S 2989 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINC-HLRCT'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJE6'T IDEPOTIFICA'FION
If,ILDING ADD[t SANITARY NO.=PIA M TADA'1'1!
Ave
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OWNER'S NAME: PHONE CON' CI'OR'S NAME: LIC NO:
�// i! C� NIC C(INTROLp
,/ , n Yo 9ifD
s T`CIYI!NGINE' LIC NO: r�� j� e ❑
c ACR PHONE: J ` [WILDING PERM I IN
❑ Consultant Fees Paid By Applicant(Initial) LDC ELPY17 PLUMB MECH
LICENSIiD CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
L hereny ammo mal 1 am Iiounsee under prosomm..1 chapter 9 k,+ rain, JOB DESCRIPTION
ren
WOOazz 'dttlerti 70fi)nf Dlvik;nnJofine Busk+esx and probes:++...Codamalm license i.. RP IDS
11-0, w full force and effect. PERM IT
�� in '�� iI 1,/) ` ❑SFDWI. ❑KITCHI!N NEMODI!I.
QUU License Ch .. I-ic.p a e-i JfJ AI'PLIANCCS-RFSIDIiNI'IAL ❑ADDITION ❑PLUMBING RE-PIPE
vFi zit a Dmc Cnmmoor
Foy R HITECI"SDECLARA 1 PANELS ❑MULTI-l1NIT []STRUCTURAL
z 0 cet z 1 un rr ta d my,lo,shall be useda.public aromas MODIFICA'T'ION
OZ-,0 UPT0200AMPS ❑INTERIOR [I CHIMNEY REPAIR
F 1 Licensed Profession.) 201-1000AMPS ImPROVENIFNT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER Ifig)AMPS ❑ If REMODEU PAIR ❑DEMOLITION
CC 6 I hereby affirm Jim,I am exempt Toth the Contmcmr'n Licanxe Law for Thu
XdXOaU following reason.(Section 7031.5,Business and lhnfessions Code:Any city or county SIGNS ELECTRICAL. HER
W 31 F' which requires a Permit to comwcl,alter.improve.demolish,of repair any structure
2^O prior to its issuance,also requites the applicant for such permit file a signed statement SPECIAL CIRCUIT/MISC.
ythat he is licensed pvsuant to the Provisionsnfthe Conwmor's'License Law(Cha,mr4
00 (commencing with Section]000)nf Division 3 of the Business and Pmfessinn,Co&)or UONIR MEIER ORPOIX INST. COMMERCIAL;
d 6 c IY that he is sor npt therefrom and the basis far the alleged Exemption.Any vididion of ❑NEW BI.DG/ADDITION .AOLITION
�"y Sedion]Oi LS by any applicant(urnpsm:is'mhjems the applicunuo ucivil mcnahy of IroWEk DEVICES ❑TENANT OD SERVICE
rnnom than fee hundreddollars(S500), IMPROVEMENT
=_< ❑ Lo due work,and
pestruc,or myot intended with Bred frlalei(See.onnpensation, SWIMMING p'OOLIJ.I:
SFC will do the wad,and thcmmdure is not intended onrffcredfor sale(Sec.](H4,Rusineas ❑0 ER
3 mand Professions Cade:The Contractors License Law does not apply u)an owner of OUTLETS-SWITCHES-McT
oki
property who builds or improves thereon,and who dues such work himxslf or through _
his own nnmleyee,,provided that such iamirsonsents no tun intended or offer l lin NIiW RESIDEN'T'IAL 1!LIiCTR
ale.If.however,the building or impressment issold within one ycmofeo friction,the rBy'-
0
.F R- II; Flt
owner4milder will have the burden of moving that he did not build or improve for put- U
po v of ede.).
