S 3142 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO REALIZING-RLECPRICAL PE ITNO.
BUILDING DIVISION APPLICATION/1"ERMIT PI.DMewG-MECUANICAL 3142
BUILDING PBO,EC'IIDEN'I'IFICA'1'[ON
BUO,DINGADDRESS: SANITARY NO. APPLICATION SURNll'I'I'AI,DA'Z'E
22Y! /1oG� cL( R�N 1LQ �2 �
OWNERSNAME: PHONE': CONI RACE OR'S NAME: LIC No
C /7 0 Gv/Jtzh /77 a cSal2a?u GH I1wcDl-''t./' fS bl9sza NIC CON•[Rol.«
' NCHITF.0 IEN(IINF;F;R: LIC No: ADDRESS. El
�stoy� S.anorpa» - sv+Ayveur 1tv
CONTACT: PHONE: N / ? BUI INC PERMIT INFO
❑ Consultant Fels Paid by Applicant(Initial) 13LDC ELECT PLUMB NIECH
S1'- Pov)s ❑ ❑ ❑
LICENSED CONTRACIOR'S DECLARATIONQTY EI.ECI'RIC PERMIT FEE
1 hereby affimt that 1 am licensed ander provisions of Chapter e(commencing JOB DESCRIPTION
CZZ with section 7")of Division 3ollhe Bitimessand Profesionesda androy liccmei. RESIDENTIAL,
WOO, in PERMIT
F full force and offem ❑SFDWL ❑KITCHEN REMODEL
sc U License Class Lim. APPLIANCE'S-RESIDENTIAL ❑ADDITION El PLUMBING RF,-P[PE
F Z W Date CUtnmetnr
m41 ARCHITECTS DECLARATION Ll MULTI-UNIT El STRUCTURAL
ZOroZ I understand my plain.hall be med.,public records IANCIS MODIFICATION
_—En— UP fO 200 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
m Licensed Profewlonal 301-1000AMPS IMPROVEMENT L]SWIMMING POOLS
C C, 1 hereby (tion bmN am exempt RomeCLARATION fle Claimant's License Law for the OVER 10X1 AMTS E3 BATH HF.h10DEf/REPAIk (]DEMOLITION
a ma ya
X 3 following¢ to.(Section 7031.5.Business and Professions Cede:Any city or county SIGNS ELECTRICAL ❑OTfiER
L U au
W m FFi which requires a permit m enrnuent,at'.,,torrents.dmn0lish,or repair any strucstructure,etu
E'[='c j poor o its issuance.atm requires the applicant for such permit n file a signed statement SPECIAL CIRCU[TOM ISC.
S[,",} that he is licensed pension to the Provisions ofthe Contractors Littmx law(Chad COMMERCIAL: O
Cy4E (commencing with Section 7")of Division 3 ofthc Business and PlumssionsCdc)or TEMP.MERiRoRPOL.I:INST.
m-00
6 a ca C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NI>W BLDG/ADDITION UCMOLITION
�-m Section 7031.5 by any applicant for a Permit subjects the applicant n a civil penaltyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
immune than me hundred dollars(3500). IMPROVEMENT
O I.as owner of the property or my employees with wageus their side condensation. SWLMM INC:POOIC f:LECIR IC
E. will do thewom
rk.and he is not intended orolicmd for sale(Sec.704U Business ❑OTHER
W m and Professions Code:The Contmm.rs License law does not apply m an.weer of OIJJI"Ef5-SWITCEIRS-IH)(TURIS
property who build,Or improves thereon,and who does inch work M1rmselI Or through
his own enrPlOyces.provided that such impmvemrnta arc not intended nr offend far NEW RESIDENTIAL ELECI'R S
sale.ILaw
hca.Nrov
Ne building.,impement i,,.Id within one yearofcnmptetion.the FLOOR AREA SISQ�I°I'.
owner Wilder will hall the burden m proving that he did not build or improve for pur-
poseof sale J.
