S 0351 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY'OF CUPk:RTINO BUILDING.ELECTRICAL THEME F NO.
CAL
BUILDING DIVISION,. APPLICATION/PERMIT PLUn1BING.MF:CUA1IFIC S 0351
nuI1.O1NG vRO1F.CT IDEN'1'IFICATIUN
SANITARY NO. APPLICATION SU13MI'1'CAL DAT
BUILDING ADDRESS. "
O/WyFR'S NA PHONE: CONTRACfCAME' LIC NO: NIC, CONTROL#
RCHD8CTMNGINEF,R: LIC NO: AOO ISS: ❑
14)d-
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Pecs Paid by Applicant(Initial) BI,DG ELECT PLUMB -MECO
EJ 1:1or ❑
LICENSED CONTOAC`IOR'S DECLARATION QTY - ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
M,Z with Section 7lXppd Division 3 nDhe Business and Posh ianCode.and my femme i. RESIDENTIAL
F full force and Olivet. PERMIT ISSUANCE ❑STOWI ❑KITCHEN REMODEL
CUFF
in
ZZ, Dine Class Cordo API'LIANCIiS-It LSIDI3N'1'IAI, [__1 AUDI M IURAI. 'lPE
v~i6a Dine—Contractor _ ❑MUhTI-UNIT ❑STRUC'1'URAh
ARCHITECT"S DECLARATION PANELS MODIFICATION
Z 0 rrn Z I understand my plans shall oe used as public records UP TO:00 AMPS
OZ-0 INTERIOR E]CHIMNEY REPAIR
P'.12 HW Licensed Pmlcssinnal 2UI-I(1(X)AMPS IMPROVEMEM' E)SWIMh11NGPOOIS
OWNER-BUILDER DECLARATION OVER H100 AMPS
❑FINE REMODEUREPAlk -1 DEMOLITION
C W Q 1 hereby minor that 1 am exemn pt liothe Contractor's License Law ton me ❑OTf IF:R
G d U following manor.ISecor 98315.B.,ircm and Prnlcasionr Cute:Any it,or,imal 'SIGNS ELECTRICAL
which rceulres a permit to contract.allot.Improve,demolish,or repair any orma ae
Cj prior was issuancc,alms claims the applicant far Inch permit mile osigneddmement SPECIAL CIRCUITIMISC.
y- that hei.slicensed pimbotto hepnsvsinaladwCmumarowILieeaaLow(Chapter 9 COMMFRCIA1,
H (commencing with Section 7")of Division 3 oflhe Business and Pmfe,sions Code)or TEMP.MEL'EROR POLEINS'T.
d Il p C that he is exempt therefrom and the basis for the alleged exemption.Any violation of (3 NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES QTE
I!NANT _ - 'FOODSERVIC
Fq
> net conic than rive hundred dollar'($510), IMPROVEMENT
pyS� wi Los own-ii ampe Itme or my mttplende withwages uxmd((See.
C,4.B sines SWIMMING PGGI,ELECTRIC
C.Foe will do he work,and the suunurcisnot intended(it offered lot mlapply 1.as Business ❑QI Ili?R
13 ro and Professions Cash:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-hIXTURIiS
pmleny who build..ar improves meram,and who dres such work him.wlf or tbugM1 NEW RESIDENTIAL ELFC`Dt SQ FT.
his own employees,provided that such improvements ate not intended or offered for SQ.FT.FLOOR AR D USG.IT.
sale If h the build 6 - p met Id ua me Ycar.fcampletir rbc il
ownerbuilder will have the burden f P ser $that he did n build or improve forpts. J
pose LWe) TOTAL
❑ 1. fdePrpny 'lowly t 't g win lsersW contract b ���� �8
loss t the p 1 t(Ss 71,11 B c; d Prf.. 1 i-Code')The Contractor: /ryG(�
c mLaw loss not upplYman owner of pmphny who beads or apror,dareon.and QTY. PI. MBING PEI2.MIT FEE U/=
who commcu for such pmjxts with a commands)licenwJ punuem nt the Cnnuanors ('(/hCc,
License law. ,n h P C(or this mason PENM1f1 CE s I�/A'u
m
CI 1 aexempt under Sec.
