S 0870 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bill]. -K1.Ec'rxH:gl, Alrr no. 0 O
BUILDING DIVISION APPLICATIONIPERMIT m.umnhnr,-huuu "'Sol'
BUILDING PROJECT IDEIVEIFICAxION
'
BUILDING ADDRESS: SANT 1'AHY NO. AI'I'LICADON SUHh11TTAL DATE
a8�1 M�kIN� P Iz 1 f I We Clff - ��Z1,tiq
OWNI:R'.STN-AMIi: P30NIi'J ONTRACrOR'S NAME: a„. LIC NO:
1 '1Y,rfYn_ r NIC CONTROL a
•gBCHITF.CTrtiNGINEEx: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HIQ ELECT PL� hl`:Cy
LICENSED CONTRACTORIS DECLARAI'ION QTY ELECTRIC IIFRM1'F Fhb TOE DESCRIPTION
I hereby diian Inns I am licensed under Amikin®of Chapter,q 1...N'mm,
WOZ w11n Serb....gV0)oI lo,ktioa 3nfthe Ruxincvcand Pmfcssion%Codu,and toy license is RESIDENTIAL:
W Q O PERMIT ISSUANCE
C-F in full Pince and c0ie. ❑SPDWI, El KITCHEN kiiMODF,I.
G VIS loosest Lica APPLIANCES-RESIDENTIAL 0ADDITION OPLOMBING RE-PIPE
F Z W O Conlmeor
mG ❑MULTI-UNIT' ❑S'T'RUCTURAL
ARC TECPS DECLARA'T'ION PANELS
0lundemm�J my plans shell Mused a.public reasNs MODIFICATION
Z0Z
OEQ� UP T02W AMPS [I INTERIOR CHIMNEY REPAIR
F intW Licensed Professional 201-100AMPS IMPROV6N'NT VIMMING POOLS
OWNER-BUILDER DECLARATION OVER If1011AMPS El BATH REMODEUREPAIR MOLLTION
C C G, 1 hereby aRem
rn that 1 am exempt from tie Contractors License Law for the
ag 3 a.V following mr oro(Seeman 7031.5.Business and Pmfe.6...Code:Any city or amoly SIGNS ELECTRICAL ❑OTHER
W a h which normic s o permit m construct,alley,improve,dersoloh,ar mpan any so mmor
F 4'Oj prion.its iswanendso require dieappiicant farsuch permil to filcasiloed statement SPECIAL CIRCUTUMISC.
That he is licensed pursuant to the provisions of the Commeors License Law(Chapter q
weiao (commencing with Section 7(00)of Division 3 of the Business and Professions Code)of TEMP.METER OR POLE NST. OEM L IAL:
d 6 e C that he is exempt Ihererrom and the basis for Nm
e alleged exeplum.Anv violaion of ❑NEW BUGIADDITION ❑DEMOLITION
Section](131.5 by any appladnlfor a permit subjects the applicant IT u civil penally of ('OWER DEVICES [I TENANT ❑FOOD SERVICE
not marc Ihun five hundred dollars(5500). IMPROVEMENT
=QM1,m owner of the propcny,or my enployee%with wage%as Their vole compamarion, SWIMMING POOL ELECTRIC
will do the work,and me avocmrc is not intended or offered for sale(See.7144,Business "{F:R
m nen
13� and I I ': Code:9M1 Contractors L L d t apply of OUTLCI'$-SWI TCIII:S-I1X'1'UHES
Ena ty I builkho, nipowe,Ih d who d : h kl : 11' through
h,r v,aply pnovidealmat such' p t:mania ine WE initiated!IT,, NEW RESIDENT EAI.ELLCI'R SQITT
sale 11 however.thebuilding improvement oldwthins r. r pl toh the $Qal`c I)S.hi Ginn $ISQ.Fr.
