S 1301 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES=USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1l.lyipll NO J.1 a,a-3 O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `v
EIHIAHNG PROJECT IDENTIFICATION
BUILDING ADDRESS: Imo- SANITARY NO, APPLICAI ION SUUMI'ITAI.DATE
ON-.E L.� � 'il LOb CSb �" 'LZ�
OWNER"N E: �� �� J ((INE: C(1 TR - R�.Nn \- �NO:�
1T1. /l.•�N`1T_ NIC CON'I'NOLp
ECT/ImN NI :k: I.LC N '. 6 ✓) 5�+ WN SJ�V�/ W l\I ❑
e
coNTncr: 4oJt(I�NIi: C>C>-C \ QdK - ' S �aA HUILDING PERMI'I'INPO
. G-� �w-e ��77Q,'JJS _ 'Sp qt ❑ Consultant Fees Paid by Applicant(Initial) V BLDG '.LECf I-LuSIR MKCH
LICENSED CONIRACTORIS DECLARAI[ON I V QTY ELECTRIC PERMIT - FEE
o z z 1 hereby affirm thm 1 am licensed tame.provision.of chapter 9(commencing JOB 1 I3SCRIPTION
FZWwith Section 1000om'Division 3ofthe Business and Profession,Code,and my license is MI'1'ISSUANCE RFdIDENTIAL
in full force and effect. L'] ❑SIUWL ❑KITCHEN REMODEL.
a-u LmenseC as U Lic.X L, ADPL CLS-RESIDENTIAL ❑AUDITION [I PLUMBING RE-PIPIT
yQa amConrenor M Liast'C
ARCIIITECTS DECLARATION I-ANIiL.S ❑MULTLUNIT ❑MODIFI STRUCTURAL
ZOyz l uodemmndmy plan,shel)he firma,public records MODIFICATION
OZ- UPTO 200 Mt [I INTERIOR ❑CHIMNEY REPAIR
F=�F"W Licensed Pmcs.innal 201.1000AMPS IMPROVEMENT []SWIMMING POOLS
s S42- OWNER-BUILDER DECI.ARXI ION OVIiR I(XXIAMI'S [I BATH RIiMODIiIIREPAIR ❑DEMDLITIQN
C tY Q 1 hereby affirm that 1 am csempt from the Connector's Liet nw,Law for the
XO L U following reason.(Section]131.5,Business and professions Code Any city or county SIGNS ELECTRICAL - ❑OTHER
which requires a permit hs conswa,alter,improve,demolish,or repair any structure
a'Oyy l t taanee,alters thea Ientn fmsuch it fitc.,d edmmemm�t
F- Q prior uirisx quires ppi permi 8^ SP[CIAL CIRCUII'IMISC.
Z)-1 that he is licensed pursuant m the provisionsofthe,Cense x License Low(Chxpter9
ii�q£O (commencing with Section?000)arDivision 3 aflhe Business and Por inns Ctale)ur TEMP.ME7.R OR POLEINST. COMMERCIAL:
that he is«corps therefrom and the basis for the allege]e,empdor.Any violation of - .DG/ADDITION ❑ot:MOD SERVICE
01.1'1'ION
Section 7031S by any applicant for a puunL,stahjcma the applicant in civil peraltyof POWER DEVICES
E3 FO
not more than five hundred dollars(551X)1. f
F Z i IMPROVF:MEN'r
6 1,as ownerof the property.onny enpayees with wages us their sole compenamion, SWIMMING POOL ELE
SO will dothe work,undthe soucrosclsnrn intended nn^Bcnd fornuls(Sec.](H4,Ilmsincis — ❑OTHER
dc:'H
m and Professions Cnie Contervan's Locant,law dies not apply in an owner of IITiLETS-SWITCHE - .S ill
property who builds or improves nherwon,unit who does such work himself or through
It,,own employees,pmvlded qua such imprvvcmcros are Dat intended or ollarcd for NEW RESIDE lA d.E SQ FT.
sale.If.howcvcn rise buildingori mpmvlatut is sold within enc Year of cnmpininn.the SQ.PR FLOOR AREA $/SQ.FT.
n h Ile wll Idee did hordiano!'provingthit he didnot built limprove brpur
pave of ) 00,TOTAL
❑ I. e r ('the p u.,wry, l rsi ly collateral,with Ir 1 tmmors uo Q 1 A
construct theproject(S 7044 Easiness f:. Ct 1 )fI C nn esor,L V PAID
xel.xw does not apply u,nn owner nfpmneny what mriltb nr irnprnves mcreau,and QTY, PLUMBING PERMIT FEE.
