S 2322 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BU ILI)ING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n
BUILDING PROJECT IDEN*rIFICATION L
RIIILDINOADORIiS$'. � ' V , ��� O� r� SANITARY NO. AYI'LICATION SlIBM1 �ATli
OWNGR'S NAMEI: V ['HONE' (l CONTRACTOK;S NACMP,: y� _ LICNnL 1
S I b LIE y X16- 1 �S k ( ` 1a V NIC CON'I'ROLp
ARCUTTEM71IINGINPER: LIC NO: ADDR^S C AVC _-1 ❑
CONI'ACI: PHONE: ` BUILDING PERMIT INP
T 1� /��_(� `,,1 ,�-7 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT 1'I.unt MECII
J J U l —1 `1 J ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am uan>ed under provision%of chapter 9(commencing JOB DESCRIPTION
F`M) Z with Section 7000)of Divioma 3oi he Bronewand Prfmsien Cdc,and my llccnmk RESIDENTIAL:
ob in full force and cRttt PERMIT ISSUANCE
�UF"
Flinn Clnxs L� C Lic.M 593616 ❑SPDWh E3 KITCHEN k6l10Di$L
G U APPLIANCES-RESIDHN I'lAL ❑ADDITION El PLUM B ING RF-PIPIT
y¢ul Dom CHITECIS DI!CLARAItra �I L�
GGzz Iundenrund lin I:mv.%hall be used u.. Mie;..ION ❑MULTI-UNIT El STRUCTURAL
F.7N PLV pp s/ 1'ANIi1,S
Lards MO(/`e MODIFICATION
--Z n'- illy Pu UPTO 200AMPS
❑INTERIOR ❑SWCHIMNEY
MING PPAIR
OOL
NNf-W Lianttd Prnle,sionW 2(11-IIXIU AMPS IMPROVEMENT
OWNlili-13111LDGR DECLARATION SWIMMING POOLS
st 1 hereby affirm that 1 an exempt from the Comescmrs❑cenoc Law for the OVER 1q0 AMPS ❑BA'PH REMODEI/RI?PAIR (]DIiMOLIT106
X G U Iolluwirg..mon.(S'clio 17031.5,Business and Profex%ionc Ced,Any city or county SIGNS ELECTRICAL ❑OTHER
LL131y I- which requires a permit m conotmct,alter, emo
improve,dlish,or repair any structure
�sit pnations also.....lso requirasthc.,huont lm,.vh permit ul ileatigneJsmtement SPECIAL CIRCUITIMISC.
E y,�„ Ike heiJicemcA pennant mlLep...Ashur,ofrhe Contractors L
' uw(CbupmrY
ta+7��L0 knmrluncing'vim Staion 70(pd Division 3.Dhc Rumness and Profe,ions Code)or TEMP.MB'TER OR POLI!INST, COMMERCIAL:
a pt ca a mhw he is exvrnpr damlrnm and the basis to,the alleged escapism.Any violmian of ❑NEW BLDG/ADDITION ❑DEMOLITION
xas
LVM to Section 7031.5 by any applicant for a permit subjects the applicant to a civil Fenally of POWER D17VICES
nth
al more an live hundred dollars 1S500). E3 TENANT C]FOOD SERVICE
FI.as owncreflho rt.ornm Iooe,wit h wince m their soletern Iron, SWIMMING 1001,17,E TRIC ROVEMEN'I'
p Pn+Ps' Y Yn7nP Y b Rruv
F will Jo the work,and the%wcum is not intended or offered forsalc(Se,7100,Business ER
13. and Po'l—in is Code',1'le Coalrrcloh Iicelne Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or rmprovet thereon,and who docs such work himcelf or through
his own employee,provided that such improvements are net intended or oficred for NEW RESIDENTIAL ELF,CIR SQ ET.
sale.If,however,the bonding or mpravemcm is ,,It within line year A rompletion.'he Q Q T.FLUOR AREA pSQ.IT.
owner-builder will have the bumen of proving that he did not build or improve for par- /
poac of nMlr_I.
