00010002 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 0,0 U U U !'
CITY OF CUPERTINO BUILDING-P,I,ECfRIC,AI, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING PRNOcTiBENrB,R: 50001
BUII,DINC PRIOJECf IDENfIFICATIII:q
SANITANV NO. APPLICATION SI113h11TfAL DATE
IIUILDING ADDNIiSS: - 1 ,r-(-a'1�) ��(�
'S � 1 F� r I '1 b'+-�
Ol1'NER'S NAME: PHONE: C-I1IVOrNACl01fS NAME: 'I Oe N/C �CONTIiOLp
CHITIiCIL (!]NEER: LIC NO. ADDRESS. ` ❑
2� a W
CONTACT: PHONE: BUILDING PERMIT INP
❑ Cnnsullanl Fees Paid by Applicant(Initial) BLDG fit PLumn Mrcil
VFp -ION ❑ ❑ Cl
CON'TRACTOR'S DECLARATQ'ry. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I an licensed under provision.of Chapter 9(commencing
CXZ with Seen..I(NN)lof Divi om3.ftbe B.drm, and Pmfemion Code.und my license is / RESIDENTIAL:
PERMIT ISSUANCE
a W in full lime unJ ellcet ❑SFDWL ❑KI IPLUMBING
REMODEL
pipll.
QUU License Ci_ Cama APPLIANCES-RESIDENTIAL, ❑ADDITION ❑I'Ll1h1BING k1iP11'li
y Q L pate Cnmmn°r ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATION PANELS MODIFICATION
ZC) z lundersand any plats.hbll be used an public omits UP 2W AMPS
_ ❑INT ❑
ERIOR CHIMNEY RITAIR
r4�Z Ipil T0I send Prnressanad POI-IIXIIIAMPS IMPROVEMENT C]SWIMMING FOULS
� g'9 OWNER-BUILDER DECLARATION OVER IWMI AMPS ❑HATH REMODELIKEPAIR [I DEMOLITION
C W6 1 hereby of nu that I ran exempt farm the Croulmo is Liceme law for the th
�°O a U following reawn.(Section 7031.5.nosiness and Profession.Calc:Any city or county SIGNS ELECTRICAL El OF HER
413 W v~i which requires a permit to arnstm i.alter,improve,demolish.ar repair any nmaure
F•�o,n 60T its iswanee,also myuirexthe opplican such perounur leasigneJ statement SPECIAL CIRCUFUMISC L7!? /__
yLha he is licensedpursmmmtbepmvisionsoftheCnnwnolsLi<enselaw(CM1apmr9 COMMERCIAL
a
po (`rmmeneing with Section YINNI)ofDivision 3 ofthe Busines and Ponfiesions Cale)or TRMP.METER OR POLE[NSE
ado C Rtat he is exempt therefrom and the basis tar the alleged exemption.Any violation of ❑NEW BLDG/ADIOI'I'ION ❑DEMOLITION
X W Section 703 L5 by any applicant for a Permit subjreu the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FWD SERV ICI:
rn more Ihnn f ve hundrW dnlinm IbSfgl.=QIMPROVEMENT(]1,ax nwnernl Wcpmpuny.rnnyampinyn:a withwngcxuxthnrsnlcmnmpassainn. SWIMMINGI'OOLELI!CTRIC ❑OTHER
F. will dothe work,onJ theswcma isnot imenddornMmd focwlc(Sec.NIM,Business
L3 m and leafessione Code:To,Cnmractor's License Law Juts not apply to an owner of OUTLETS-SWITCHEii-FLU NRES
property who builds or Intpmves thereon,uud who does such work hiuudf or through NEW RESIDIiNT1A1,IihliC l'k SV 1'I'.
his own employees,provided that such improvements ore not intended or affered for SR FE FLOOR AREA S/SQ.FT
sale If.however,the building or improvement issoldhewithin one ycaof iprovetfon put-
%S
eIf.howev will h building
r int rovemeproling that he did not a ild yeror improve for,ahe
pascal
1,as owner of the property,am exclusively contracting with licensed Contractors to BEL
onstrom the projoet ISsv.7W4 Business and Professions CWc:)The ContracmG,Li-
nsclawdoes not apply bsonowner ofpnycrtywilt,builds orimpmeesthereon,and QTY. PI.UMBING PERMIT FEE
whocommnsforsuch projects withaca Imemrts)Licensed pursuam tothe Cummnors
License Law. PERMIT ISSUANC
E3 Punt exempt under See ,B&PC htihls rcnson
ALTER-DRAIN& '1 VALUAIION
Dam
caner WON KIlR'S COMPENSATION DECLARATION BACK FLO
I hereby affirm under penally of perjury one of the following declaration':
[have and will maintain a Certificate of Comsem to self insum far Workers Compen- DRAINS-P s TYPE CONS'L'kUCI'IOn'
cation,as onvided or by Seninn 39 W of"tbe Labor Cade,for the pemmnance'If he
walk for which this petil is issued. I1X'1'ORES-I'GR'I'RAI'
m
[have and will maintain Workers Crmp:nmtion Insurance.as teyuircd by Swoon
37INIOI the Labor Gude,lit the periomusnne of the work for which this permit is issued. GAS-EA.SYSTEM.]INC.q OUTLETS OCC.GROUP ANN
My Workg Cnon,rsnam Inornme caries and Policyn
Camcr. I�� 'a�Policy QkL2-�` GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OIEXEMPI'[ON FROM WORKERS' GREASFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANC17 BUILDING DIVISION IBES
(Thissectionunal notbecomplemJ it thepennit isfornnchundrNJoller.14110) GRBASE'I'RAP PLANCHECK FEE
or las.)
