S 1644 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE81T NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `V
-BUILUING PROJECT IDENTIFICATION
1644
11-DING ADDRESS'. SANITARY NO, APPLICATION. I CIAL DART
WN/T �iK GT— "
ERS NAME: PHONE: COWRACFOR'S NAME: LIC NO:
CGu° rwo Racy, rn .ram NYC CONTROL#
ARCHITFCC/ENGINEER: LIC NO: ADDRESS: ❑
P it
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EIEC" PLUMB MCCH
LICENSED CON]R CTOR'S DECLARXRON QTY. ELECTRIC PERMIT FEC
1 hereby scrum incl 1 air Bee..wd under pookinnx of Chapter 9(mllllmncing JOB DESCRIPTION
F"Z with Salies700B)of Division 3 ofthe Business and Professions Code.and my license is RESIDENTIAL:
❑2 O O e PERMIT ISSUANCE.
Fa+agF Ia fall linm oral effe£I. b �eKG3p CSFDWL O KITCHEN REMODEL
dVV License Class - 1I-icp i (( APPLIANCES-RESIDENTIAL ❑ADDITION OPLUMBING BE PIPE
ZZED Dam Cnnlmalor
ANCII]t'ECI"S UCC.'LARA'I'ION ❑MALT UNIT OSTRUCTURAI.
F O rn PANELS MODIFICATION
Z O o,i ZI underserd ray plain shall be used as public records
OZ„_Q UP TO 200AMPS El INTERIOR ❑CHIMNEY REPAIR
N.�.F cer,al Pml'cssiond 201-100PAMPS IMPROVEMENT [5 SWIMMING POOLS
aG� OWNERTUILDER DECLARATION OVER IOW AMPS El BATH Rich I;IJREPAIR El DEMOLITION
a C W G 1 hereby aff n that Into exempt train the Contractor's License Law foe the `I�
�d O G O into,in reason.(Sectio.70.11.5,Business and Professions Cade:An I I ❑Tyl'HL'k rb
g ti city or count SIGNS ELECTRICAL
W 3: y which reala permit m nmsuun,alter,improve,demolish,or repair any stmaure
IC"a.,0 Q priunoi(s iounnca,rJnn mgnires lheuPPliwnl Easuch pennon.file aligned aunemcml SPBOALCIRCUIT/MISC.
2;!(}•] that he is licensed pursuanvo lheprovlsiansoflhe Connectors License Law(Chaper4
1?�ap0 (mmatendn wish Smile. (Division 3 mfthe Bminessand Professions Code) COMMERCIAL
g )n TF.MI1MEfI:R OR POLE INST.
d W m C that he is exempt then,from and the hasis for the alleged extralaion.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
i4C1 4i Section 7031.5 hyany applicant for a pcmtit mhjeclsthe applicant tend,,]pcna¢yof POWER DEVICES El TENANT ❑FOOD SERVICE
Z} Dol nine man five hundred dollars($500), IMPROVEMENT
d O 6o the work,ands the
sir mymnntendedwhhwoges for sale
anrtpmtsines, SWIMMING IOOI.ELECTRIC
$y�QO
will docisionsCde,-Me mureartmes not License
roffered dos et apply
aq, owner of
OG'1'HER
a 3� and I'rofesinns CoJe:'ITe Cnmmemrs License Law mks net apply Ir an owner of OUT].ITS-SWITCHES-IIXTURIiS
Properly who builds rr improves thereon,anti who does such work Mansel!or(trough
his own employees,pmvi&d that such imprnvements are not intended or offered for NEW RESIDENTIAL ELECI'R SQ '
sale.11,however.me huildingdimprovemem is sold within one yemnfcompiner,,he SQ.EI'.FI )R41HIA s/SQ FT
owner-builder will have the burden of proving that he did not sold or Improve Int pur-
p] 1,us owner
TOTAL: A� ��
❑ 1,os owner of the property,am exclusively Precisions with:)ceased convenors t. j� All-,
construct the project(Sec.](141,Business anti I'mfcssinns Code:)The Cnmrum.r's Li-
cease Law class not apply toanownerofpropenywho huildsmimproves theater.anti hQTY, PLUMBING PERMIT FEE
womnvansfsv
nrstab,rjeely with ucnemnngs)Ikemedpurannnme Con ounnr's CCOIF U
Ur
License Low. PERMIT ISSUANCE L'ul"Cn111YIJ
O 1 am excinpl under See ,R&P C ferihis mason
ALI ER-DRAIN&V PINT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty rlperjury ane of the follnwing daaamlFons.
