S 1041 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIN0 BDu.DING-ELECLHI(AL PF`� I I NO
BUILDING DIVISION APPIACATION/PF,RMIT 1'LIIMISING-h1HC11AMCA1' �J 1041
BUILDING PROJECT DOES'1'IF'ICAI'ION
L SANITARY NO. APPLICATION SIII{MI'I'I'A I.DA'I'li
DING AU RESS: �� Y l\ 1�` 0/�� O ♦ n
I'1 NL CONTRACTOR'S NAME: LIC NO:
OWNF,R:SN F.:r HwK lk � 737- 89 NIC CONI'H(_lLN
• ARCH00.
ITECT/Ii GINEHIC LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
SU 737-fl89 E] CongullaDl Fees Paid by Applicant(Initial) BL ` F T LUNE Nj(:CI!
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE JOB1DESCRIPTION 'f-ice
1 hereby affirm that 1 am licensed under prevision%of Chapter 9(commencing
WO -OO with Section 7000)of Division Sof the Basins and Professions Cod.and mYliccnw is TI L:
CkkF in full Rome and eRcO. PERMIT ISSUANCE ,PDWL ❑KI'TCHEN REMODEL
aVkJ License Clash fart APPLIANCES-RESIDENTIAL []ADDITION E]PLUMBING Rl%PIPE
hGL Date. Comromba MULTI ❑STRECTURAL,
ARCHITECTS DECLARATION PANELS MODIFICATION
Z Oy
�Z I understand my plvn,,dall be used us public records UP TO 210 AMPS
OZ4 ❑INTERIOR ❑CIIIMNI:Y NI:I'AIR
F-FYI Licensed Profesdowl 2111-HKOAMPS IMPROVEMENT �SWIh1h11NG POOhS
6 S.� OWNER-HUILDER DECI.ARwrioN ❑BATH REMODEVREPALR ❑DEMOLLI'[ON
C Y.g'J OVER IfXN)AMV$
C ¢ 1 hereby uS, that 11.exempt it the Canacteis License
Am,l Low geode ❑OTHER
O Wy U tattooing teems[Somion 903 L5,liuslness nnJ Pmfcxsiotm Colic:Any lay or munlY SIGNS ELECTRICAL
W a W y which requires a permit m mnaruc,aper,Improve,demolish,nr repair any orucmrc
OC poi t t mo I, 4 :II p,im tl hpc tl II 6 dua¢ncnt SPLCIALCIRCUI' '-
999999 r thorn T dI ft h p- + III C a t 1 (Chapter9 COMMERCIAL:
�� ("nnay.'..voll,Sec, +r7000)dpvis +r 3oldo,annos.ul lr f:: mCudO).r TIME ME Y),1
a E a 0m he is exempt IInotilmr and the book fur the alleged esamp,ion.Any violation of ❑NEW d1.OG/ADDITION ❑UIiM01,1'1'ION
X n 4. Smtien 91131 5 by any applicant fur rr Mrrnit enhjccb the uppllcum to a civil penalty of POWER DE S []TENANT ❑FOOD SERVICE
yy al m omihan Gvc hanlmd dol Lrv($5ro), IMPROVEMENT
2� [-1 1,as owner of the pru,,cry.or Illy employees with wvgomWcranlecompencation. SWIMMING POOL 1:1.10 C El OTHER
F. will do the work,and the svucmrc is nnfimm�deJ anfturul lbnula l5ec.9BFi,BaronesspUTLETS-SWI'1'CHI1S-IL%"T 'S
d3 m Pull Professions Code:'The Colonel—Licunw Law duo"nm apply m an net of
P
who builds or improves theram,and who does such wed,himself o through NEW RESIDENTIAL EhECI'R i'1'.