❑1,as owner of the properly,am exclusively conrracring with licensed comnnotx r TOTAL:
marue me project Se,7144,Business and Proks%ions Code:)TW W Contractor's Li-
cencLnwdocsnrnupplymnnowncrnfPrpcnywhohuilavurimpnrvcslhcrarn,unJ QTY. PLUMBING PERMIT FEE
who contact,Fortner projects with a,a n exuami)licensed p.,.an,to the Conimaor's
Liana Law, PERMIT ISSUANCE
❑ I am%tempt under Sew. ,B A P C for this reason
Owner Dom AFTER-DRAIN in VENT-WATER(EA) VALUA'f[ON
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT'.DEVICE
I herohy;lion under perAn of perjury nuc of the fallowing Jcclaeumn:
❑ I have and will maintain a Certificate of Consenno wif-inwr for Wader's Compero DItA[NS-1�LOOR.ROOI7,AREA,COND_
oaken,at provided for by Section 3710 of the Luton Gde,for the performance of the STORIES TYPH CONSTRUCTION
work for which la,permit is Tsar W. FIXTURES-PERI RAI'
❑1 have and will maintain Worker'%Comper%mion Insurance,at required by Section
3700 of he Ember Code,fur the prifonninse W he work on which this Permit L issued. OAS-I.A.SY$'fP.b1IINGJ DUTLEI'S
My Wm cC°npW y. Iq...are Order and Policy t hcrrrc OCC.GROUT' AI'N
Currier:S,)ner5 ;s) Policy N..R�JG 1 "1 to7 CAS-Ii,.SYSTEN-OVER 4IEA)
CAGee'FICAMOFEXEMPION17ROMWORK ERS' C)-L_l COMPENSATIONINSURANCE GREASE/INDUSTRI,WASTE 1NTIRCEPTOR
Clbisnation mud our becomplctea II mepartedis I c hoodreddollars ISI(R) BUILDING DIVISION PIiES
nr Russ) GREASETRAP
1 clamor that in tire performance of the work lin which this permit is issued.I shall 1'LANCHECK FEE
not employ any person in any learner so as to became subject m he Workers Cl rS[WEk-SANITARY-S'IOItM HA."'
Pen ENERGY FF.13
Z tothm Law,nl California.Date
Z O A li nI WATER HEATER W/ 'f/1'1EC'1'
GRADING IPG
aZ PP ti hoc( c uh APPLICANT:If,ager making thi.-O,aCrhi ,of of FLine,inn,you should WATER SYSTEM?RL
becmne scom,p m the Wodewv Cnor,or ila, provi%inns nF the Inhor Cade,you must 'OILS TTG
fnnM1wilh mnmply with ouch pravraonn nr Ibis permit shall re JcerneJ mvukeJ. Wq'1'BR SERVICE
7z CONS'I RUM ION LENDING AGENCY NF,WRISIDEN"1'IAI.PL. SQ.1.7. Pi U
U p l humby offirmma there itacnnthe,lam lendingagency fur the perfomt°ncc of cretink
Pthe work for which this lac all is issued(Sec.NEO,Civ.C.)
U l,cmdce,Name
O Ud 1<ndch Addmas OO H vL TOTAL
0. 1%oily That I have read due aPPlicarlon rind slam Thal IM above information is O J RUILOINC FEE
lin correct,lagree to comply with all cityand county ordinances and sine laws iclaung ,, Q'rV. MECHANICALPERMIT FEE
U Z Imilding constmenon,and hereby aumorim representatives of this city to enter upon the SEISMIC FEF,
akwmmenlio tell progeny fur inspuaion pompom. PERMITISSUANCE
(We)agree to erre,indemnify and keep harmless the City of Cupertino against FLEC'FRIC FEU
li;bil... jud"notis, oo,and expenses which may in any way scans againm.emid Co., ALTTR OR ADU TO MECII.
in onsmgrence of that gr a gof this permit. PLUMBING FI?E
At c .IC . 90
AN"I'UND-R.f OS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNI'T(TO 10.000CPM)
5f (CE REGULA / MECHANICAL FTE
✓B/�� AIR HANDLING UNIT'(OVER,f,pi I C17M)
CONSTRUCTION TAX
6 turc of ApplicaHAZAR O Uulc Ii XI IAUST 11001)I W/DUCT}
HAZARDOUS M ing(ic p.DISCLOSURE HOUSING MITIGATION PEIi
Will the applicant or(Mune building,Chapt aura or nd t e Health an materiel IIEA'fING UNIT(TO IIXLIXXI N'1'U)
C defined by the 32(a)?nn Municipal Cale,Chapter 9.12,and the Health and Safely
Cuda Scmion 25[321u)7 HEATING UNIT(OVER IULgXI FIT U)
Yet F-1 No
VENTILATION FAN(SINGLE RESID) PAID
carat Will the air contnl or future asbuilding by the Bl use ea Air Qu lir devices which Dule Receipt p
haeaNnm air nmammanms as defined by the Bay Arca Air Quality Management BOILER-COMP DHP OR I0I,IX013TID
Dist'i'll TOTALf
❑Ycs E)No BOILER-COMP(OVFR 11X1,0011 B'1'U)
I havoreal On,hu,ndmw materials roequilearm,under Chapter 695 of the Cull- Al R CONDH ION'IJt
=BY
NCE DATE
Bmmia gdoes m Softy Gala Saekn.%8505.25533 anti 25534.1 undemund IM1m if the NI3W RESIDENTIAL MECII. SQ.FT
builJingammosecurrently hoveisenator,that it i%myrepomihility mnotdytht try.nl
of me mquiumemc ouch must he mm pn)nnissurnce nfu Cenilienw oftknpmunq.
Owner or anhontod agent Date TOTAL ISSUE
OFFICE