❑(hove and will maintain a Cerificde of Conmrno.elf-insom for Workers Condst DRAINS-FLOOR,ROOF,AREA,C'OND, STORIES TYPECON$TRUCTION
ration,as provided far by Section 37110 of the labor Cele.for the pemamo ce of the
work for which this permit Fs Issued FIXTURES-ITER TRAP
O 1 have and will maintain Workers Compensation lie un.ser.as remained by Section
370041he labor Curb.for the prommusace of the work far whichdii,permit is i.ss.ad. GAS-EA.SYSTEM-1 INC.J OUffLF IFS OCC.GROUT' APN
My Worker's Compensation lmumncecturierand Policy n y y �f�f
arrier. r7bn G./Ib policy Nn:��ao�iq_�/ GAS-EA.SYSTEMOVER 4 Baeo
l If7a�CEh OP L%IiMI'r10N FROM WORKERS'
/ COM PENSAI'[ON I NSURANCE (IREASFANDUSTRL WAS"ITB IN'IiRCEPFOR
BUILDING DIVISION(IAS
(Tills senior Dad not be completed WE,permit is fornnehundand dollars($100)or In,,.) GRF.A513 TRA(' PLANCH[CK PEE,
Icenifythat nthe perfmmanceof nhewrnkforwhichmispemtit is issued.].hall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to became subject a the Workers Compcn- ENERGY REE
0 Z amion Laws of California Date WXI'17R HEXI'17R W/VBN/ELECTR
Z 2 Applicant GRADING FEL
h NOTICE TO APPLICANT:If,after making this Ccnifirme of Exemption.you should WATER SYSTI?MG RGTING
CZ5 become subject to the Worker's Compen.mnian pmvkirm of tie Labor Calc,you must SOILS FEE
ser forthwith comply with such provisions or this pentilahall be domed revoked WATER SERVICE
W G
U Z CONS'T'RUCTION LENDING AGENCY NEW RESIDENTIAL l'LMII. SQ.PT PAID Dane I p
L)0 I for
thi lhdthere isaamsvuc.imnlendis,agency fonhe performance of
the work for which this permit in issued(Sec.3fH),Civ.CJ
{!•r I"I Leander',Name 'TD
Icnder' Address TOTAL:I
atilt that 1 have ratA this uPPlicminn and gwe Thal Tho thous information is BUILDING PI?B
i.. rV) correct l agree to comply with all city and county ordinances and some laws relating ,, QTY. MECHANICAL TERM[F FEE
U Z building constmnion,and hereby authorize representatives of this city nt enter upon the SEISMICFEE
'� shove-tnomiuned prnpany for inxpemion purponu.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCELLBCI'RI :E
liabi]iiies,judgmems,costs and expenses which may in anyway accrue against said City ALTER ORADDTOMECH.
in nscquamx ores,grunting of this permit PLU NG PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T010,000CPM)
(ONkCE R1iGULPj'R S. . / �1 /tg�
AIR IIANDLING UNI'I'(OVIik I4IXXt CFM) CONSTRUCT]LFEB
RUU CT( TAX
A c
5 nemofAPPlirnn .minder �� EXHAUST HOOD(W/DUCT) HOUSING MI"IGA ]ONR!H
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hateadous neterial ffEATING'ONi'r(TO 100,020 BTU)
es defrost by the Cu,ramo Municipal Code,Chopler 9,12,.,at the H.,11h and Safety
Cade,Section 25532(a)^ HEATING UNIT OVER 100,000 BTU)
EI Yes FIN. VENTILATION FAN(SINGLE RESID) PAID Uute kcceipla
Will the applicum or future bulli ins uwcupatn use equipmeut or devices which _
emit hazandouv air turnaround,.dcfned by the Ray Area Air Quality Management BOILER-COMP OHI'OR 100,000 BTU)
TOTAL.:
District'! BOILER-COMP(OV FR 100,000 BTU)
[]Yes E)No
1 have rand the"Drano,n e","Is remulrcm n's under,Chuptcr(95 01 Pte Coli AIR CONDITIONER
ISSUANCE DATE
brain Health&Safety Cale,Sections 25505.23533 and 25534.1 aalarxnand that if[lie NEW RESIDENTIAL.MECH. SQ.IT.
building docs not c manly have a mount(hat a is my ar,a sihilily a it the eccupant
of the requirements which must be met prior to Issuance it a Certificate of Occupancy.
Ownm or malrozed agent Dom TOTAL ISSUED BY:
OFFICE