S 2590 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2590
BUILDING,PROJECT IDENTIFICATION
BUILDING ADDRESS, SANI'T'ARY NO, AI'1'LICA"f10NSUB1,11'1 LDAH'
10a04 s PoQrAI, AVE _39--
OWNER''�SN�MHIi: PIIONE: ! CONE RACE OWS NAME: LIC NO:
r-Akn l A/ GUN�I N/C COME ROE,
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: I'HoNE: 13U ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG .f� U Cf PLUMH LCMliCli
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I..licenmd ender provision of Chapter 9(commencing JOB DESCRIPTION
FCZ full force an liem�avisionlnfthc Nusinesc and l'mfeccinns Gde,anA my fiesta is RESIDENTIAL
X00 wa PIiRMI'1'ISSUANCE ���
aur' in ❑SFDWI. ❑KITCIIIiN REMODEL
,c U License Class Lic.p
y Z a Dam Conamcmr APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMNING RE-PIPE
ARCHITECTS DECIARATION ❑MULTI-UNIT [I STRUCTURAL
F w y RANEIS
Z O rn Z I undcmand my plant shall be usedm'.uM1lic..a,, IMN1NECAI'ION
=
OZ � UI'TO 2(MIAMPS El INTERIOR ❑CHCHIMY REPAIR
[-..ul Licensed Rofessinnnl 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
CY1� owNER-BUn.miN DECLARATION OVER 1000AMPS �TH REMODEUREPAIN ❑DEMOLITION
6 I herehy affirm that I am esmm.,from ane Contractor's License Law for the
�3Lica.FV- following ret.con.(Section]031.5.Business and l'roflionow Code:Any city or county SIGNS ELECTRICAL El OTHER
LL y which regairex n.sant m construct,elm,improve,demolish nr repair any swewrc
6 .nor to its issurict,. ten rrymbe,the...firm,kawsh pamhino flcasigned stactord SITCIAI,CIRCUIT/MISC.
>—T that he is licensed pursuant In the provisions of the Cotracmrs License Law(Chapter 9
=00 (commencing with Section 7000)of Di vision of the nosiness and Profusions Code)it TEMP.MLniR OR POLE INST.
COMMERCIAL:
a q y that be is exempt hherefrmm and he basis for the alleged exemption.Any viola ion of ❑NEW BLDG/ADDITION ❑DEMOLI'T'ION
W..y Section7031 S by anyapplicant bre permit subjects the applicant to a civil penalty of POWER DEVICES
not more than live hundred dollars 111010. TF ❑LbGD 51?RVICIi
ROVEMENI'
Q ❑Lothew.owner Athe propn$nr my employees with wagesastheir sole a+mpen itis SWIMMING 1'001 ELF;CTRIC
ul
mwill do the CdeIfic Corcisnoli Liosusomfferedfanot apec.'111un owbor it ❑OTTER
and Professions Code:The Contmetor's Licence law sous hot apply a+an owner of OUT'LITS-SWI'ICHF,S-FIXTURES
pct own who builds or improves thereon,and who dam such work
te tiled or of through
his own however,he
that inch.ro mv,uld,are nut in or of,or offered for NEW RISIDI?N'I'IAI.NLP.CfR
mIe.IL M1nwevnq,he builmng urim.nrvcnem In xnlJ within Lina ycundunnpletair.the SQ,IT.FLOOR ANIIA SISQ,fT.
rrhadder will have We burden of proving that he did not build ur improve for par-pose ofsola.)
t9)1,as owner of the property,ma exclusively commuting with licensed contructoOs a
( nrua the proja,(Sa.40,14,Boxitcxa and P ole"ions Cnle:)'fhe Conmamm's J-
seLow docsnot applyunnownanf property who hoildsor ivec harbo,:cod QTY. PLUMBING PERMIT FEE
who contacts korsnch pmiects witharonat lx)flora'''l pamoannotnc C...tacur's
Liecnve Law. I'EHMIT ISSUANCE
❑ Inn eaen tit der Sec, 6"1.,ll&1'C for tax muxnn
AMER-DRAIN&V E.NT-WATER IIA) VAIAA'I'ION
Owner hate
KERS COhIPENSAITO l[,a t Mowll,Al KW" BACK PLOW PROTECT DEVICE O O
I herehy noir,Inde penalty of pre.Inc of Ore tollnwing Jeclnr:uinns:
❑I have and will maintain a Certificate of Consent n sell-ins,r for Worker's Compcm DRAINS-FLOOR.ROOF.AREA,CONE. S"ORIES r 'TYPE CONS'I'RUCI'ION
cation,os provided for by Salina 391X1 of the Ia bo Code, or the performance of It I
work for which this permit is issued, p1X I URES-PHR TRAP /.1//
I] 1 rove end will nminmin Worker's C....i,fion bamance,as required by Section
3900 orthe labor Code,for the performance of the work for which this permit islssued. OAS-EA.SYSTEM-I INC.4 OUTLETS (ICC.GROUP l p 8N?