ALTE -DNA EM'-WATER(SAC VALUATION
Owner - Date
WORKER'S COMPI!NNATION DECLARAI ION BACK FLOW PRD .D'VICE
I hereby main under penalty oft'arjm,one of tine following dr6am1mrs'. -
F-IIM1avmnJwill maimmnaCerilicxmofCanscmtosell-insure fur Waders Cnmpen- DRAINS-I'1, RA.C( D. STORIES T1'PIi C(1NS'1 kUC'll0
nation,as provided for by Section 3700 of the labor Coda far the performance of the
work far whiehthis permit is insula. FIXTURES- 1'
I have and will maintain Worker's Compensation Insurance,as occulted by Section
17M of the LaMn Cod,for the perounience ofthe work for whicM1thispermiti oobcd. GAS-IiA.SYSTE 1 ITLETS (ICC.GROAT' AI'N
My WnT 'Cot p nmtio JPalleyn nt 'C GAS-IiA.NVSTEM-OVEk '
Currier wrx 'ccamc policy No.:a • 2J
CER'IEr 1'E 01'EKIiMIT10N FROM WORKERS DER ASEINUUNTRL WASTIi iN' CIeFT'Ok
COMPENSATION INSURANCIi Bl11LDING DIVISION PERS
(This sectionn®dnm a completed it the permit is nume hundred dnllan(SIOX) GREASETRAP ENCHECK ITE
or less.)
I certify that in the performance ufthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT. ENERGY IEE
not employ any pecum in any manner sit as or become.subject to the Workers'Compen-
Z ration Lawoof Culifomia.Date WXIER HEAT ER WNENTIEiXC7I'R GRADING FEE
Z Applicant t
NOTICE TO APPLICANT:IL ope,nmk'ng this Cendinac of Exemption,you should WAl'lilt SYS'I 11MGREATING SOILS FEE
rN
> fccowit subject to lWoke,Compensation risbs d nof the larCede,you moa
forthwith comply with
rkerh such previsions visinns nhis permit shall Fe deemed rcvakW. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
Z Date Rettipl X
UC) 1 larceny union mat mere is a construction lending agency for the performance o!
ILthe work for which This permit is issued(Sec.3097.Cr,C.). 'IOTA,:
O f, Lcri Nome TOTAL:
} W Lenders Address BUILDING FEE
6. 1 certify that I have read this application and state tom the aMrve infnmtmion is
Ir h cone, lagree as comply with'If city and coutny aNinancesandstate lawn relatingm QTY. MECHANICAL PERMIT PEE SEISMIC FEE
U Z building convenience.and hereby anatomic representatives of this city to enter upon the
olnwementioned property far inspection pu,ow, PERMIT TISSUANCE ELECTRIC FEE
(We)agree or save,indemnify and keep barmless the Cky'nf Cupertino against
Iinhilint,judgmcntscantsandcxpcn.scswoich cony in any way accmcagnmst sniACity' ALTER OR ADDTOMF,CH. PLUMBING FEF.
m cit
rwyuence of the granting of permit '
APPLICAN 'U )ERSTAN NI ILL COMPLY WITH ALh NON-POINT q1µHANDLING UNIT OO 10.001)CFM) MECHANICAL FIiIi
SOUR sC ATIONS. ^�'
�.
5EEal'�A
G UNIT(OVF.H I(hgX)CFM) CON STRIATHON'I'ANSig wre of Applicant/ nmmcmr Dam OD(W/DUCO kLOUSING MITIGATIONITEHAZARDOUS MATERIALS DISCLOSURE
Will the applicmmsrlm�se building nccapunt store or handle byurdousmmcnal T(TO 100,000 BEOf -
defined by me Cupcmro Municipal Calc,Chapter 9,I2,and the Health and Safety T'(OVER I(p.(XX)BTU)Cede,Section 25532(a)I
❑Yo ❑No FAN(SINGLE BESIDE PAIDDate kcccipt#
WII the applicant or future building amel am us ccipam,ser devices which P(3HP OR 11%1,1X0 BTU)
mit haeaJous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
District? - BOILER-COMP(OVER IB),(XXIIITU)
Yes ❑No
1 have rend the Brooders amtedulnrequirements.2533aundo4.1Chapter oun 0l the if the
AIR CON DI'fIONER ISSUANCE DAB'E
funis Health n Safety lCode.lyha Sectio.235U5.is an,sod 25531,1...demand that if me NEW HESIDLiM'IAL MECI1, SQ.1'f.
building acs nm currently have a tenant mina it is my resrymsibility m nrnify the necurym
of me requircmems which must be ma prior m issuance of a C<nificam of Occupancy.
