00010036 APPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY coolao_'1 h
CITY OF CUPF,RT]NO BUILDING-ELKC'I'RICA6 VERMIT NO
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECIIANIC'AL 50001
Bvf )ING PRI ECT IDF,N'1'IFICATION
HUILDINGADDRESS n / SANITARY NO. AI9'LICA'I'ION SU11AfU"1'AL D,\T
V L/
OWNER'S NAME: P NE: CON'TRACTOR'S NAML: LIC NO
NIC COKI'kOL p
(CHII'EC'I'ENGINE[R: LIC NO: ADDHIISS: �Igl 0 / �n ❑
CDN'I'ACI: PHONE: y� � ` 13UILDING PIiRMI'I'INTO
-6 /O 2-f-3
93 1 ❑ CoDSBllan[ CCS dl Y I I Ill(Initial) BEl LI❑! PLUS M❑C f
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC 1'IiRMIT PEE JOB UESCRIFa'FION
I hersby affirm that I am licenssd under provisions of Chsp¢r 9(ro on.c.0ag
OCZ with Section 7")of Division 3 of the Busine%.and Profudmo Code,anJ my license ix RESIDENTIAL'
W p PERMIT ISSUANCE
F 1y� in full forecvnd effect. ❑SFDWL ❑KITCHEN REMODEL
9-1- License Class�}�—Lie#5T� APPLLWCES-RESIDIiN'1'IAh [I ADDITION ❑PLUh1NING RE-PIPE,
vFi Q Ume Cemmcfnr
ARCHITECT'S DFCfARA'1'IUN PANELS ❑h1U1.T1-UNIT ❑9RUCTURAL
f-tiZ I moderated my Plans shall be owdas pahEarccmd, MODIFICATION
ZO,�,� UP10200AMPS ID INTERIOR El CHIMNEY REPAIR
I
-o, o. 111 Lien IProm"innul 201-1100AMPS IMPROVI'.MFNT ❑SWIMMING POOLS
6 , OWNER.BUILDER DECLARATION
p;Y ,� - OVER I(XXIAMPS ❑BATH REMODEUREPAIR i Mi
W,C < I hereby affirm that 1 am cxcntpf from the Cnnlrmtor's License I.aw Ins the Q OTHER
E:ow,3 LL U following rcumn.(Section 7031.5.Business and Pndcalon,Code:Any city or counlY SIGNS ELECTRICAL.
y which requires a permit to construct.aher,impose,clannish.or repair any structure �� s l• w
F��; primnrits I....ecx,alm requires the applicant for such Permit o file a signednmmntettl SPECIAL CIRCUIT/M ISC. �?
���. that he is licensed purruanue the provisions of the Commmol'a License Law(Chapter 9 COMMERCIAL
W�Mo (commencing with Section JBW)of Divisum Sof the Businevattd Professions Code)or TEMP.METER OR POLI?INST.
a a C that It,is eaerttpt lhcrefrmm and the basis for the alleged exemption.Any vinlmio I of ❑NEW BLDG/ADDITION ❑DEMOLITION
X^mSectinn 11131.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
n more than five hundred dollars S51X). IMPROVEMENT
=Q Q I,as owner of the property,or my employees with wages as their site compcmation, SWIMMING POOL ELECT RIC
L. will do the work.and thestmcwo n not intended or offered Emsnle(Secs 1614.Business ❑OTHER
C r OUTLETS—SWI"TCHES-FIX I URES
w. and profession,who b Cade:The Coes therm§L nIt w Law Jou no,apply m rot owner or
pn9wny who huilA.v or sided fol such t,and who Joe,much wurk deed a or fhmngli
his own anpinyccx,provided that such inmmvcmm�s arc nnf intended nr oftcreA for NEW RLr511113NTIAl.I?hliCl'R SQ lot's
.ale.If.however,the building or impmeaticnf is sold within one year mf enmplclion.ten SQ.17,FLOOR ARBA $ISQ.IT
owner builder will have the harden ler proving that he did not build or Improve fie Pur
post of sale). TOTAL:
h as per of the xmpa ry,an exclusivelycontracting with licensed contractors to
m.tract the project(Sed. Business Imd Professions Code:)The Contractor's Li.
