00010050APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUIL,DINC-F.LRCTkIkCAI-%'1/ ) PERMIT NO
BUILDING DIVISION APPLICATION/PF-RNIIT err ^IAu.+t^vNGLt 'CnnslC,v (J•V(l(f l�
mTn�t.vnnv
10-710 /
LICENSED CONTRACTOR'S DFCIAR, ON
I loch, milt. that I am Ileclry A mde' pmvi,iws iff - tun 9 (commcnciug
with Gctim V(00)"f D�i L, n3ofthc Business Pmf C wJ ly lie me is
in full fe a end elle«. iS L
Iyd,l21 �J�Cmn
Duc 1_11 J'S DE err
ARCHITECTS DECLARATION
it bl' dis
611J71U1 " coLn l
❑ Consultant Fees Paid by Applicant (Initial)
)TY ELECTRIC PERMIT
PERMIT ISSUANCE
AMIANCPS - RES ID13.TIAL
O Z= � I unmkrsland my plum shall he uv Is" to rcamr
Fes- C' li<rnsal Pmft..vitmnl
Y�
OWNER-RUILDER DECLARATION
6 1 urtby .Oke Rut f em. 11.1c t from the f.imastCos License law co the
x1x 6 V whichfIffleasingm, un,s a IS¢tion ]0313. c, mc.0 ud Pmfesxiom Cade: Any city m comma,
W Y3. LLO ya which rtgoi¢a v ptmit to,Immune, titer,
.J :im hml i«repair aaem«e
pdmmiaiuuae,.Iw nyuirca lMpl,lnmIs,sucM1 Pttnitnit Rkaatgneedamamcnt
;!j N C) That hcanamrtovl pur'aima 7 tk).f Diamrm o .f C R."u « ani! Pmr law l Code) ,
OIS (m be,
ng wll9mS¢tien]WO) of Division3 of the Hasina,v uW 14"An, itsCovk:)or
6 L ,vV M i, evernpt themfvn end at Ivan f« the alleged exemption. Any viPs"Ity of
X'4+u' no, mn,dean by anyapplicant dou.(epermit subj¢ts,c epplicev toacivil l�t�llyM
I W y m snare Run Eve huedred dallm (SNIO).
~ZQ � I,uowrt¢of Ne praprny.«mY empty¢s wiN wage err thch.urincmepensatwn.
will do the wsrt, nodTh Com ix mX , License
ives Lia, I ,, .,I nosiness
std Aofcssimbs ild,Code: iIhc Cmtruchr's LiW hlaw ,rex ors apply h. an ixwmco of
a progeny who hail,, m impeavm thmrm, aal h. does such w«k himnalf m dfff
r
his own empty¢ , pmvidM that .such mthu is alial w art not intaymer ofd oT mympamon. f«
vk.ILhowever,llebuidirshmin mfpn¢visadd withinsaey.Jrofc«nplctfmPa-
the
Prs-builder will M1ase the harden of pmsiog slut he dN lot Wed « imprvve fm pw-
e4< ).
❑ I, a tmwr of Ih[ prgcn$ am exclusively comocl ing with licensed aunt mcuus to
.uwcl the Ino,,, (See. 7014. Rnsias, and Rnhsi«ms Ctvlc:) The Contmamrs Lk
case law,ows not aWlytow owner of Popaty win build.mimp��ves lbtn'ua, and QTY.
wto cmlcuu fa such pmjecu with a cmuactMs) I'csnspl purvant to Ire CoxurstsKs
licaec Taus.
I em cxctnpt ami¢ S,e.
PANELS
CPT02W AMIS
OVER rl FCT PS
SIGNS ELECTRICAL
SRICIALCIRCUITNISC.
'LANE. METBR UR IY)LB INS(.
POWER DEVICES
SWIMNIINGPOOLIIX TRIC
OOTLEs-SW(TCIIEC-17[' RIS
NEW RESIDENTIAL ELECTR SQPT
HERMIT ISSUANCE!
BAPCf«dmu ream
Ownea Data
WORKER'S COMPEbISATION DECLARATION
1 beach, alRmm under pmmity "f pt ury me of In, following Jcclarvions.
Ihave argil will treatment, Canifrve of Comrnt In self -ins"¢ fmwaAec', Conn rn-
s oma. u povi Tal for by Section 3700 of the Lobar Code, for ,c perfmtunce of the
I
xvrwNix pmnit is iwseJ.
❑ hvv c me will ttxivlvo Worker, Camprnmtion Imunrcc, as tcquiacd M Smion
3]1X1 ofthc laNr Codef«thcicHnnnanecof the w«k forhi cM1 this ry.rntil ie� ted.
My Wn tem, s mccc wdl'ul'rpy My
CurticcT Policy N Z.LI
IiRTIFlCATE OF EKF.MPI'ION FltOM WORKERS'
COMPENSATION INSURANCE
(This anion oced not be corapked ifthe p¢ tis fume hummed
«Ina.)
I e,di fy dbm in tbn perfonni e, of the wM fm which this permit is ixw d.l sIW
am employ any lore anym . wmm�t�c tv,LFmL Tu_ihc wndcn'campco-
Z wian 1"'vhFYlnas
z o Applirnn,n r-i��
NOTICE'IU APPLICANT. If, afar trunking this Cenifu�ve of E,etrtptiw, yw ahouM
auomptoto W'mkrnlvismocreahis pmviri«uod thetabor Cock,. trout
1x21 � fonhwith c«nPlY aith ssnh pmvisiummthis permit .shall poke invoked.
