S 1155APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO aUII.DtNG. F.LECI'RICAL
BU TING DIVISION APPLICATIONMERMIT PLUMB ING-MECIIANICAL
- BUILDING PROJP:CT IDI!N'ri FICATION
PI§ITNO.
S. 1155
V
LDINNGGAADDRESS:
SANITARY NO. - APPLICATION SUBMITTAL DATI!
OWNruuSNr) /O /P NI;' C��
J
NT TOR"N M/o ^ / �I O.
NIC CDNTROLp
❑
RCI1,ITq/F,CI'MIiNGINL'IiR: LIC NO:
�Q'I4J(y
ADDRESS
C•-
CONTACT:T PHONE:
BUILDING PERMIT INFO
Ii ELECT MECH
❑
Ira IID
7�
❑ Consultant Fees Paid; by Applicant(Initial)
{g{yyaZ
F-010-
CHIC-
aUU
Lk..Z 4411
LICENSED CONTRACTORS DECLARATION
I herehy affirm th:n 1 am IittnscJ under provisions of Chapmr 9lcnnunencing
wish Semi.n]1NNp ofDivlsinnJof the liusinevs unJ l'ndessionz Code, and any liunec is
infull force and effiI
Liccna Class Lic.#
Dam Contractor
QTY ELECTRIC PERMIT I$
RIPTION
❑ KITCHEN REMODEL
❑PLUMBING RE-PIPb;
tMULTIPUN[T❑STRUCTURAL
MODIFICATION
[I INTERIOR ❑CHIMNIeY REPAIR
IMPROV ., ❑SWIMMING POOLS
❑IT EMODEIJRIiPAIR EIDE, LI'UON
OTHLR
_
PERMIT ISSUANCE
APPLIANCES -RESIDEMIAL
fn Q 4
R,Dv1
Z O y Z
OZ -0
ARCHH'HCT'S DECLARATION
all he used as public cordx
1 odenend my plans shre
PANELS
DPTD 2(NIAMPS
F,�6-pJ
�ZT;
S''�a
x4 0 6 U
IC 3[y Fm¢'
Licensed Profesl... I
OWNER-R1111.ULft DECLARATION
I herehy affirm that 1 am e.empt from the Contractor's License Luw for the
follnwing across. (Section 7031.5. itusiness and Profeui... Cale: Any city m emery
which requires a permit m construct. slmr. improve, demolish. or repair any I mcune
prior to its issuance, also rcyuircs the nppiicunt for such permluolile asigneA stmenmot
211LIgII1AMPS
nVIiR IgN1AMP5
SIGNS ELECTRICAL -
SPECIALCIRCIREC.
}
Cad
Y mi+•
Nulheishcensed pu... I i the pn+vi.einns of the C.nuonna's License Lnw lChupter9
(commencing with Section 7000) of Division J ofthe Business and Pauessisns Coke)or
that he is exempt thertfrma and be basis for the alleged <xentginn. Any vinlmion of
Section 1011,1 by any applicant for a permit whiecu the applicant or a civil penalty of
TEMP. MET 12 PoLIi(NST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ i!MO1.11 ION
❑TENANT ❑'OOD SERVICE
POWERD ICES
ZQ❑I,
Ft7
0. 3
ore III,, hundrel dollah ($5(0).
a mChn li
as nwnernf the property, ormyenmloyeeswithwagesxstheinnlcenmpensmion,
will Jo the wort, and the nmcwre is nm imendeJ nrnlTemd for salc(S«.]MJ, Rusinnss
and Professions Cade: She Cammctnr's Liters. Law dos not apply to ua owner of
pmpeny wba builds or honorees thereon, and win dons such work himsclr nr t...
his own employees, provided that such Improvemenas arc not intended or ,ITe..J Inr
sole. IL htwever. the building nrimpnrvmmem is sold within nnc year of nnnplction. the
IMPROVEMF.N'I'
❑OTHER
SWI LNG POOL ELIiCTRC
TLEI'S-SWITCHES- PIXTURIi
NIiW RESIDENTIAL HLECTR SQ iri'.
SQ. FY FLOOR AREA $/SQ. FI�
owner -builder will have the burden of proving that he did not build or improve for posto
pnse.f vaI..).
❑ L, as nwnernf the No6erty,rinn manacling wilt, Ilecnsed contrueom to
TOIAL:
conewm the pngect (See. 7044, Business and Prom,ziotn CM,:) The Comment's I.i.
•- -
censeLawdoesnotapplytoanowner effort who builds or improves themon, road
QTY. PLUMBINGPERMIT FEE
who contracts for.such projects with a cnnvannr(s) licensed pursuant to the Contractor's
PIIRMI'F ISSUANCH
Licenee law.