My Worker's Com.ensation lnshmnce carrier and Policy number are: (p f
Cartier: Policy Na: JGAS-E .S STEM-OV, EA) �O
CERTIFICATE OP EXEMP'DON FROM WORKERS'
COMPENSN'IONINSURANCI? GRIiSSP STRL STP. RAR BUILDING DIVISION EEES
(Thisscanon neednothecom.IemJ iDhrpennit is lbronehenemAsollom(5I00) GREASE.
or less.) f s PIANCHF.CK FIC
Trendy the im in pa,member so
as
k-sureork r which this It,he Workers'
Cot hall SEWER-' NITA - ORMIA.200FT.
Inti employ any person in any manner sn as m Ma¢hme object It, Warlcri Cnmpcn- ENERGY hT:E
O z cation laws of California.Data WATER IJER WNENT/ELECIR GRADING FEL
z Applicant ��55
IA NOTICE"10 APPLICAM':IL after making this Certificate or Embi,dion,you should WATERS S`p4r/1' SOILS FEE
a 5: become subject m the Worker's Compensation provisions of the I.aMrt Gale,you mutt
forthwith comply witnsuch Previsions or this pcnni,shall he deemed revoked. WATER SERVICE
Q
CONSTRUCIONLENDING dingAGENCY NEW RESIDENTIAL PIbfd. SQ.Cr. PAID
.�J Z Date Raeipp
U _O Inereny errmh,tune,isaamzwrdmn lensing agency(antes leKomemeor
the work far which this permit is issued(Sea.309],Co.C.)
01"t Lender's Name
U OO
T(yl'AL:
Landers Address ET
a 1 candy that I hove twit this application and stale the the eMrve infnarmion is BUILDIN F'.
FOi
0 commLlagrectocomply withullcia,.mI county oNinanms and ntam laws relmingm QTY. MECHANICAL PERMIT FEE
V z building construction,fall herebyau,horim aptesenmaives of this city h+
enter upon the SEISM01 v
above-mentioned prei for inspection purposes, PERMIT ISSUANCE.
(We).,.,a+eve.iademnilyand kap hamnlrsstne City nl Cupnimit,mied L•LE RIC iL'
liahilities,judgments.costs and expesas which may in any way accrue against said City in OaAI,TT:RORADDTOMECH.
nca,vaceof the granting ofthis permit 0 PLUMBI 'ItiL
APPLICANT U ERSTANDS ANTI WI ,1 OMPLY'"WI'1'If ALL NON-POINT' AIN HANDLING UNIT(TO IO,WOCFM)
SOURCLI IQ .A'I'IONS. 3 w, n10,000MECHANIC NT
GWS./'/'.""a_••"�' 1AIR HANDLING UNIT(OVER ICFM) CONSTRUCTI1 ON TAX 70, szo
SlgnameerfA,,IIL Inman, Data IXI IAUST HOOD OODUCD HOUSING M ITIGATION FLL
HA9ARDOUSMATIBUAfS )ISCLOSIIRE
Will the upp)Iran,or firms be hartgtccmpam sum nr handle nmaNnus material HEATING UNIT(TO 100,000 BTU)
as defined by,he Cupertino Municipal Code,Chapter 9.12,and he Health and Safety
Code,Section 25532(,)? HEATING UNIT(OVER 100,008 BTU)
Yac [Try
VHN'I'ILATIGN CAN(SINGLE RES ID) PATE Dom Rc,aiptW
Will the...locant m hour,nuilding nc'cupad all,equipment W&Vkes which
emit haeardmLc air contaminants as JcGncJ by the Buy Arca Air Quality Man,antrnt BOILER-COMP(3HPOR 10),(100 BTU)
DlstrinYBOILER-COMP(OVER 100,000 BTU)
71Ye, m
I have mad the Irra I ns materials mnptirtmens under Cbupmr 695 at III,Cali AIR CONDI'T'IONER ISSUANCE LIVE
forme Hc.Ith&sma y Gxle Sections 255 . 25533 and 2.5594,1 unAeeund that i1'Lha NEW RESIDENT(A),MELD. SQ.Ur
buildi 'Ane: ncurenlly have.tennnl,t n OsmyrRxTons, day to notify me occupant Z
ml the 1 'as IIIc am � tet. Ccnilicnm n' I+L yyt T
wnern timb.4e agent Dom TOT ISSUED BY: ` r�
OFFICE