whoamrocts for such projects witho ennvucnorte) lmnwd pnwm.. r,rhe Cnmaron's
License Law. PERMIT ISSUANCE
❑ I not cxmnpt under Sac. ,0&P C air dd,rereon s
ALTER-DRAIN&VENT-WAI ER(EA) MAR ALU
Owner Bute
WORKER'SCOMI'ENSA'I'ION DEChAl2A'I'ION BA FLOW PROI'ECL DEVICE qly��� �s
I hereby offnn undm penaltyof perjury oneol'the lidlowlrtg Acelurmlons: A4. 11 "��
]I hoveundwillmuimainnCmifcmenfConsenuni,rdl nxura fur Worker'sCompete DRAINS-'I.()OR,R(H)E,AREA,COND. STORIES '1'YPH CONSTRUCTION
aatern,vs provided for by Section 3V0d uI'the Larne Code,for lie,perfannatae of the
'
work far which this"relr is issued, FIXTURES-PL TRAP
I hove unit will mu'mmin Worker's Cantpensollnn Insurance,ms required by Section
3700 of the Labor Code,Erz the larfnrmmnrol'the work for which dal,pt is issued. GAS-EA.SYSTEM- INC 4 OUTLETS OCC.GRODI" AI'N
My Workq� a u luVNce cxsrier ad l'
nnlicy�ym�pt 59
Carrier: �L s l'oliuy No �1\�" CAS-EA.SYSTEM-OV 4(EA)
CHK(IfICA[1i OF EXEMYfION FROM WORKERS'
COMPENSAHON INSURANCE GREASDINDUSTRI.WASTE'VE /I
H1 ILD( 3DIVISION FEES _
This section raccoon he c...opleted i f t he rani,in femme bundrcddulle,(S 10X) GREASETRAP
ar less.) I'LANCHECK FI : r
I certify that in the locraommncmdthe wed.for which dik,vor,is i...ed.I shat l SEW ER-SANITARY-S'FORM EA.2 FT.
at,,employ any penton in any mm�ncrin atm hereunto,subject rhe Wnrkcrd C.... e.- rkf
Z aasian]-.a., mia
of Califn .Dore WAIER HEATER WNENI/ELECTR
z 0 Applicant o GRADIN
y N(YIICE TO APPLICANE If,mf tar making Ibis Cenifanc of Bacmpsion,you should WATER SYS'I ENIGREATING
a ; become subject ,,the Workers Cnmpenaminn Pnrvisions of the IaMr Calc,You nwst _ SOILS 'G
forthwith comply with such provisions or lhis permit shall he deemed revoked. WATER SERVICE
4 CONSTRUCIIONLENDINGAGENCY NEW RESIDENTIAL PLh1B. SQ.FT. PAID
7 at
Z Ihereby nation that is constru=lending agency lot perfnnmence of me Receipt
LJ the work for which this permit in ismed(Sec.3097,Civ.C.)
F" fenders Name TOTAL:
V Lenders Address TOTAL:
W 1 cenify that 1 have read this application and state that the above information is BUILDING FEE t,-a-
06
h contact.l agree to comply with all city and mumy ordinances and slatelaws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction,and her authari/c mpresenmovcs of this city no enter upon the SEISMIC Eli
above-mentioned prnpeny ri pectiva pnrptms. PERMIT ISSUANCE
(We)agree m sav in unify and kee11.rmless nlie City of Cupertino against ELECIxI'FEE
liah,hers,judgmems.c sat enp,,acs which may in any ay attme against sail Ciry ,TF.R OR ADD TO MECH. ��
in caused of the rani gof this"noil. PLUMB( aPP.F?
APPLICANT UND xS', .DS W'IhL COMP WIT({AL1.NON POINT AIR .LING UNIT(TO 10.0000CFM)
SOURCE RF MECIIANIL L RE
AIR PIAN No UNIT(OVER Iff"CFM) CONSTRUCT I TAX
Ssg ur cant/ ontramnr Una EXHAUST HO (WMUCIL HOUSINGMITIGA ONFEIi
IIAZARDO I9�N ATERIM,. . Rli
Will the applicant mfutu fiu"Lling oceupun stoner handle hazardous material HEATING UNIT(( 00.01X)BTU)
as defined by the Capet iia Mmticipd Calc,Chapter 1).12.and tine health and Safety
Cala,Section 25532m)7 BEAT INC UND(OVER ,"BTU)
C]Yet 7 N VEN'HLATION FAN(SINGLE SIU) PAID -
1)me R s
Will the applicant or probe building maditc l use equipment of devices which EOILI?k-COMP(31IP OR 100,000IE
�,it hoaaednus air comminution,vs leaned by the Bay Arca Air Quality Mun,i'morm '('OTA I.:
District'? BOILER-COMP(OV Ek 100,000 RTU)
❑Yes El No
I have reed rhe hazanluus mretiWs regnimtnents^oder Chapter 695 of the Cali- AIR CGNDIq'IGNBR ISSUANCE IJA'I'I?
forms Ilealth&Safety Code,Seel Ines 2.55115,25533 and 2.5534.1 undec,lvnd thm If the NEW If I zSI DENT IA 1.MECH, SQ,IT.
building dues not cuncntly have a mnunl,rhut it Is ny msp^^sthility m nilly rhe uccupi r(
of @c mgaimmeens which most be^rel prior m insunnav of a CcniOcnm nl'occrlter,
Ownerorarhon,criagc l Date TOTAL. IMUEDIl,
.OFFICE