B 0311APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL rtRmu ro, 0 311
APPLICATION/PERMIT PLUMBING. -MECHANICAL
HULLOING 1/1VI51(IN 1 e,,,, ,,,�„ dn,add. ,-,.,,,,,r.nlna IS0001
4::�en6-rOVE De -
CONTACT PHONE
31- 38y s/ ❑ Consultant Fees Paid by Applicant (IniHal)
LICENSHD CONTRACTORS DECLARATION 'QTY.
I hcaby aRfm mad 1 am Iiamed under previsions of Chwi f 9 (comneaciny
.'C)Z with Scction]II(11do'Divisio J oflM Bushes. and Pmfiet6n, Code, anmy liccmc is
Y�� in fulltma awl cfftt'I It I
QUZU Lienor Clu, l- Lw
6� Date
RCHfIIiCrs TS D1UECrorfA ATI N
Zv-'Z IultMsfad my Plans,.• hausedsspddJiefmrd,
Z—_
rn F_ W Lialucd PafasimtW
OWNER -BUILDER DECLARATION
C Q I krwhy affirut I am camnpl from the Conln,r'n License IWw for Thu
m Nmc
O6 UF folldrring reason, (Section 703EJ. Bte neas unit Professions Code: Any city or,unt
cy
LLEO N which requires a pemtit to amlreal, .11w, impm.x, demolish, or repaif.1 swoon
sn y -j Pnr,.00,suaOee.alson,macs the m,licam fm ouch pcmot1. Hlctiolotd uwcoant
y1 T that be I, licensed pu.at to One fwvisims of the CnnusctNS Liam. Le. (Ch,.r 9
X00 (extrowndng with Satian](M)ofDiveawt 9 of the Huai dens. and Podlessions Gdc) or
1 e p( ltdu be it exemq then(. and the bvu for the alleg 1 exemption. Any vimfumb of
�mINLSection 703 IS by any apPlicam for a permit wbijec, the sppli.-am to ac,%il p,wdty of
f=C
not omen Than It, hmdreJ dAla s (SN)()).
o I.ssder of Oe ploPi u my employee, with wUc, ueir en enmpem.
rdao
'HE do Jen wrxk, mdI the afuclme is not intended or o ferN for ole (See. TOW. Bad..
awl Pmfasi,n, Co&: The Crnlri LLenx I -mw dor not apply to an ,wmr of
ta' Popcny who FuiM, err ma mve, dcrcon ad who docs wan work himfclf er through
his,wn employext, provded d a mch impnrvemem, the nit moodded a aRefed for
talc. If, o :roc,, the buil'og or impnwemenlo. taXJ withinone yearofcomph,tiat. Ile
awfer-Wilder will M, Ue hmden of IeovinS that he did not haid or ma, we fa pur-
Iw.e of rale.),
1, as u rte, of Je poperl , em ctclusivcly corn ting with mocnud aodwtm to
codw,el the prolene( (Sea. ]BLT, Busime and Proftvvass Code:) Tac Conuaclar's li-
neLawddc. not apply to an tomr of,roeny wlc buihL er mpreve, lured. old QW..
who comment, Encroach pretence with a cvwsout Ikcnsul Pnvwtnn met conmam'I
Littnsc "..
Tum eaemp uwf,r lee. B R P C for this rwwn
ELECTRIC PERMIT
PERMIT ISSUANCF
APPLIANCES - RESIDEN IAL
PANELS
UI" IO 210 AMPS
2014000AMPN
OVUR 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUHfl ILSC.
T MP, MITER OR POIJ? INST.
POWER ULVICFS
SWIMMING POOL. ELECTRIC
OITf LEIS - S W ITCHILS - F1X'1'ORES
NEW RESIDENTIAL EL EC IZ SQ PT
Owrcr Dae
WORK17R'S COMPENSATION DECLARATION
1 hereby u1Rrm unclear Tomah Of perjwy orc of de folbwiog dzluaimu:
IMvc end will mnmvnvCrnifalc of Gxutmnn,dGinaum for Workrr't Compere
wide m pnnldal for by Suctim 9]IL of lM Isbn Cal, for the pufantcncc of the
k ry✓ Tenn wt rcmOl E unrd.
�rYha,c unJ will ntainmin wdrtkcr'x compcmffic "ark
fi, a.,h a, pee by Stttim
3]1X1 ooflyneer l�a(l'yy�C�o+le. far NenypyeyAdwx�runce floe woto lar whlcM1 lhissp�rm�tul>uqux,eJ.
CwW{ 79 VIT J'r.IIC Polly NoTrlaDa Ivl4
Came Palmy Ni 1���
CIRTFIC OF FROM W
ORKERS
COMPENSATION INSURANCE
([nit rection mrxl nmbcannpewd1,1en '
pcmtil u for.,. dAlurs (3 1X)
or ka'.)