Dam TOTAL: ISSUED BY:
Owner mouth t spent -
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY'OF CUPk:RTINO BUILDING.ELECTRICAL THEME F NO.
CAL
BUILDING DIVISION,. APPLICATION/PERMIT PLUn1BING.MF:CUA1IFIC S 0351
nuI1.O1NG vRO1F.CT IDEN'1'IFICATIUN
SANITARY NO. APPLICATION SU13MI'1'CAL DAT
BUILDING ADDRESS. "
O/WyFR'S NA PHONE: CONTRACfCAME' LIC NO: NIC, CONTROL#
RCHD8CTMNGINEF,R: LIC NO: AOO ISS: ❑
14)d-
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Pecs Paid by Applicant(Initial) BI,DG ELECT PLUMB -MECO
EJ 1:1or ❑
LICENSED CONTOAC`IOR'S DECLARATION QTY - ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
M,Z with Section 7lXppd Division 3 nDhe Business and Posh ianCode.and my femme i. RESIDENTIAL
F full force and Olivet. PERMIT ISSUANCE ❑STOWI ❑KITCHEN REMODEL
CUFF
in
ZZ, Dine Class Cordo API'LIANCIiS-It LSIDI3N'1'IAI, [__1 AUDI M IURAI. 'lPE
v~i6a Dine—Contractor _ ❑MUhTI-UNIT ❑STRUC'1'URAh
ARCHITECT"S DECLARATION PANELS MODIFICATION
Z 0 rrn Z I understand my plans shall oe used as public records UP TO:00 AMPS
OZ-0 INTERIOR E]CHIMNEY REPAIR
P'.12 HW Licensed Pmlcssinnal 2UI-I(1(X)AMPS IMPROVEMEM' E)SWIMh11NGPOOIS
OWNER-BUILDER DECLARATION OVER H100 AMPS
❑FINE REMODEUREPAlk -1 DEMOLITION
C W Q 1 hereby minor that 1 am exemn pt liothe Contractor's License Law ton me ❑OTf IF:R
G d U following manor.ISecor 98315.B.,ircm and Prnlcasionr Cute:Any it,or,imal 'SIGNS ELECTRICAL
which rceulres a permit to contract.allot.Improve,demolish,or repair any orma ae
Cj prior was issuancc,alms claims the applicant far Inch permit mile osigneddmement SPECIAL CIRCUITIMISC.
y- that hei.slicensed pimbotto hepnsvsinaladwCmumarowILieeaaLow(Chapter 9 COMMFRCIA1,
H (commencing with Section 7")of Division 3 oflhe Business and Pmfe,sions Code)or TEMP.MEL'EROR POLEINS'T.
d Il p C that he is exempt therefrom and the basis for the alleged exemption.Any violation of (3 NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES QTE
I!NANT _ - 'FOODSERVIC
Fq
> net conic than rive hundred dollar'($510), IMPROVEMENT
pyS� wi Los own-ii ampe Itme or my mttplende withwages uxmd((See.
C,4.B sines SWIMMING PGGI,ELECTRIC
C.Foe will do he work,and the suunurcisnot intended(it offered lot mlapply 1.as Business ❑QI Ili?R
13 ro and Professions Cash:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-hIXTURIiS
pmleny who build..ar improves meram,and who dres such work him.wlf or tbugM1 NEW RESIDENTIAL ELFC`Dt SQ FT.
his own employees,provided that such improvements ate not intended or offered for SQ.FT.FLOOR AR D USG.IT.
sale If h the build 6 - p met Id ua me Ycar.fcampletir rbc il
ownerbuilder will have the burden f P ser $that he did n build or improve forpts. J
pose LWe) TOTAL
❑ 1. fdePrpny 'lowly t 't g win lsersW contract b ���� �8
loss t the p 1 t(Ss 71,11 B c; d Prf.. 1 i-Code')The Contractor: /ryG(�
c mLaw loss not upplYman owner of pmphny who beads or apror,dareon.and QTY. PI. MBING PEI2.MIT FEE U/=
who commcu for such pmjxts with a commands)licenwJ punuem nt the Cnnuanors ('(/hCc,
License law. ,n h P C(or this mason PENM1f1 CE s I�/A'u
m
CI 1 aexempt under Sec.