❑ L as owner aide property,ant exclusively contracting with licensed Genucom, ,, TOTAL ❑PR 2 O •I(]Q 3
onstrucl the project(See.](H4,Business and Pmfcssinns Cale:)no Contractor's Li- APR O IJ
Li-
cerise Inw Ames not apply to an owner of property who builds or improves thereon,and QTY. L MBING PE T FEE
whoeooraets fmsuch pmjeemz with aatmtnetions)licensed pursuant 1.the Cosmic is
License Law. PERMIT ISSUANC
1 am exempt under See. .B&P C for this reason
ALTER-DRAIN&Vli WATR(EAJ VALUATION
Owner Date O O�
WORKER'SCOM d(yof,ramyon DECLARATION RACK PLOW I'ROTE DEVIC'
I and
under penally to perjuryonerills,insum for darker'ime:
wide.,
and will maintain ssion 3cme.f,ho LiduoCode.for shererforms Compon-
close DRAINS-PLOOR,RWP.A ,GOND. STORIES TYPE CONSTRUC'T'ION
abate,as hick this
far ul Ss issued
3]1X1 of the Irbnr Coda for me merformace close
work for which thisom mil is issued, FIXTURES-PER'I'RAI'
❑ have nLa willode.for Worker's ante ofttinnNforwhihhis pied by issued
3700 of the Labor Codgfor the performance of me work for which Ni..pamtit is issued. CAS-EA.SYSTEM-I INC.40I1T'LhP' OCG GROUP AI'N
MyW.rkeefompemation Insurance carrier and Policy number am: GAS-G.SYSTEh1 OVER 41[A)
Carrier. Policy RO
B II' AT5 0P IiXEMP'1'LON FROM WORKERS' GREASNINII05'Fn WASTE INCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION F_E_Rti _ ____
(Tltis.cemion axed not bensmpletcJ ifmc penult is 4mnnc hundrtJ dollars ISIgO
or kssJ GREASETNAP PfANCfiHCK FEE /
codify that Eubeperfmmnnm ofthe work Por which dr,permit is is sued,IshuB SEWEk-SANITAR -STONM 13A.2(N)FT.
ENERGY PER
not efrpiny any fee...in In any frontier so as to became surest to the Workers'Compen-
zz saner Lawsof CdAnlyia.Dat ^ WATER HEATE 1VHN`UELECfR
0 Applicant f GRADING FEE
L.I ti NOTICH'1'ft ICA IL alter making us Ceniticato of Escandi n,you should WATER SV' EMII'RIiAI'ING SOILS ITIi
F
became xuhj t to the Wnrkefs Cntopensation provisions of the LeMn Code,you toed
W Q
forthwith comply wilh,ach provisions onhi,permit shall h,domed revoked. WATE .-RVICE I
az CONSTRUCHON LENDING AGENCY NF RHSIDHNf1AL PLML SQ.FT PAID
V p Ihbreby affirm lNn there Lacnnslmminn lending u6c'ncy fonho merronnancc of ate R xil
the work for which mispermit is issued(Sec.IID].Civ-CJ
Lenders Name TOTAL:
�U Lender's AJdoss 101A1 BUILDING TLE
I nify Nat 1 have read this application unit state that tfieabnve information is
� ti uocrrecLln,rcemrand,wilh.]Jerry andernmry ordinance.and,tamraw,relating h+ QTY. MECHANICAL PERMIT FEE
(..1 z M1uilding tam,trvdion,and M1creby uwM1oriu rtPrexcnmtivea of Ibis city a+cn¢rurym the SEISMIC FEB.
above-mentioned pro,ony for inspection vartows. PERMIT ISSUANCE
(We)uer m save.Irdc ad'y and kap harmless he C'dy of Capenln.anion IiLECTRIC NR
s
liabilities,judgment,.costs and uxpcnscs which may in any way acme against said City ALTER OR ADDTOMHCH.
in consequence othe griming of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONTOINT AIR HANDLING UNJr(TO EkoboCFm)
SOUR_RCC1JiF: 'PIONS. MECHANICAL FEE
AIR HANDLING UNIT GVER I00DO C ) CONSTRUCTION TAX
Signam A,N am/ ommcu+r Uam EXHAUSTHOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the opplicand n,fuom buildinguec T,tel atom or handle buvurdau,anterial HEADING UNIT IT Omm 1'U)
'i,defined by the Cupertino Municipal Cede Chapter 9.12,and the Health and Safoy
Code,Section 255326")? HEATING UNIT HOVE 00100113TH)
❑Yes E]No PAI
VENTILA'I'ION P (SINGLE NI!SIU) Dote sceipt OF
0511 the appliranl or lumrc(wilding rccupam use eyuipmem nr Aevices which 13011.EN-C 1P(3111'OR I1N1,1XN1 BTU)
emit harnNous air nmmminanu.s defined by the Bay Arra Air Quality Management 'TOTAL:
District! BOIL- -COMP(OV1iR 00010X)BTU)
E]Yea 0N
I have mad to harallous materials asFiremenu tinder Chapter 6.95 of the Cali- /—CONDITIONER I CF DATE
fomite Room&Safety Cale,Sections 25505,25533 and 25534.1 understand that if the ol NEW RESIDENTIAL MECH. SQ.ET.
bui Win,Joe,not.mr, ly have l+roam.Mota is my rc.ry Whil ity to mai ry theoccupant
of the requirements which all he are, He,u+iot ane,nfa Certificate of Occupancy.
Own,,or..In....ce anent Data TOTAL: ISSUED BY:
OFFICE