S 0629 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
F0WNflR
Y OF CUPERTINO Bull.VING-ELECTRICAL PERMIT NO.
ILDING DIVISION APPLICNI'IONIPERMIT I'hUAIHING-AIfIDEND IFIC C 0629 Q n('1
B11I1.UIN(;tsRO.IIiCT IUENI'Ifll'ATIDN J v L .7
DING ADDRESS: SANITARY NO. APPLICATION SUHMI'I'I'AI.DATE
a c- R �nS J e5
'S NAME.: PHONI: ON'I'NACTOR'S NAM,: LIC NO.
I e-( Owlin o — T e— . 1 N/C CON 9' (Il,p
7�.
OUTH IF CrlENG1 Ii13R: LIC NO'. A RF"_SS: �I // /�/ ❑
ONTACT: PHONE; BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ALDG ELECT' PLUME MECH
❑ ❑ ❑
LICENSED CONTRACTORS UIiCLARATION QTY. ELECTRIC PERMIT FEE )O DIiSCRIPTION
1 hereby^firm Thal 1 vin Ilccnn,A under pnrvininnn nl Chapter Y(culnnrncing
n Seaton 7fl0mof Divi,ion 3 of the Buslnessend Professions Code,ond my l kens,i. RESIDENTIAL:
PERMIT ISSUANCE
full force and enecl. r 4 9 ❑SFDWL ❑KITCHEN REMODEL
QUV License Lic.N APPLIANCP_S-RESIDEN'T'IAL ❑AUDITION ❑PLUMBING RE PIPE
l-ZW Dmo Commmr
ion ARCIIHECI"SDECLARA'I'ION PANELS ❑MUI:1'1-UNIT ❑5'IRUCI'URAI.
OZnQ nalactair Inns shot usedanpub Ns MODIFICATION
,!�/� ..16. i UP TO 2N)AMPS El INTERIOR ❑CHIMNEY REPAIR
w Liccnx 1'nsfcssional 201-100DAMPS
IMPROVEMENT SWIMMING I'OOIS
G $J OWNLR-BIJILDER DECLARATION
C Q hereby p OVER 1000AMPS [I BATH RIiMq`1F:IJNEPAIR ]DE'MGLITIGN
C C I Loeb Bir t mm I ren cmm� I From the Cummeons L isms,Luw Gm life C�aAeAGiC IA.�
X 3 a U following reason.(Section 70315,Business and Probe ss..^s Craft:An I t '1'111iR
A.,city nr crus Y SIGNS IiLIiCTRICAI. Q
w LL vFi which requires a permit re<onatrvcn loplie Impn)vC,demolish,ore—retail any nructurc
�4 b
prior
he iu icua^ee...armyn he ba.mo,i,ilicamfof C,,., fminnrocr,c aw(Chned mmem SPECIAL CIRCUIT/MISC.
swly¢F mol he in Hcon.mpur.oanuom)oila a sone commnmrn Li<onm Law lcnapter9 COMMERCIAL:
w�00 (cemmm�eingwim Scctinn 7(X)111 of Divisum3 of lie l{nnmcas and 11 lrs,am,Coolcpa 'll?M P.MEI'ERORPOI,EINST.
W G ey that he is exempt therefrom and the hams for the alleged exempro n.Any violation of ❑NEW BLDG/AUUI'IION ❑DE410LITION
Nation 70M.5 by any applicant for a Permit subjeeds the applicant to a civil Penalty of POWER DEVICES CO3 TENANT FOOD SERVICE
nm more man five hundred dollars 1251X11. IMPROVEMENI"
FZa ❑ Lus owner of the pmpcny.or my employee+with wager as their tide nmmpcnxmion, SWIMMINGPOOL ELECTRIC
LS.,� will An the wnd,mind the strucmrc ie not lntnnd,do—Ildre fia'ad 15ec.7044,11mincw (TITER
W 3 m and Ptolessionn cea e: the Commnor's License Law docs not apply to an owner of UUTLEIS-SWITCHES-hl%'HIRES
properly who builds m improves mcreou,ane who dress such work himself tor through
his own employees,provideal mm such improvements am not intended of offered for NEW RESIDENTIAL ELECIR SQ FT.
sale.If.however.the building or improvement is sold within one year ofcompletion,the
SQ. xM AdE.YI ASU.IT.
ri A V
own
erbuilder will hove me lmoden ol'Foraving thw he did nor build or Improve for pur-
Pow ofsme.). 'InTAL: SEP fGi e)
❑ 1,as owner of the property.am exclusively contracting with licensed mmtrectnrs to p[I1ry1
construct the perfect(Sec.'1M4.Business and Professions CMB)The Contractor's Li- RC{!U
verve Law does net apply to an owner of Properly who builds or improves thereon.and QTY. PLUMBING PERMIT' FEF.