ALTE -DNA EM'-WATER(SAC VALUATION
Owner - Date
WORKER'S COMPI!NNATION DECLARAI ION BACK FLOW PRD .D'VICE
I hereby main under penalty oft'arjm,one of tine following dr6am1mrs'. -
F-IIM1avmnJwill maimmnaCerilicxmofCanscmtosell-insure fur Waders Cnmpen- DRAINS-I'1, RA.C( D. STORIES T1'PIi C(1NS'1 kUC'll0
nation,as provided for by Section 3700 of the labor Coda far the performance of the
work far whiehthis permit is insula. FIXTURES- 1'
I have and will maintain Worker's Compensation Insurance,as occulted by Section
17M of the LaMn Cod,for the perounience ofthe work for whicM1thispermiti oobcd. GAS-IiA.SYSTE 1 ITLETS (ICC.GROAT' AI'N
My WnT 'Cot p nmtio JPalleyn nt 'C GAS-IiA.NVSTEM-OVEk '
Currier wrx 'ccamc policy No.:a • 2J
CER'IEr 1'E 01'EKIiMIT10N FROM WORKERS DER ASEINUUNTRL WASTIi iN' CIeFT'Ok
COMPENSATION INSURANCIi Bl11LDING DIVISION PERS
(This sectionn®dnm a completed it the permit is nume hundred dnllan(SIOX) GREASETRAP ENCHECK ITE
or less.)
I certify that in the performance ufthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT. ENERGY IEE
not employ any pecum in any manner sit as or become.subject to the Workers'Compen-
Z ration Lawoof Culifomia.Date WXIER HEAT ER WNENTIEiXC7I'R GRADING FEE
Z Applicant t
NOTICE TO APPLICANT:IL ope,nmk'ng this Cendinac of Exemption,you should WAl'lilt SYS'I 11MGREATING SOILS FEE
rN
> fccowit subject to lWoke,Compensation risbs d nof the larCede,you moa
forthwith comply with
rkerh such previsions visinns nhis permit shall Fe deemed rcvakW. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
Z Date Rettipl X
UC) 1 larceny union mat mere is a construction lending agency for the performance o!
ILthe work for which This permit is issued(Sec.3097.Cr,C.). 'IOTA,:
O f, Lcri Nome TOTAL:
} W Lenders Address BUILDING FEE
6. 1 certify that I have read this application and state tom the aMrve infnmtmion is
Ir h cone, lagree as comply with'If city and coutny aNinancesandstate lawn relatingm QTY. MECHANICAL PERMIT PEE SEISMIC FEE
U Z building convenience.and hereby anatomic representatives of this city to enter upon the
olnwementioned property far inspection pu,ow, PERMIT TISSUANCE ELECTRIC FEE
(We)agree or save,indemnify and keep barmless the Cky'nf Cupertino against
Iinhilint,judgmcntscantsandcxpcn.scswoich cony in any way accmcagnmst sniACity' ALTER OR ADDTOMF,CH. PLUMBING FEF.
m cit
rwyuence of the granting of permit '
APPLICAN 'U )ERSTAN NI ILL COMPLY WITH ALh NON-POINT q1µHANDLING UNIT OO 10.001)CFM) MECHANICAL FIiIi
SOUR sC ATIONS. ^�'
�.
5EEal'�A
G UNIT(OVF.H I(hgX)CFM) CON STRIATHON'I'ANSig wre of Applicant/ nmmcmr Dam OD(W/DUCO kLOUSING MITIGATIONITEHAZARDOUS MATERIALS DISCLOSURE
Will the applicmmsrlm�se building nccapunt store or handle byurdousmmcnal T(TO 100,000 BEOf -
defined by me Cupcmro Municipal Calc,Chapter 9,I2,and the Health and Safety T'(OVER I(p.(XX)BTU)Cede,Section 25532(a)I
❑Yo ❑No FAN(SINGLE BESIDE PAIDDate kcccipt#
WII the applicant or future building amel am us ccipam,ser devices which P(3HP OR 11%1,1X0 BTU)
mit haeaJous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
District? - BOILER-COMP(OVER IB),(XXIIITU)
Yes ❑No
1 have rend the Brooders amtedulnrequirements.2533aundo4.1Chapter oun 0l the if the
AIR CON DI'fIONER ISSUANCE DAB'E
funis Health n Safety lCode.lyha Sectio.235U5.is an,sod 25531,1...demand that if me NEW HESIDLiM'IAL MECI1, SQ.1'f.
building acs nm currently have a tenant mina it is my resrymsibility m nrnify the necurym
of me requircmems which must be ma prior m issuance of a C<nificam of Occupancy.
Dam TOTAL: ISSUED BY:
Owner mouth t spent -
OFFICE