music,Law does not apply to an o,ner or property who builds car improves thereon,and QTY. PLUMBING PERMIT FEL
who contracts for such projects with a commcua l licensed premium to the Contractor's
License law. PERMIT ISSUANCE
1 um c.empt under Sec. .B&P C for this reason
ALTER &VIiKI'-WATER(EA) VAIAA'TIUN
Owner Date y
�� WORKER'S CfXMP1iNSA'I'ION DECLARATION BACK FLOW PR(YIECr.Il1iVICli
I hereby aid rad under Penalty of Iw,,u,one of the following declaration,:
IOU, IhxV,l I wi 11 mainmin a CenlfcarcofConsentto self-i n.cum for Worker's Compo. DRAINS-FLOOR,ROOK A 14 HA.COND. S'UBUFS 'I'VI'1?CON1rRUC1'IO
.mien,as provided for by Section 3101 ill he Lnlror Code,for the pemmttance of the
work lin which f ia,permit is ism ed. FIXTURES-PER'1'RAE'
M I have and will mainmin Work ',Cnmpensalion Insurance,as required by Section
311X14 a ahtr Carl for then rmance'If'he wurk fill which this permit i.issued. GAS-FA.SYSTEM.I INC.a DUE CUTS OCC.GROUP q APN
Ca yAFk r m tion lr� Ica elle EysNo nu r GAS-EA.SYSTEM-OVER J EPA)
nGl/ CERTIFICATE OF E%I;MPI'I0N FROM WORKERS' DI GREAS.M,NDUSTRLWASTti1KfF.RCEPIOR
COMPENSATION INSURANCE BUILDING[)]VISION FEES
(This section need nm trcmtmpkreJ if the pcmtit is fur unchandreddellem15100) GREASETRAP
I'LANCf11iCK FEE
or lots.)
ttni,thminthe any mannroltthes t workm for wublese to permit i.is,ued,lshall SEWER-SAN ITARY-S'1"UHM CA.21X)FT
not unminy any person in unY manner,n na trr M1u�nnm nub'Iwf m the Wurkerd Cenlpem I?NIiRGV PEB
z vulinn Low,,ill Col'forma.Date WATER HEAI'IiR W//liN'UELEC1R GRADING FEE
Z
APplkmn )
h NOI'ICIi TO APPLICANT:If,alfcr making this Certificate of Exemption,you should WATER SYS'FENITI'RUA1'ING
a ; bccnme.mbjee,m the Wnrkek.C upemation pmvi.ion,of be LaWr Code,you tonal sons PEE
Ill forbwifh,amplY with such p...kio I,or this pemtil.hall he deemed meeker. WATER SERVICE
PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIMIC SQ.ET. Doc HewittX
U O I heathy affirm fludd is o construction leading agency for she performers,of
Pthe week for.had,this permit is isw0(Sec.31N7.Civ.C.) TOTAL:
U Lensl Name TOTAL:
r G] Lcodcr's Address BUILDING FEE
a I cenily that l have mad this application unit state that the above information is
F` h
correct.I agree to comply with all city and clearlyordiornce,coasmte low,rel,amg to QTY. MECHANICAL PERMIT PEE SEISMIC I'EE
V Z btBf gc , f dh by' th 'a I dal' : ffh. kyt t open the
:b dplotted,I 'P I P P I'HEMET ISSUANCE 111.1.(71RIC PEI:
(W ) p , n,wd,ime lilyiIk 11 I.:the City fCpct against
.hlfu,jrdgaum:cessandcxpcnscs ohich tuay it any way reemeagals,said City ALTERORADOTOMECIL PLUMBING TEE
In mnmqucmcc.d the gaming ar Ni.permit.
APPLICANT UNDERSTANDS AND WELL COMPLY WITH ALL NON-POIN I AIR HANDLING UNITOO 10,00(1 CFM) MECHANICAL FEE
SOURCE.REGULATIONS.
AIR HANDLING UNIT LOVER IROIXICPM) CONSTRUCTION TAX
Signature ofA,icanJContmaor Date EXHAUST HOOD IW/DUCT) HOUSING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future thuddingmrcep:mtstem or handle hvN
anux material HEATING UNIT(10100.000 ROD
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Sullay HEATING UNIT(OVER 100,00o)ETU)
Code.Section 25532(a)?
p Yes E:1 No VENTILATION FAN NINIIAI RESID) PAID
Dare Rea'ipl M
WilltheappRotm or future bui'dingteatpam lose aquipmcn,or duvicea which BOILER-COMP(9111'OR FXIIX,l B'rU)
at hnrardous air cammminualx v,defined by the Buy Arca Air Quality Munngcmcnf 'I'OIAL:
U'griel? BOILER-COMP(OVER 1000X111'1'UI t
❑Yea F1 No
AIR CONEDBONER ISSUANCE DATE
1 have rmJ,he harmdoas material.mryircments under Chapter 6 95 of the Cali-
full Ilcalth&Sudy Core,Swims 255115,25533 and 25534.1 understand that if the NEW RESIDENURAL MECH. SQ.Er.
buildingiii not currently have a moral,that it is my responsibility to notify the trculdent
of the tequiremenu which must he ntet prior to eddince of a Cenificam of Cods-1-y.
i Owner nr amhoriaeJ agent
Duo I
TOTAL: ISSUED BY:
OFFICE