C11.m er ownof the property.am exdusi,ely Gmaractin,with licensed amtratton to 'I'UTAL:
n..trmt the project(Sea 7000.Basiners and Prom,,innv Crde:)'Rte Cnomm nr's. -
cemeLawdoesnotapplytoanownerofPropertywhobuildsOrimprovethereon,and QTY. PLUMBING PERMIT FEE
who,onaaas f mall,pmjecti with u eontranmk)licensed pursuanuo the Coatmi
Lfceme Law. PFRMIT ISSUANCE
1 um exempt under Sec. .dl h P C for this reason
ALI ER-BRAIN A V17W-WATER(EA) VA
Owner Dale
WORKERS COMPENSATION DECLARATION BACK FLOW PRCTI:CL'.DEVICE
1 hereby affirm under pmmlty of perjury one 01 the following declamtiom-
)nIhzveand will muimoiaaCcud,mcof Comauoself-imu,t lin Worker's Com"'. DRAINS-MOOR,ROOF.AREA.COND. STORIES TYI'F,CUNSTRUCTION
emion,as provided fOrby Scotian 3701 ofthe Labia CoOr.for the perlinmmince of
work for which this pttnnt in oounl. 19%'1'G GES-PER I RAI'
n 1 base and will nainmin Worker's Cnmpmumion Insuraac0,tc required by Section
37000 the Luhrn Cade,for tho,,dammice of the work lbr which thispenal is issued. GAS-IiA.SYS']FM-I INC.i OUTLE'Iti OCU.GROUP APN
My Wed.ee,C( creation hountna emricr nvd Polley number are:
Carrier Policy NO, GAS-IiA,SYS'[I1M"UV L'R i UFA)
t]:R'1'II'ICA'FI'Op 11 7 I'I'ION FROM WORKERS' 7AS191NU11S'I'RL WAST,INFI:RCF.I'R)R
COMETNSAIIGN INSII ANCH BUILDING DIVISION FEES
(In-r.rourneed Im,onn,II I'f0 t ., annelin 1I Illo'clion ASI3'I'RAI'
in 1 ) I PLANCHECK FEE
suntm l.uws nt R tlt1 1 I- DI kf Id-.I Ilsht ll S LR-SANITARY-5'fORM hA,2(X)PI'.
of
cm to ype..tn r. y.,.an -n,to n Mvo by mOv Woda+s L. qnr. ENERGY 11.E
O "� rcal'dmnia.Dum I'ITRIIIiAI'ERWIVEN'1'11711; 'R GRADING FEE
Z2 APp atm a
.Gy NUT ICE 10 APPLICANT:H.aOcrniakia,thin C i lime 01 lncmption.You xhWA I'ER SYS'I'Iovill WHAT'INC, SOILS FEE
I"t hecunil cable,,n, Its W..kera'COtnlwmadon pnry lans ol the Labor Cada YOU inua
fimhwl@ comply with such provhione nr on, orm,Hnll.hcdcctncdmvnknl. W '1'13R SERVICE
Q 7TT PAID
7z man here is. ION LI!NUIN, i; WRCSIDIiMI'IAh I'LMe. sV.Irl'. Date Receipt#
U O I hereby aflirnt mm there is v ninsavctinn lending agency Iia the pert rtn.mwof
W the work fnrwhlch this pemm is issued(Sa.,IND,Civ,C.)
O Lender's Name '1(YfA 1.:
L) Lender's Address TOTAL:
�'•' G I certify thin 1 have rad mi,apph,zlion end state thud Um ahove Intonation Is BUILDING 1:121:
N 'Omar l again,n,Comply with.11 city and county Ordinances and amt laws relating In QFY, MECHANICAL PERMIT FEE SEISMIC FEE
f, Z building construction.and hereby authorize representatives of thiecity to euterugm the
above-ancin Old property far inspection Impoaca. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,ind atundy and keep hairiness the City 0f Cupertino against
tubi lines.judgments,costs and expemcawhich may in any way accede againntsaid City ALTI?R OR ADD'In MECH. PLUMBING FEE
an consequence of the tinting of this pemtit.
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH AL1.NON.PDWT AIR II A N YANG UN IT(TO I0.(XXI CFM) MECI IANICAL FEE
SOURCE:REGULATIONS,
AIR HANDLING USE"I(OVER 11.(00(t)CFM) CONS'I'RUCrION TAX
Signature Of ApplicanUContmetor Date EXHAUST HIRED WT)UC) HOUSING ME I'[CATION ItiE
HAP,ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Oaupam sure or handle hazardous material HEATING UN]-['('1'O 1101.10X)It'I'll)
is defined by the Cupertino Municipal Coal,Chapter 9.12 and the Health and Safety
Code.Section 255326d? IMAfING ON IT(OVER 100,000 BTU)
El Yes ONO V ENr11AT10N FANS ENGLE R&SID) PAID
Date RecciPr M
Will the applicant.1 future building maup.,use cyai,meat or devices which BOILER-COMP(31111 OR 100,000 B'I'UE
mit hoeatdouu air contaminants as defined by the Bay Arca Air Quality Management
District! BORER-COMPIOVPR 100.00BTU)
G Ycn -1 No
I have remlthe acquirement,under Chapter 6,95 Of the Cat- AIR CONDITIONER SANCE DATE
a
fomia Health n Safety Qde,Section 25505.3.5533 am12553i.I understand notify the
that it the NEW RISIUENI'LAI.AtIiCH. SQ.Ff.
building does not cunendy have a,memothat it is m cc of a eni hr notify theOccupancy.Occulting
.(the reyuimmems which moa FT mc,prior to isxmncc.f a CeniOcme nl lkcupuncy. � / n
Owner or authotiud agent Dae TOTAL: ISSUED BY (—
OFFICE