his own employees,provided that such hnprovements ere not intended or offered for SQ.FT.FLOOR AREA $/SQ.PE
sale.IL however,the building or intpmventem issold within one yevtnfoomplomn, he O
owner,builder will have the burden of proving that he did not build or+mpmvc fur put-
pose of nalcl
0 1,as owner of the property,um exclusively commeting with licensed contractors to
construct the project(Sec.]ELI.Business and Probosinns Gseel One ContactorLi- FEE
's t
nsc Law does not apply tenpc
r an owner tprnny who build,or improves thereon,and QTY, PLUMBING PERMIT
who contracts for such projects with o cunvactor(d licensed pursuant o the Contralo's
Licenu Law, PERMIT ISSUANCE
C] Iamescmptundcr Sec. .B&PCRlrhisnamn
ALTER-DRAIN&VENT-WATER I VALUATION
Owner Date
• WORKER'S COMPENSATION DIICEARA11ON BACK FLOW PROTECT,DEVICE; 2 • /�
I hereby affiar under penalty of perjury one of the following declmaeons: J Y
I have and will maintain a Certificate of Consenuo ulronsore for Workers Cmnpcn- DRAINS-FLOOR.ROOF.AREA,CONO. STORIES TYPE CONS'IRUM)ON
scion,a%provided for by Section 3101 of the labsr Code for the performance of the
work for which this permit is issued FIXTURES-PER TRAP
❑I have and will maintain Workers Cntnpensatinn Imurance,as required by Section
39Wof the Labor Code.bathe perh+nnanccoffle work for obichdos permit i.e.i...ed GAS-L'A.SYSTEM-1 INC.J OVf1.E1'S OCC GROUP APN
My Workers Compensa an,hoomae currier and Policy number to: GAS-EA.SYSTEM-OVER 4(HA)
Cartier: Policy Wt:
CEBI'I I7ICATF 01:ExlV`PI'ION FROM WORKERSGREASIVINDUSTRLWAS'111NI'ERCEMOR
COMPENSATION INSURANCE BUIL 6 DIVISION FEES
(Thi,wc,nermcdnol hceunrplcmA ifdoe,on,is fonaelmndredd.lia,($100) GREASE TRAP PLANCHECKF
less)
I ri 1, th pd Itl work for FIthis ,is Jlshall SEWER SANITARY sD1RM IiA.31X '1ENERGY 17
n t I Y person on
Y i h hj r,u,h M w Compn
az 5:1 I ICff ]late WATTRHEATERW/VLN DEj_FCTR GRADING If
Z
o Appl t
h NOTICE lO AIIIICANC ,fI Ir. WATTY SV$TEM GRE AING SOILS FEE
a ; becoom ni vet a,the Worker,C nmmrs.n...r pou,kinneal tbe Lvh n Cede run mast
s fonhwhh comply witheucM1 provisions or This pennit shall be dccmcd revoked. WATER SERVICE;
(� PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENT[A],PLMB. SQ.FT. DPm R'cid M
U 'T 0.: I hereby strum thvuhe.is.cntome,Linn lcndingvgency l"or the performance of
ENewark for which this pemtit is issued(Sce.3092.Civ.C.) 'TOTAL:
UanLenders Name O
L[ Lander',Address BUILDING
J L candy that I have rend this application and state that the above information is
Fy collect l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC '
V Z building construction,and hereby authorize representative%ofthis city to enter upon the
a4womentioned property rot inspection purpose. PERMIT ISSUANCE ELECTRIC Elol
(Act agree to save,indemnify and keep harmless,he City of Cupertino against
Liabilities.judgments,costs and expenses which may in anyway accrue against said City ALTERORADDTOMECH. PLUNOUN FEE
in consequence of the granting of this permit. +
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO IBOBH CFM) MECHANIC,L
SOURCE:REGULATIONS.
AIR HANDLING UNIT(OVER 111,000 CFM) CONSTRUCT] ETAS
Signature ufAppllcurao0maacar Dun EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hmnoloas material HEATING UNIT(TO 100."BTU)
nc definW by the Cupenino Municipal Code,Chapter 9.12.and @e Health and Safety I]EATING UNI'F(OVER 110,000 B'FU)
Code.Seel 25532(11)!
LD y" 0 N VENTILATION FAN IS I NGLE REMD) PAID
Date Receipt p
• s Will the uppllcum ar future building occupant use equipment or devices which BOILER-COMP QHP OR UXONX)HTU)
mit ilc u' os air ennmm shots a%defined by the Boy Arca Air Quality Management 'I'<'
,)is
vid'I ;{OILER-COME(OVER 100,000 BTU)
❑ye, ❑Nn
AIR CONDI'I'JUNIiR
I have red 0vrdmor
e.haonmlOnal,rcipdar cut, der Chn,m,6"Por the Cali- _ISSUSUANCT-/k
li+miu Hcalb&Safely Code,Sectinn%25505,25533 and 25534.I understand Iha,d the NEW RESIDENT AL MF IH. SQ.FI'.
buildingdnes not cnrmnlly lamer to a.Iain it Ix my mspnnsihdoy w notify the i".pmn
of the tcmamama s which rad,he act In e+;%sauna of a Ceniecme of Oceapvncy. Is 09D
Owner or authorized agent Dec Te ISSUED BY
OFFICE