❑ I am exempt under Sec. . B & P C for this reason
A O
ALTER- DRAIN&VENT-WATHR(FAT
Owner oat.
ev
WORKERS COM I'ENSA'TION DECLARATIONown,
13ACK IIpWI'ROTIiCf. DEVICE
penaltyte for Barker's
ofConencofaiefnllnw
o
❑Ihaveaonvidc for bynection Certificate Comenuosclf-insurefor Workers Compact
have and willlinntain a
satins, provided for by Section J]fN1 of the f.uM1nr CWe, for the peRommnce of the
DRAINS - MOOR. ROOF, AREA. GOND.
STO• NSTRUCI'IUN
r this haindt is lsouul.
work have
❑ 1 have and will ore, int Wnrker'e anceofste w Insurance, h required by Section
J]00 of the Lacher Codc, font,. performance ofthe.lmyfar which this pcmtit is hood.
ly%TURL'S - PER TItAI'
qq�/ !l
•lvlJ hMJ'IN(U
GAS - EA.SYSTEM-I INC. 4OUT 'LETS
C. GR P
OCC.GROUP
AI'N
My WoCumtionl sn c� era", l'nlicy nun Mr
Otrriec s Tf a'�ll Nt^rinm Policy No,—, � KS�
_
7 GAS -EA. SYSTEM-0VIiR4(EA)
CERTIFICATE OF 13XEMVI']ON FROM WORKERS'
COMPENSATION INSURANCE
CREASIJINDUSTRL WASTE IM'IiRCE'TOR
BUILDING DIVISION FEES
GTL section need not lwcompleted ifthe permit is for one humfsd dollars (51(in)
or lewd
GRF.ASETRAP
PIANCHECK FEE
I cenily that in the purl'mmuncc of the work for which thispmmir islssucd.l Shull
note y any person in any manner so as to became suhjem m the Workers' Geopen.
SEWER-SANITARY-STORM HA.2 1' •
7
IiNERGY FEE
WATER BEATER WNENT/ELECTR
GRADING ItiE
f~
rows of Califomin. Date
rN7kCE TO APPLICANT: If, ofteranakirg Ibis Ccralcncol' exemption. yndsbm'Isl
become suctbjeto the Workers Co u,scnti.n pookiens of the Labor Gate, you otos,
WATER SYS 't'BM/fRl!ATING
SOILS II!li
W
.aJ. z
L)Q
� f"'
O U
[r
forthwith comply with such provisions or this permit shall he demand evoked.
CONSTRUC'T'ION LENDINGAGENCY
that There isaconmm�iun lending agency for lrcrlt,rmamcof
agency
hereby which
the terms far which this Permit is issued (Sec. JlyJ]. Civ, C.)
Lender's Nume
WATER SERVICE
PAID ac Receipt#
NEW RESIDENT AL PLMB. SQ F7.
TOTAL
T(TI'A L.
Lenders Address -
BUILDING PEE
1 cenily that I have rent this application and stem that the above informaion is
correct. l agree to comply with all city and county ordinances and state laws relating to
building co.con tion. and herebyonhon. mpresmnmtivesa(.his ru,mcnterurym the
abovo-n colioned pmpeny for inspection foutenes.
(We) agree to save, indemnify and keep harmless live Cit of C'nlenino ugainxt
r
QTY. MECHANICAL PERMIT FEE
- -
SEISMIC(tie
tap
U
PERM jr, ISSUANCE
ELECTRIC FEE
liobilins'. andgm .. sondespen.,whi,hm.yi..yw ac hediol nsts id City
inconsequent ft ranting of this pc
APPLIC UND .RST DS AND "1 . C PL WIT ALL O POI
SOD C CGU f10 ,�
ALTER OR ADD TO MECH.
PLUMBING FEE
MECHANICAL FP.F.
a
NR HANDLING UNITOO 1'1(NNICFM)
AIR IT IFNIT (OVER 10," CF
CONSTRUCTION TAX
1/,f
.i initiate of \pplicantContoctor V bahe
I IAZARDOUS MATPALS DISCI,OSIII .
EXHAUST FOOD(W)DUCT)
HOUSING MITIGATION FEE
HEATINGUNl'T(TO1110.01Ni ID
-
Will th. applicanwrfmuru hnilJing srcupant store nr boa lehueardnusmamdul
as defined by the Cupertino MunicipalChapmr 9.12. and the Health and Safety
ONI'P(OV E W.IXNI BTU)
LAID Uum Remc N
•
.F90,
Cade, Section 25532(a)?HEATING
❑ Yes
VENTILAI'ION F (SINGLE. RESID)
BOILER- MP(3HP OR 100,001 B FBI '
Wdl the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined b the Ba Arco Air Quality Management
Y Y Y
TOl'AL
BOIL-COMP(OVER IO, Be) D'I'ID
District?
#
CONDITIONER
I have read the bazmdnus materials tequircmems unMr Chapter 6.95 of the Coli.
fomi�l Ienl 'lea CMe. S ms 25505, 255]9 rn St4. 1 unJemund tbm it th
- ISSUANCe AT '
NIiW RP.SIDENTIAI. MECH. SQ. FI'.