S 1939 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUn,IRrvr.-III.ECTRICAL, I'ESIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUn1RING-M1IECHANICAL J 1939
.) ' _•IlU1LDING.PRO,IEC7 IDEN'T'IFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMI ITAL DATI
OWNER'S NAME: PHONE: CO�kN.TRACfUIfR NAM&' LIC NQ
-44e r_6 y �1 Pikt20ya ,/A-S 0�2 Y'N'�4,$ NEU CONI ROLN
ARCI111HC'I ENGINEER: LIC NO AIIIIRISS ❑
4" 'Al c A-X✓• r/ V
CONTACT: - PHONE: .sof: i.
i BUILDING PERMIT INTO "'
� . 66-0 If$4-7oliL/ E] Consultant Final,Final,Paid by Applicant(Initial) BLDG F,LFCT PLUMH MECH
V El 171 L]LICENSED CONI RACI OR S DECLARATION QTY.ir'II I'I;ECTRIC PERMIT. s ). CF6'•'1•
II by n d tI 1 1 orderp = t Clubtair al a .dE, JOB DESCRIPTION
OWZ wills I' 7000) fD'v.an3 oflh &� sunJl mlcxsl uCuJe and nyl close'. RESIDENTIAL:
WOO V PLRMITISSIIANCE
NW-. In flit and all I 0 VVV p ❑SFDWL ❑KITCHEN REMODEL
�UU Lionise Clu's Lick * / /- APPLIANCES-RESIDEN'T'IAL ❑ADDITION [:1 PLUMPING RIE PIPE
NCL IJWc� Conlrate �
ARCHHFC'E'SDECLARA'I'ION ❑MI11S1-UNIT ❑STRUCTURAL
yZ I nndcrvmnd n1Y Plane shall be u'cA Ila pnbllc..cords PANELS MODIFICATION
Oz`�0 CP'r0200AMPS DINTERIOR _ ZGCMMNEY REPAIR
F„�,,,F",W Lmm'cd Pmfceslonal 201-I000AMPS IMPROVEMENT []SWIMMING POOLS
.] OWNERBUILDERDECLARATION
Eo: 6 1 hereby vfflnn Wa I nm exon I From the Cnmmcmr's Gcenw Lee for the OVER 1000 AMPS D BATH RF.MOGFL/REPAIR []DEMOLITION
pp, {� P
x C U rollowing resat.(Sedan 70315,Business and Prnfes'inns Cole:Airy nnon manly SIGNS ELECTRICAL ❑OTHh.R
W 3 W y wloan hea hale a pennil no eansbna,niter,improve,Jemolish,br repair any.unron,
I-vW_i0Q Drala t 4ow,'he applicant bpernal fl 'y ITtonenl SPECIAL❑RCUII'IMISC.
W y ti that he liveneled pDoWitill I theproonrosof the C t a 1 E' (Chapter9
�00
(eationactio n,willaS l A00) f Division 30 he B ''n.1,and Palfiellion,Cale). 9 IM P.MEI BIt OR POLE INS'1'. COMMERCIAL:
IY a Ib.t he s exenTe 11weld o t and he basis bar the alleged enempl a Any oo lafo 1 of ❑NEW BLD6,ADDITION D DEMOLITION
m Section 7031.5 by any applicant for 0 permit st,bjele the ap,lu,nd to a'tell Penally of PO NEk DEVICES D'PENANT []FOOD SERVICE
Wzy not momlhan Live hundreddollan($5IX0. IMPROVEMENT
�+, 6 [] I,a'owner of the...pang.or my cmploycex with wages as lheirvnlecnmpeneatinn, SWIMMINGPOOLELEC'f
y� O will do the wcO.i Ith,Oactufeix lot intended m offered tinsel,(See 7044,Business []OTHER
3ro and indecorous Cd TheC 1 'I Io J tapplyt lie,of OUTLETS-SWI"PCIIES 'IX RES
or
property h bulls mp 'c 0 d h does h k1 If through
his own erployms,p 'd d the I h p I lintended rfid red fo- NFW RESIDENTIAL ELB R Q IR
sale If.however,the handbill, r'nt.mval n is sold within line year-Ill i pcionthe - - SQ.FT.FLOOR AREA g/SQ.FT.
owner-hu'Jder will have the harder tit provio Od he did not build or urpmva rorbul-
vc of ale.). .
[:] 1,e'nwner of the pmpeny,ran vclesrvely calibrating with licensed umvmturn to T(YfAL'.
lierosional the. J 'l(.Sea 7044 9 arid Porta,son,C I )1 lie Corrientes L'
Law does not applyt fn par 1 boadds or ininevesm - 1 QTY: "(- fPLUMEEINGP.ERMIT 7tI I '-)'•` FFFI'E
wit uhict, p jeerswd acontractor O licensed.'noun [lie Contactors
Liars Law. PERMIT ISSUANCE '
❑ I are exempt0odor See. ,B Sir PC fa thlsnrrnn
ALI HR-DRAIN&VENT-WATER IFA), VALUATION
.Owner Data I I ^
WORKER'9COM ld,,U'r10N DECLARATION BACK FLOW PROTECT.DEVICE V
have
eand drou antler penallYof iCouinenr floc fnliowing declandinm:
�IhOvcand willmelamine Ceni find'of the Labor
C 1,-insurefar Worker'xCnm EI, IIRAINS-NI.OUR,ROOF,AREA,COND. S"fOl11F!S TYPO CONS'fl<IJCTIO!
