S 2697 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUn,DEXC.-RLEC'I RICA PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT TING PROJ�MkcuAry HLM. S 26 C17
IIUILDINI:I'RI)JhC'1'IDILY'1'IPICA'I'IUN O v.7
BUILDING ADDRESS: • SAW IARY NO. APP[,]GA[1QN SUliht l'1'I'AI,TIME]I
C :> 'I( fig
OW F SNAM E: PEIfINC: CONO: (I
I RACfOR'S NAME I.IC N
X NIC CDMIRI,X
�AHCh'rECT?.' HN IiH: LIC NO .' ADDNF_S5: ❑ 7(
gyaZ
CONTACT: PHONE:
�Q6UII,DINC PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RILUG ELECT' PL�UUM13 MI�iCCHH
!J LJ C L
uCli 'EU PITRACpoR;S 1 GC..RAI'1 N QTY ELf:CI'RIC PERMIT IIiE
1 hereby affimt that 1 out licensed under provisions of Chapter 9 mordineneina JOB DESCRIPTION
w pZ with Savors 20(not'Dismon 3 ofthe Busincssand Posh me Code and my License is RESIDENTIAL:
PERMIT ISSUANCE
CSF in full t...rd effelL Ll KITCHEN REMODEL
QUU 'lasso Clans Li,. AI'1'LIANCES-RLSEDENIJAL ADDITION [I PLUMBING RE PIPE
FZW Dam Contractor
mQa ARCHI'I ECI'S DECLARAT ION ❑MUhTI-UNIT ❑STRUCTURAL.
F, y PANELS MOOEFICATION
O Z�Z I undootanJ my plans shad be used use public miand, UP TO 2(X)AMT'S
El INTERIOR ❑CHIMNEY REPAIR
O
F4f'W Licensed Prnfcc,innal 201-1000AMPS IMPROVEMENT SWIMMING POOLS
j OWNER-nUILDHR OECLARAI'[ON OVERHXXIAMPS C1 BATH REMODEL/RF,PAIR ❑DEMOL['r[ON
'1d I berchy aRino Nut I 1 1 enanipt frons the Contractors Licenw baso for the
X d V fudwong reason.(Section 91111 S,Hu um,,and PnifieWons Cole Any city nr county SIGNS ELECTRICAL (_1 OTHER
W 31Ly which m ims a panni,to aolounCt,iNim
ar, prove,demru
olish.or repair any stcture
cQ InnorIo'n,io,00 11,also r.,I'm,Nc iq+pl leant lbrsueh pcnui,to No asiEaod,uucmcnl SPECIAL CILIUM I/MISC.
that I jairst,unt to the provikillus itII Cordraclors Alcolose Law(Chapter9
Wasp (con y 'nS i ]Islip fD J 111 If - II ^ :Cudc)nr ILMI!M-1 IR OR POLE.INs'I: COMMERCIAL,
d d C that he-s esc npt d all..t and,no sois for Ns a IKgW use n c t Any ' Irmo+of EINE W 6LDGIAIJUITION ❑UhMOLI'll(IN
7C�_ Section 90]1.5 by any applicant lot a luno i,suhiro,tha applicant m a civil penalty of POWER DEVICES
nounaimtnan five hundmddu0ux($500) []TENANT ❑FOOIJ SI?RVICIi
=O I,us owner nf,ho n SWIMMING POOL ELECI'RIO IMPROVEMENT
❑ pmpc r,ormy on+ployees with wage.asnmirnole oupcnendn , ❑OTHER
F.. willdomownrk.and,immotatur ix oul in ardeduroR'uralforsale(Scc.9194,Bmine"
W�'m and Professioax Code:'[he Cn.ans, is I.kense Law duo not apply I,an nwncr of OUTLETS-SW I'ICIIES-FIXTURES
properly who builds or improves,hereon,and who does.such work himself or through
his own anployecs,provided,hat such insprov nsco s are out intended or offered for NEW RESIDENT IAL 1:1,CIR SQ IT.
sale.If.bowr,ontire Isiddingorintpmvcmcal is sold within one year ofearpletion,the ^ �� �s-� SQ.FT.ROGR AREA !E/SQ F1'.
owner builder will have the burden of proving that he did not build or improve for pur- L 1/
ppsc o(sale e. '1911'
��yl{.L as own r of the Leopeny,sen esdusiod,commcling wall Licensed amtrenorx 1.
t vonshim,the project(Sec.9194,Ilwines and professions C Arc)]be ContmGar I%Li-
cerise law dam not apply to an owner of property who builds or impmvcahemon,and QTY. PI,UA1HING PERMIT Plili
who contracts list such pmjmN with a canal licensed pumueolIn the Centocor s .-...