CONSTRUCTION LENDING AGEING,
V 0 Ibeach, aff.. mmthere l.a<unurvcliun leading agency for the perfsntmntt of
the work f« which this prrmit is is,oad (Ser. 3a97. Civ. C.)
0 txhke, Name
GW IsMcr'.AtMhc.sx sx r
1 eenify Pau 1 hueal Nis applicaend a
tion ve dw the .dove information is
ry I, most. I ugnx It comply with all city and county «ditances ud sate Los relining to
U building cansmuoiou, and N r,h, dhonm"fail city to cmtar upmlbe
nbave-mentitne,l pmpcnyfur mo,ec(um aq,c .
(We) g. to vvc, imtanmity and kccp barmkv, the CII of Cupmtino agaitm
Judditie.Jadgmcnta, anus ud expanses which may u any way accmc most said City
in conso,,I a of ma pryxing of this pemdt.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RECUTATIONS.
Sigram¢ mf ApplicenVCmaactm Dve
HAZARDOUS MATERIALS DISCLOSURE
Will tM.pplicant m forme building o vu,sm ,cure m h tedle hvardrua smtcrid
as &,a, by the Cu,,na n Municipal Code. CTupt¢ 9.12, and the Hcelth sad Safety
Cada. Scctim 25532(.)?
DYce ❑No
Will Inc applicant a lattice budding o,af,unt use ss,m,h t In otvl s,s which
emit haaudov, aI, cmtamioam, v dehrd by the MY An, Ail Quality Mmag l
D'mr cP
E] Y,, 0 N
I hove tend the hazaromns mmaridI rtyulmmams undo LTwpta 6.95 of he Cali
-
fomi. He.RN & Safety Cade, Sections 25505. 25533 ud 2553,. 1 uM1ICrsl:md tut if tic
building oA not cwrn,Iy have atUVUw it is my rtvl.msibduy lu umthy the occupant
SQ. FT.
�.F�FLOOR AREA
nantimpr.
NEE
ALTER -DRAIN R VENT -WATER(
VALUATION
095,000
.ZZ•2000
6
NC
COATROLII
FlATURES - PER TRAP
GAS- FA. SYSHN - I INC. 4 OVIIJTS
BUILDING PERMIT INFO
GRIiASFJINDUSTRI. WASTE INTERCEPTOR
PLUG ELECT PLUMB MECH
GREASE TRAP
FT;E
JOB DESCRIPTION
RFSIDENTIAL'
❑SIVWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RIiPIPE
❑MUErl-UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT L]SWIMMING POOLS
❑ BATH REMODEIJRFPAIR ❑ DEMOLITION
❑ OTHIN
SEWER -SANITARY- STORM IIA. NXI FT.
ENERGY ITH
WATER HEATER WIVEN-VELFCTR
GRADING FF.F.
WATER SYSTEN'PREATING
SOIIS IIS
COMMERCIAL:
EW HLDGIADDITION ❑DF_MOLff10N
TENANT ❑ FOOD SERVICE
MPROVEMENT
❑ OTHER
O
N17W RESIDEN UAL PLMR. SQ. Ff.
SQ. FT.
�.F�FLOOR AREA
nantimpr.
NEE
ALTER -DRAIN R VENT -WATER(
VALUATION
095,000
RACK I'LOW PROI'f;CT DEV ' i Is,
DRAINS- FLOOR. ROOF, AREA. ClsIlta",
STORIES
OCC.GROUP
TYPECONST
API
FlATURES - PER TRAP
GAS- FA. SYSHN - I INC. 4 OVIIJTS
CAS - EA. SYS TEM -OV UR Y Ud O
GRIiASFJINDUSTRI. WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PIANCHECK FEE
SEWER -SANITARY- STORM IIA. NXI FT.
ENERGY ITH
WATER HEATER WIVEN-VELFCTR
GRADING FF.F.
WATER SYSTEN'PREATING
SOIIS IIS
WATER SERVICE
PAID
N17W RESIDEN UAL PLMR. SQ. Ff.
Uwc Kviceipt X
TOTAL:
TOTAL
BUILDING FTI;
QTY. MECHANICALPFRMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
AI R HANDLING ONIT(TO 10.000 CI)V)
MECHANICAL HY.
AIR HANDLING IINO'(OVER 10,10) ClM)
CONSI'KUCI'ION TAX
EXHAUST HOOD (WNUCD
HOUSING MITIGATION PER
HEATING UNIT IT) Ian." BTU)
I (RATING UNIT (OVER 110.00 BIG)
PAIII-
VIN 'I'NATION AN (SINGLE RPSII))
Uam RcttiptX
BOILER - COMP (THP OR IOO.OfO BTU)
TOTAL
ROILIR -COMP (OVER (Oft" BTU)
AIR CONDITIONER
ISSUANCE
X DATE
Z r _ 2,2- / _ V (� 1D („J
NI2W RESIDUbLIALMECH, SQ. FT
OFFICE
TOTAL:
9074