I rertify thuGn the perfnnnunccof dot work for which lM1in permit ivLmed,lshall SEWER-SANITARY-S'FORM EA.11X1 lT' I'NERGYI9?li
not employ eny person in any mnnncr su as m benne subject m the Workers'Cnmpcn- '
Z ration Laws of Califomia.Date WATER HEATER WNENT/ELECfR GRADING THE
Z O A,h,naut 1
i'Z.y NOTICE TO APPLICANT:I[alcor making Unix Cenificnm of Exemption,you should WATER SYS'I USIGTPIAI'[NO SOILS FILE
1-•' baso'subject m the Workds Compensation previsions of the Labor Csdc,you must
ai r^ forthwall... ly wintsuch pmvisiu.,u,,i,pearn shall be lenood mvokod. WATER SERVICE
W �
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PFMIL Sp.PR PAID,U Z Date Reeeim p
L)Q (hereby uffmm that Mercnucrnntmminn lending agency for the of
W f•-' the work Lim whichthis)'unit isis,oval(Sri.3097.Civ,C.) ToIAI,:
OU Ler&ns Name TOTAL
Lender's Address
W HULLOING I}E
C 1 ccNfy than 1 have read this uppluallon and 11-re that 0c uMne mformanion is
H0 asmen.Iagmeu.comply with all city and county oNinaacesnnd state laws reWng to QTY. MECHANICAL PERMIT FEE
U building eunetmainn.and hereby authnme reprevmativo nfthis city loenmrupon the SEI5111'C lyifJ—L� U 11
ub,,vn.mentioned property for inspection purposes. PERMIT ISSBANCH E !:,,m�G
(We)agree In save,indemnify and keep harmless the City at Culeninr against
r I'mbllitics.juJgmems,ax.¢and espenses which may in any way came against said City ALTERORADDTOMECH. P I
m' on,,oloceof the,maningofihis fworml. - _
s
APYLICANr" UND FIONS,NDS AND\WILLCOMPLY WI'T11 AL1.NON-POINF IT'P AIR HANDLING UN (TO I11,11(X)CPM) li (IAN ip_L 1131?
TIONS. /^\
SOUR C 'GU � v j
nom'/) AIR HANDLING UNIT(OVER IQ(NNI CFM) 1N TR ON'fA%-��V�'L It�rtl
- gnat of Appheai l/Camrvemr nate EXHAUS'I'Hoon IWIUUCI'1 HOOSIN (TIG TEE
HAZARDOUS MAA ERIALS DISCLOSURE 2 20
WIII the applicant rr furan building occupant store in Imndle solution,maneriel IIIIATING UNIT(TO 101000 BTU)
ns Jefincd by'he Cupenino Municipal Code.Chapmr 9.12,and the Heulth and Safety BEATING UNIT(OVER 100.000BTU)
Core.Section 155321.1'! RV
❑Yes ❑No VI7NI'I LADON FAN(SINGLERESID) PAIDDo
Wilt rile applicant or fmurc building sccupam me ryuipmcm or&curswhich BOILER-COMP(TOP OR IW.00fI BTU) .!)
ntit hamrdou.s air cumaminunts as defined by the Ray Arca Air Quality Management TOTAL: 2
Disuinn. HOLLER-COMP(OVER IIIU.(NIDR'TU)
E]Yes No
AIR CONDI"GONER ISSUANCE DATE
1 hove read he h ode.S s materials rcyuimmmas nn153 LTapicr understand
df on if the
forma HwINn Safely Cale.Satinst,tho.it is myandns534.1 to notify thatifon' NEW RIiSIDENTIAI.MECII. SQ.IT / j —T
I,Inengdoes imnu,,ot constantly
,.bichoo-t amnom.Ihat.,,larve M.imficeofyamracupant G-
al the rcyuirmncna which maxi by n¢f prior to Lsuhnm ofu Ccnilicam of Occupancy. �J
Ownerrr.uthorimd agent Dam tOIALo ISSUED RY: C
OFFICE