owner Wildcr will have the burden of Proving that he did not build or hnprow ser par- r u
pence of soled, 'IGTAL:
1,as mune of the property,am exclusively contracting with licensed contractor,to NOV0 25
p��m.amct the peojel(Sec.01144.Business and Professions C(ac:)'He Conuact.rx Li- rXt l
se law secs nm upplYman aw^era of Property who milds or improves mcrcon.and QTY. PLUMBING PERMIT FEE raf.V
whae.noncu for such projects with a contrazlorfs)Iiecrood pumuanun IM Contnnor's
License Law. PERMIT ISSUANCE �'�� Uf "Urtr1I INU
(]I oro exempt under Sec. .B&P C for This memo
ALTER-DRAIN&VIiNT-WATER 11',A) VALUATION
Owner nate
•
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT'.UIiVICF,
1 hereby affirm under penally of pe Jury onc.f the foll:w�ing declarations:
I have and will maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS-FLOOR.ROOF,ARBA,COND. STORIIS 'TYPE CONSTRUCTION
sminn,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is i...ed FIXTURES-PEN TkAP
1 have and will nmintain Worker's Compensation Insurance,as required by Section
3901 of the labor Code,for the performance of the work for whlen lhis pennn is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUT' APN
MyWork-' Cni "Iii Inwrencc cahrieroliy Nicy( �
Carrier. ��_Pnliey No. AS-RA.SYS'THM-OVER 41HA1
CIT. I'ihl ATB OP EXEMPTION FROM T 5x5' GREASFJINDIIS'IRL WAST IT 191 ERCEPTOR
Aiisis
COMPENSATION INSURANCE I )I 'C I (MON FI?IiS
1'Tnix vection nttUnm MPENSA I NhINSURAnfaone hundmJ Jollun($IIXB GREASE TRAP
PIANCHEX ITE
or Icxv.l
I certify that in the performanceof the work for which this pam iv issued,]shall SEWER-SANITARY-STORM PA.200 lrr.
not cnhploy any Persm in any manner so as to become subjecrto In,Worker:Compcm ENERC. :H
Z xmionlaw%nf Califismit Date WATER HEATER WiVENDEL.ECfR *I ,
zO Applicom
DIE NMICE10 APPLICANT.If,after making Ines Certificate of Exemption,you should WATER SYSTEMlrRE4TING
Meme,ecce,m the Workers Compvnxnb.n Passion.,of the LIM,Code,you must
.. forthwith comply with such provisions or this penal shall be deemed revoked WATER SERVICE
0
5Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.14. pta
V Q lherebyaffirm 1.1 them is a construction lending agency for the performance of
the work for which this pmon is issued(Sec.3097,Civ.C.)
V.
E" Lenders Name '1 OTAL:
L) Lender's Address TIyITI.:
�'s y 1 verify that I have rend this application and state that the uN"c mllnmttion is
vF-h N m..I,,.I^yrw In comply with all city and county ordinance%and state laws ali ing to QTY. MECHANICAL PERMIT FEE
U Z building cumlmetiomand hereby authnrlm reprawnwtives of'his city m emm�tpun One
abovcmmntio ica Trope+y for amism0on pmpasd,. PERMIT ISSUANCE PIT,""FEE
(Wu)a,ma to xavd,indemnify and keep hannlco Rte City of Culw'linu against
liahilitics,judgtncros,mets and expense%which may in any wayacaruoagainp said City ALTER OR ADD TO MECIL PLUMBING FEE
I. a,v....rail the 6mana,m this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT('H)1d'h XI CFM) MECHANICAL,FEE
SOURC17 REGULATIONS.
1/1i. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCI'ION'rA%
Signature ITfAPFlicaMContmcwr Dam EXHAUST HOOD(WIDUCT) HOUSING MEI MAE ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding:wcupam pore or handle haraN.u%material HEAT(NG UNIT(TO 1110.000 BTU
us defined by the Cupertino Municipal Cade,Chapter 1,11.and the Hra th and Safe,,
Cede.Section 25532(%)? HEATING UNIT(OVER 100,(00 BE
[I Ya, [-1 No VENTILATION FAN(SINGLE RESID) PAID
Dale xeccipl p
Will the applicant or future building accupent use equipment or devices which BOILER-COMP(31111 OR HX).001 BTU)
mit h maims air contaminants as defined by the Bay Amu Air Quality Management TMAU
District! BOILER-COMP(OVER 100,00106)
❑Yes F1 No
I have read the Maardous materials requirements under Chapter(I al the Cul'- AIR CONDD'IONER ISSUANCE DATE
forma Heullb&Safety Cock,Sections 25505,15.533 and 25534 1 nndersmnd that Tithe NEW RESIDENTIAL MITCH SQ.FI'.
handiing Anes ma currently hove u Icnam,that it is my responsibility to notify the"I'llanl
of hen=laiearents which roup be sect priorm issuance era nauic:de AOccupany.
Owner or authari agagent Dam 'I(yl'AL: ISSUED HY,
OFFICE