I 1 certify that in the perf.e of the wort for which this Pctmit is issuM, l shall
ret cmPlny any perom in any manor w as to Become uthjecl to the WwIecw Contpcn-
7, .union liwsaf Califmnis. Dec
z2 Applicant (
(n NOIUCE'GO APPLICANT: If, after rating Ni, Comfiewe of ExcmlNion, you should
Fa bccrntte whject to tho Worker's Calm metai an provision, of t1e labor Cade, you must
form. in amply wire muh prevision, or that Permit shall he decmml revoked.
a Q
CONSTRUCTION LENDING AGENCY
1 Mrehy a[Rrm lMnMm io n anucd
aridm Lending ugatcy for Pa
to' rfumtutrc of
LL- the work fm "ch this permit is dewed Sec. 9(19], Civ, CJ
Q ULenient'. Name
Lancer'. A,1f,,
C I edify than I lave read this appliaatioo sod . that the above iafeentation E
h axrcct. l egfa In dimply with all city end county orJitnnav vod stem lows rtlalin6lo QTY.
UZ building comartainn, end thereby uulhuriac rtpdeentativ6 of to% city locator upon the
shove-lteattwred lro crIy fer in.Pce6da purposes. .
(Wer) mace In.wve, in wwaTy wit ott, Moles, Ode City of Cupeninn egaiml
IiabiIiIic.juJgmcm,cw, oral cape.. which may in anyway ac me erg 1said Cily
n cnsugcrce of the glaring M Of%permit.
APPLICANT UNDIERSI'ANDS AND WILT, COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Il"ARDOUS MATERIALS DISCLOSURE:
Will the opplicanl or future building ofaupanl tore, handle 6u mod u, nulerial
lineal by the Cupertino Municipal Cal, Cheper 9.12, and Bte Huhn aha Safety
Satire 2S532(a)4 �
❑Yes
Will me uppliunt of (alum building occvpnm um cyuipncm nr devices which
heaadnu, tw anuminana u dented by the Bay Are, Au puamn, Mwgemeat
no Ye, 6
I have read Oe hafnnlu mrerinlo d�uilrnnn, uakr CTaptcr 6.95 M'thc Ctle
a HrN1 Selo G � dos 255(H. 23593 aha 2a33d. I wJntiaml Ihw if tM
iogdct`d)�uic lcnvtl. lltvbia my luponsibilidy to ftm;fy theoaVpan
PLUMBING PERMIT
PERMIT ISSUANCE pi
ALTER -GRAIN L VBHT-WATER (EA)
BACK FLOW PRO ECL'. DEVICE?
DRAINS - FLOOR, ROOK AREA, COND,
II XTURIS - PER TRAP
GAS -IIA. SYSTEM -1 INC. S OUTLETS
GAS -EA. SYSTIN-OVER X (EA)
GREASHA NDU.STRL WASTE INTERCFOR
GREASE 'I'RAI'
EWER - SANITARY - STORM IIA, 21X1 FT.
WATER HEATER W/VF IOELECTR 1
WATER SYSTEM/TREATING
WATER SERVICE
NEN' RISIDENTIAL VLMB. SQ, FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ACFER OR ADD TO MECR
AIR I IANDLING UNIT 1'1 O 10,000 CFM)
AIR HANDLING UNIT (OVER If," CFM)
EXHAUST GOOD(WIDUCI)
HEATING UNIT ('1 O 100,000 If IL)
IIEATNG UNIT(DVBR IM.000 BTU)
VENOLATON PAN (SINGLE RISID)
BOILER -COMP (3HP OR 100,000 BTU)
BOILER -COMP kOVER 100,000 BTU)
AIR CONDITIONER
NEW REMUENTAL MECH. SQ. Fr.
TOTAL
OFFICE
5120)99
FEE
BUILDING DIVISION FEES
PLANCHECK ITE
ENEKGY FEE
GRADING REE
SOILS FEE
PAID
Bac R,,cipt #
BUILDING FETE
FEE SEISMIC FEE
ELECTRIC FTP.
PLUMBING Ill
MHCI IANICAL IEE
CONSTRUCTION TAX
HOUSING NIGUGATION FEE
BUILDING PERMIT IN
BLDG ELECT Pi MECH
FEE
JOB DESCRIPTION
RESIDENTIAL
❑ SbOwL ❑ KITCHEN RGLOUEL.
❑ADDIT[ON ED PLUMBING REPIN:
❑MULTI-UNIT ❑SFRUCFURAL
MODIFICATION
El INTERIOR ❑ CHIMNEY REPAIR
IM PROVEAENf E]SWIMMING POOLS
❑ BATH REMODE11RUAIR ❑DI:MOLITON
❑ OTHFR
COMMERCIAL
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE:
IMtKUVIi ON'I'
❑ OTHER
I
SO. FT FLOOR ARBAUIQ.
IT
FEE
BUILDING DIVISION FEES
PLANCHECK ITE
ENEKGY FEE
GRADING REE
SOILS FEE
PAID
Bac R,,cipt #
BUILDING FETE
FEE SEISMIC FEE
ELECTRIC FTP.
PLUMBING Ill
MHCI IANICAL IEE
CONSTRUCTION TAX
HOUSING NIGUGATION FEE