sudors, r pmvidhi for by SN issued
37(10 of the Labor QrJG nhc perfmmana o!the work far I' hlh:p I d. IIX'I'I1RPS PER TRAP '
❑ I have and wdl antrandoin Worker Cour,busearban nourance.asartured by See In
3700 cloth,Labor
JJC�oll for
tI�it pe[ w 111 it which the Parent is or otl CAS CA.SYSTEM-I INC.4 DO I I.FCS OCC.GROUP APN
CaaE s;Y:QL (�/hp/curt Policy Ne.: ryllh 1GAS EA.SYS P17M OVER 4(EA)
CE KI'll'ICAI'17 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASE/INDUSTRL WASTE IN'I-ERCP.PTOR
cad nal N mnuplecti Blhe permit Iv far ane hundred dollars(S 100) B�IyDWG DIV1910N•FE0.S
CI'hls sctllnn n GREASE TRAP O,
or less.) PLANCHPAK PEE
I"and"Ina inlhepufa...EE mfthe wnrkr..whihWis pennil ulssod.I'hull SEWHR-SANCI'ARY-STORMEA.2110FI' a
nm unpiny any conal in aty mannerronn't bee n4-okovd In We Worker.Conryen- �1 ENERGY PEE
cz salon laws A Calidurlkanl .DOye WATER IHEAT IIR W/VENT/ELFCTR GRADING PEE
O Apt " A _
ry NOTICE TO APPLICANT:If,after making lit' Ccnlfcaonf Eurarplien,you shonlAWATER SYSTEM/1'RP.ATING Ja
become subject lir the Worked Cmnpensation.mvisions of the Labe,Cade,you nmel SOILS PEE
Icy fnnhwith r0h ply with such provisions orld,pennil'hall he dwmal revoked WA'fEk SERVICE
a \
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELME. SQ FE PAID kecei IW
U O 1herebyaf&m bad there i'acomwenon lendrgagency or pedivou'neeoI p
the work rorwhich this Farad is Issued(Sec.3097,Civ.C.)
w '10 AL
Uch
Lend ,Name
OU LendersAdI .: : it -
I'YI LIQHUI LDING FE
fa L nfy11'lrp dthis a'pp I doltthat m 'h r t - - r t
•". h ca I I'g I ply I'll all any I tr r da t r relining ill QTY • MECHANICAL":'PERMIT "�'(i' FPE
U z fundingconstruction, dh by thanrepresentatives tf eerytoe terupon the t ..("-. i i `: SEISMIC PE
above renfloned property for-inspection partleact,
(We)Gecto ea,c indannilly and later,harm's'the Ch,or Cupenoaagainst PERMI'C ISSUANCE IILEC'I'RIC IN
liabilities,judgments,mets and exp, is whichmay i a luny way acne against said Gly ALTER OR A DD'CO MECH.
cmeprolc of he granting of the,Dab,il. PLUM HING FF.
APPLICANT UNDERSTANDS AND WILL COMPLY WI'CH ALL NON-POINTAIR HANDLING UNI f('fO IOIMIO CPM)
' SOURCE REGl1LAf1099. MECHANICAL FEE
AIR HANDLING ANI'I(OVER 111,000 CFM) CONST'RUC'TION TAX
S..mmne,of A,PliwnUCnmrauor Or EXHAUSTHOOD(W/DUCT') HOUSING MITIGATION FIE
HAZARDOUS MATERIALS DISCLOSURE
Will Fee ap.hcam or fame handingo¢uINn ,lan,lir handle lmz.dar,awocnal HEATING USE'I'(TO 100,000 BTU)
as defined by the Cupertino Municipal Coda,Chapter 1).12,and We Health E I Safely
_ Code,Section 2592(0)! HEATING UNIT(OVER 100,001 BTU)
e Nn
VENTILATION FAN(SINGLE RES][)) PAID Dam Receptor
Will Ire applicant or fhmre building occup int Use CFuipmenl or devices which
,limithazardous air eonmnrinams Its defined by the Bay Area Air Quality Managemenl BOILP.R-COMP(31IPOR Itl(Idell BIU) TOTA!:
shiaY BOILER-COMP(OVER II0,000 BTU)
Dyes E]No
T have rule thchmnldom maenaN rc ix undal Cha iter 6,05 of the Cali- AIR CONDITIONER ISSUANCE.DATE
w
to Health&Safety C d Sections 2550525533 and25534 1 hadchmandWto fthc NEW RESIDENTIAL MECH. SQ.Ff.
bu lJ yI I dyl t td
itY sp 'ibllyl ffyd xoupait
al th1Fmncns wash onsibtenct piiceafaCertiticalent Oscpaney
Owner or aulhorired agent Dam TOTAL: ISSUED BY
OFFICE