00020043 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATIONIPERMIT m.UMBING-MECHANICAL
BUILDING PROJECT IDEN'I HFICA'1'ION
SANITARY NO APPLICATION SUIT,11 PIAL DATE
IINLDING AIIIRESS:
2 cr WP fITJO 2000
P3sN[FS NAME: 111110 is C(NTRACIOR'S NA is �� LIC NO'� NIC ^coN'1/RRoLit
ITE( Z7 NO: ADDRHSS../{•� G SSD ❑ ! !
It Itsol.)
COM'ACT: PHONE: w BUILDING PERMIT INFO
�, �aYd�► 37g��g�q Cunsul[anl Fees Paid By Applicant(Initial) BLD' [LTi=,CT PLUMB Ef
LICENSED CONTRACTORLA
'S DECRATION L QTY ELECTRIC PERMIT FEE JOB DESCRIF`TIION rL�l
1 hereby anion the,I vm licensed under prosmom of Chapter 9(cnmmtacing
CzZwith Section mxxb nn>ivi.�ioto ofnne nnnxines and rrofc..im+s code,and my Baan.in RESIDENTIAL
WOO I'IiIIMIT ISSIIANCE
I� — in lull fora nJ eRccl. ❑SFUWL C1 KI I CH17N REMODEL
<UU WI- Lacn •CI s Lie
p APPLIANCF-S-RESIDENTIAL ❑ADDITION ❑PLUMBING KIi-EIEC
h Q d Onto G+ I,en
RCHII ?"T'. I .A NI[ON PANELS ❑MULT6UNIT ❑MODIFI URAL
w=i Z u ...nand ray Ins shall • bli records MODIFICATION
O Z,— — ' OL'I'O 2X1 AMPS ❑INTERIOR ❑CHIMNEY RI7PAIR
FE n 'mtc....nal 201-100AMPS IMPROVEMENT OSWININUNG POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS
El BATH REMODELIREPAIR ❑DEMOLITION
Q 1 hereby affirm Ilmt 1 am exempt from'he Commean,Licen.c Law for dIe OIHIH2
taXj 3 a U fol o ing rcaout(Station 7031.5,Bovie ss and Profcoarans Cndc:Any city or county SIGNS ELIiCI RACAL
W c
y which requires a permit to construct.akar,improve demolish,or repair any succmm
�- un to t also y ' s theapplicantl h Kralt rile a signedstatement SPECIAL CIRCUITIMISC.
fly-'
I art he is I :dpmsmnn he 1'avi, . dre carrun.an,1 Low(Chasur1) COMMERCIAL;
�IY
(commencing with Section 700(yof Division Jofthe Nasneanand Profen: n:Code)or I EMR ME I17 OR POLE INST.
a d a�e ce that,he is cxanpt therefrom and the basis for the alleged nempjurr,Any violation of NEW BLDG/ADDITION ❑DF;h10L1'I'ION
�m
Section 7031.5 by any applicant for a rcamn subjeae the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
+t more tfum live M1undrcA dollar,($500) IMPROVEMENT
fS0 [D1.¢s owner of the proryny,onny employees with wages vn lhcirwlc ampennntion, SWIMMING POOLI?LIiC'I RIC ❑GTHAiR
[_ will do the work,and the.amcmre is not intended orolTcred formic(See.B W.Im ncss
W 3 m uad Foah minas Code:The Coatevenae,License Law does on apply to an crane,of OUTLET'S-SWITCHES-FI%TURES
property who bnilda or improves themon,and who docs Such work hlnnsdl nr mnmgM1
his own mnployces,provided that such improvancnts are not intended or ottend tar NHW REto SIDER TIAL HI,L'CI'It SQ Irl'.
sale.If,however.the building or improvement issold wilnin one year ofcnmplenimn.the SQ.PI'.FLOOR ARBA SISQ.IrT.