won contracts for such pneects whL a connecnm(s)licensed purst am m me Contractors CIT Y Ur
Law. PERMIT ISSUANCE "UrtH I INU
El I am exempt under See ,B at PC for this rcnsnm
ALTER-DRAIN&VENT-WATER(IT) VALUATION
Owner Date
WORKER COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of Perjury one of the following Jcelamtinne:
I have and willmdnmi^aCenlfrcata of Comenneself-inmre Fir Worker s Enation- DRAINS-MOOR.ROOK AREA.COND. STORIES 'TYPE CONSTRUCTION
Iran.In provided for by Section 37(X1 of the Unfair Code,for the berfennarlce of the
work for which this pernn is issued. FIXTURES-PER TRAP
i] 1 have and will maintain Worker's Compensation Insurance,an required by Scctinn
3]1X1 torso Labor Crile.fur the farlirnate eof the work for which this pennil is levacd. GAS-EA.SYSTEM-I INC.4 OUTLH'IS OCC.GROUP APN
My Workers'{!'[ -tio Insuamc^ mer and Policy nm:t'JA GAS-EA.SYSTEM-OVE?R 4(EA)
Camcr. "tet TC Fi AI(1 Policy (l�y�ll
CERTIFICATE.OF:EXEMPTION FROM WORKERS' GREASFJINDUSTRL WASTE.Pat ERCITTOR
COMPENSATION INSURANCE BUILDING DIVISION PEES
IThinsection need not licennlpletediftheltnnil infarona hundreeeot1u,($100) GREASE'I'RAP
[PLA;NCHECK FEE
Icenify matin the performance
cesm.,I bOtoomork ,obje his Permithe
is issued.o shall SLN'ER-SANITARY-S'IORM GA 21X1 tT.
not enmploy any person in any manner m as m Maomc subject to the Workers Cnmpen- ENERGY ITE
Z cation Lawxcr Cmhfarnia.Date WATER 1117ATER W/VENT/ELECTR GRADING FITE
zo Applicant
N. NOI'IC11 TO APPLICANT:If,after making this Cenificate of E?xmmption,you should WATER SYS'ITM/fBCATING SOILS ITE
became subje<uu the Worker's Compensation provisions of the lsbr Cafe,you must
pl `" forthwith comply with such provisions..(this permit shall be decimal resoked. WATER SERVICE
� Z CONSTRUCTION LENDING AGENCY NEW RESIUIiNTIAI.l'I,MB. SQ.F1'. PAID
Date IIceCIPIM
UQ I herebyalfirm that thereaucamvclion lendingageney firm,ferfimmmance Of the weak for which this pemmit is issued(Sec.3097.Civ.C.) 'IOTA]-;
O(LU F•) unslcfs Name TOTAL,
LSI Le m'n Addm,s BUILDING FEE
Q, I certify thin 1 have read mix application and slate that the above infortuanon is
rVi correct.l clow to comply with all city and county ordinances and state lawn Totaling to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V Z building convocation.and hereby radiance representatives of this city m enter upon the
abswe mentioned propcny for inspection purposes. PERMIT ISSUANCE ELECTRIC PEE:
(We)agree to.save,indemnify and keep harmless the City of Cupenino against
liuhilitics,judgmm�u,cosecs anJ expenses which may in any way omrvc against said City ALTHRORADDTOMEC14 PLUMBING FEE.
in tonsegaeOnce of the grouting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(I'O 10.0010 CFAU MECHANICAL PEP
SOURCE RS 'UTATIO{�S J /y,[
r 1/ ' ,2_ �+//_)+Z/� AIR HANDLING UNI T(OVER 100)(7ICF,M) CONSTRUCT ION TAX
Signmu pPlic^^AI/CLo I /1/O✓Dale EXHAUS'fHWU1W/DUCT} HOUSING MITIGATION FEE
HA RDOUS MATERIALS DISCLOSURE
Willmcapilicvmof future building occuea^I store or handle harnNous tmmtenal HEATING UNIT(TO 100.1010 BTU)
as defined by the Cupcnfno Municipal Calc,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER H0.0DO BTU)
Covlc,Sectio^25532(a)'1
❑Yes o VENTILATION FAN I SINGLE RF_SID) PAID
Date Rrven a
Will the applicant or future building occupam use equipment of devices which BOILER-COMP(lHP OR Did X)B'1'UI
mit hrfardom air comandecros us dcrood by the Bay Arca Air Quality Management 'TOTAL:
District? BOILER-COMP(OVHR 110,00011'1U)
❑Yes NO
I have read the hazvdom aiducm,requirements ander Chupter 6.95 of me Cali-
AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 uneersmnJ that if the NEW RESIDENTIAL MUCH. SQ.IT.
buildingdarc torn c,rrcnly havea too,; 1.'he'it ix my roxpor,ihihly mnotify ticomammn
of se requite menu which mu.a R met poor m issuance of a Cenifica¢of O,cupancy.
Owner of authorucal agent
Dar TOTAL: I"UIiD By
OFFICE