
owner,,raamadeeJagcm Date Targl,: IssIDtUBr.� A,e /9NcdTOWw�
OFFICE