owncohmaider will have the burden of proving that he did not mild or improve for For,
Pse ofsale') TOTAL:
1,as own r of the pmpeny,am cxclusiv y conuactm with licensed eonnaci m
construct th proja�I5cc.)IW.tlu.i c mfcssians Code.) Co -A:
ceme Waspplym an own f o ys obamldsurintprovcs Q 1 FEE
want ntW Kn,r.vaen +itmawan ,(.o �encetl Parsnam nine
Licen
I n cut under s .II k PCI es
V VALUATION
Dae
WORKER'S COMPENSATION 7 LARATION AqNitii
I hand waffirm under pcttlty ul'Pcrjury nnc t) the firom ving dminmtioa llr lJ
e and will maimaina Cenibcat nsennn elf-einem for Workers Co S- OI:,ARET, OAU. glpgp;, '1'YYIi CfINSTRUC'fION
sari:i.as provi for by Scain I7( f o Labor Calc,for the Pana t
a for whi n i Permit o innl +E
1 have almain n Wn .'. + p airman Insurance,as occur
3700 of the ode, she r + a ofthe work O for wbicb this pe OCC.GROUP
My WmIace , menet olns a. c cr and Pn' umherlac: GAS•-EA.SYSTEM-O ER4(EA)
CEKI'1 [CAPE ' i ll At 'ION FROM WORKERS' GRLASFJINIJUSTRI. EIN'1'IiRCEPIIIR
COMPENSATI INSURANCE BUILDING DIVISION FENS
sate:in of bcnsmplmad if the permit is fes o hu do11as15100) GREASETRAP PLANCUECK 17EE
Icduty In tin n 111111oluale -mcwbeco, hie tl .el r v...Co
0adI",- SIiWCR-SANI'T'ARY-STGR 1 FI'. I[NIiRGVl9ili
not employ any enY m vs m bean s bJ c dcri Cumpcn-
rsa1 ' anncr I
n
z warm LwvnfC ifo m.Date I WATERHEATER W/VENTAI-ECTR GRADING PLC
z O 'Applicant
iUCE'1 ) 1.11 ANT:If,after. a ing this C ¢amu Ellen,a I,you should WATER SYS'I'1!MIIRI?AI'ING SOILS FEE
? become al cc n the Worker'.Conquassumn pnry.ions of the Labor 'de,you most
U1 forthwitha y with such prat this permit shall hm
IN,deemed revoked. WATER SERVICE
Qa
CONSTRUCTION LENDING AGENCY NEW'RESIIIENTIAI.PLMH. SQ 17. PAID pato ReaiptN
UOIt...by iffrindult mere iso co metim,lending agency for the pen mamoof
IL (-' 'he work for which this perms is issued(Sec.3097.Civ.C.) 'POTAL:
Q Isndcis Name TOTAL:
LeoJeT'x Address BUILDING FEE
Ly 1 candy that I have read this application and stat Ihvt the about infnnnmion Is
f^ N cormel.I agree to comply with all city and county ordinances and slate laws relating to QTY. AITCH ANICAL PER M IT FEE SEISM IC FEE
U Z building contraction,and hereby aumnrin representatives of this city to enter upon the
ahrnc-mm�tioncJ mpcny for iaspcct u.purfi MUNI
ANCE CLECTRIC PEE
near agrc r rave,indemnity and keep harmless a City of Cupertino against
liabilitiesjdgm ns,costs andexPenseswhich ryin 'a accrue against said CityDD TO MECH. PLUMBING PEE
in conwque cat egmming of this permit.
APPLICA TT ERSl'AND. ANUWIL Cth \ I HALh NON-POINTING UNIT CFO 10,00 CPM) MECHANICALFE
SO 10E iG .AI'IONS.
HANDLING IJNI'1'IOVER 111,111X1 CPM) CONS1IUICTI(IN'IA%
.-gnu rc h anUContracunr ateOOD WUDUCp HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCL(I. REI the applictn orfdurchuildingtrrnpum sore nr hanUlc hw.urdous mturNITHOI ANS)RI'C)asde' s by the Cupertino Municipal Code.Chapter 9.12,and the Health and SafetyHEATING UNIT(OVER I W.M)BTU)
Cole.Section 25532m)? PAID
0 Ye, VENTILATION FAN(SINGLE RES ILII
Mato R'.."#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OUP OR U0,000 BTU)
^nit heranlous air comaminents m defined by the Bay Arca Air Quality Mrmlg rdcm 'TOTAL:
Drone z,J/ BOILER-COMA'(OVER Ray00I BTU)
Yes l
AIR CONDITIONI?Ii ISSUANCE DAT'li
I a a the haevdn ry materials reyui n rat I I pre,6.95 of the Cali-
lismia H +Wn afny CWe,g•tions 23505,'+5. u 5 )J unJersmnd the it the NEW ftFSIDENTIAI,hlECll. SQ.F[
building +. n1nendyhay. tnan,lnalit + al to notily mcoxvapma
there uirc is which mu, nal prior it,'sun Cc bcubeat Oavlmncy.
agent
Date TOTAL: ISSUED BY.
OFFICE