License law. PERMIT ISSUANCE
❑lame t Iorder See ,B&PC forthis roams
AL'IF.H-DRAINA VIiNT-W ER(EAI
ne "" �
AIDATION OS
BI /�
Owr I -1 I�
010 Wf 'ER'S COM SNSr' (IN DECLARATION HACK FLOW PROI'E E
I hemby.!fins under penalty of perjuty line la the following declarations:
❑I have and will maintain a Certificate of Consent mself-inwm for Workers Carl DRAINS-FID ,R E+,AR. 'U. STORE: 'IY1 E CONSTRUCT ION
salon,as provided for by Section 370()of the"thin Code,for the perfommtnc,of the
work for which this permit is issued. FIXTURES-PE R
❑I hoc and will moinmin Workers Compennudon Insumncc.as required by SectionPUIl nfthc Lahr Gxk,(nrthe performmore nl the workfr which this fle.it is issued- GAS-EA.SYS'rEM-I INC. O ifS (ICC.GNOUP ��AI'NO,..S
Camcr; Policy No.:
My Worker'sConEursation Insurance carrier and Poll icy number am: GAS-F,A.SYMI'13M OVER 4113A) /
CF;R'IITICA'1'E OP UXFMI'L'ION FROM WORKERS'
CHF.ASI%INDI159RI.WAS'i'IiINI'IiRCIH'1 OR H'1 OR DIVISION 1
IiNSAL ION INSURANCE 9iliS
(thki,retionnoyal IbecmnpletW iOh ,wroo,is or one hundred dollars($10) GRF,ASETRAP O
' or less,, PI NCI til!
I"city thatinthe ledonnunec nf,hcwark forwhiil lbisperual isissmal.Lshall S13WER-SANITARY-STOIiMP.A,21X1FIL
nu, il.... Y ^ Y oust 1 beet n+the Ko kers Gnpcn "'My E
Z, rani I C 1'1 in Ut H'API R IIRAI'OR WIVCN'SI.LLC1R
Zp11 tEaG GRADING FEE
NOi ICE f0 A'I'I.ICANI:IIIc1l" taking,bis Ccti uleatEs npuon,you altmid µAPERSYS'1'IE G14EA'IING
H � he"uno s.bj", ,,the Workers C.m.Penpninn pili sin oot'Ili^LnN+r Code,yet malt SOILS FEE
.�j Emnwin comply with such provisions nr this p^nnit mall M beamed mcok d. WATI?R 5EHVIC:�'--
dWp„ Q - PAID
CUNS'I'RIICfION 1.13NUING AGENCY NEW R1351DIiN' I.I'hMli. r1 SQ. are Rcccipa
U O 1 lowly unit,Ino Lelia is a aonamctiou,coding agency for the pen'urmanc,IfEl
w H me work for IshkO Nis punnI,is i smell(Sea.9097.01.C.) /
r '
s Scale p TO] I /
UL7 Lenders Addrnn I'O'IAh ,l
I eenifa r thI have mail Ibis application and stale that Ilio aMrve inlarmaenn is _ ISUILDIN( 'EE
W
f-' fq correct.l agree In comply with all city end scanty ordinances and In,, awsrelafngm QTY, n 'IJANICAI.PIiRMPP 'I' SEISMIC FEE
U building constitution,and hereby authorim representatives of this city to enter upon the
abure-mentioned pmpeny for inspection purlwws. PERMIT IS ELECTRIC F'E
(We)sEpor to save,indemnify end kmp harrnlcus the City of Cupertino against
liubilities.judginenu.costs and espcmos which may in any way accrue against said City ALTER OR ADD TO h1EC11. PTUMBIN Z
'n consequence of the gmnling of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLkWITH ALL NON-POINT AIR HANDLINGUNITHO 10.000CF14) ME I LFLE
SOURCE REGUI.N1 IONS
AIR HANDLING UNIP(OVEIR I0.00ICFM) CONS CrION TAX
!AA 0 . q
Signamrcof Appiman onmectur �T---Tem EXHAUST HOOD OVIDUCT, HOUS GM1I ITIGATION FEE
HAZARDOUS MAEHRIA SDISCLOSURE
Will the applicant or future building+ecupantstom or handle hmardous macnzl HEA'L'ING UNI I'U 0100.001 RI'U)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code.Seclinn 251320)PHEATING UNI'['(OVER VaJRX)131 U)
1
[j yes 0N PAID
VENTILATION PAN(SINGLE RESID) [)air Hceci_1t
Will the apEdio.ol nr fmuru buiWiati oci upam use epopmant or dryorl which ROLLER-C(IMP fJi II'OR
IIIO.(XXI ill G)
_
it hxeanluus air comnntinanu ns dermad by the Bay Area Air Quality Management
QiNnct7
❑Ya ❑Nn fl(111,13R-COMP H)VIiH IIXLIIIXI BIG)
Ih "Ill' J I 'I ' I t' d Ch pl (JS fth Cali- AIH CI1ND11'IONIHI ISSUANCE IJACIi
fur 11cold,hI a S'f ty l SEivn,25505.25533 and 25534 1 J :0 I End 11lho NLW RCSIDIN'I'IAL MECO, SQ,FI'.
build gl urr11)I Ld , I Y 1 'I IIY 'fy,hu"Paul _
nfRuav, L�lswl �s,b u, +r atf.L tt1 ��+1 ) 1 y.
��s .tut g,d h/.�71
Owner ur nu,hnn¢J col / Lir I�C 'ITyI' ISSUIiD13Y:
OFFICE