S 0633 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
RGII.DING-Kl,FC'1'RICAL 1'Ii RcM I'I'Nt).
CITY OF CUI'EK'I'INO r1.u5HBNr. 111!CIIANICAI, S 0633
BUILDING DIVISION APPLICATION/PERMIT
ItUI1.DIN0:1'NOAHC'1'IDEN'1'IFII'A'PIUN'
SANITARY No AI'I'LICAI'lI1N SlJRht 1'I'1'AI.DAI
BUILDING ADDRI��
OWNER'S N L: P >'`: CONTRACIOR'S NAME: LIC NO.
NIC COM ROI.p
lost NPIS-3
�ARCHITECI'/fN. IAM: LIC NO: ADDRESS:
CONTACT. 1114ONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLDG HLFCr PLUMB MELEE
!RXll_ .4k ❑ pir
LICENSED CONTRACTORS DECIARAT[ON QTY ELECTRIC PERMIT EE JOB DF,SCRIPTION
1 Touchy affirm Thal 1 am licensed under provisions of Chapter 9(commencing
nwz with Section7doinofDivision Sof the Theme,and professions Cudte.and my license is RESIDENTIAL:
O PERMIT ISSUANCE ❑SFDWI, ❑KITCII17N REMODEL
F1_ to full force and enact. `--
aUU License Clans Lic.p APPLIANCIS-RESIDENTIAL J6M)DITION C]PLUMBING RE PIPE
y_u pate Cmnrudur r❑M1 UTA bUNIT ❑S'I'ROCI'URA.
ARCHITECT'S DECLARATION PANELS MO[AFICATION
z0oiz, I understood ntyplanahull hcuwd.'EmhIlcmcmI1 [it'10200 AMPS [I INTERIOR C]CHIMNEY REPAIR
OzM IMPROVEMENT 0 SWIMMING POOLS
W Licensed l'rnlcssionnl 201-INXIAMPS
a , Ihcrehy xlllnn OWNI7R,BUII.IDtlRtn EC`.CRA'DON �BA'L'I I RLMOUCLIRI?PAIR ❑UEMOIJI ION
C a '� Bacons License Low for the OVER 10X1 AMPS
�, ❑OI'HIIR
,R,UU holt: L - (S y' 90131511 . JI f a,Code A., lly,country
SIGNS IiLI'C'IRICAI,
rqX� wh sh 4 P 'n t 'It P I',h P' Y.I marc
Fey; pram I is 4 rill ppl' II hp tl II 6ed.11omat SPLCIMXIRCUII)M ISC.
� } thmh dpursuant II p n flh C t t L L (Chapter 9 F I '
a�07 (con 6 tl Seco .YOXaofD vstn Sof the Biraes� dP dens ons Cude)nr ThMP MLII'R Ok IN)1,1?INSI'. NEW BLDG/ADDITION ❑ldwo l'I'ION
C y o y' Thal he is exentpl Ihorclrotn nnJ the Turin lie the alleged enompltna Any violvtian of
W..y
Section 7031.5 by any applicant lin a Pmrmit,wbjeclr the apPlawam a civil Penalty of MW17R DEVICES ❑TI?NAN'F ❑FOODSERVICH
of more than live hundred dollar;155001. IMPROVEMENT'
=Q ❑La owner mf the propcny.or illy employees with wages as their mile compensation. SWIMMINGI'OOLGLECfRIC ❑OTHER
F will do the work.and the stmclurc is not intended oroffeed tarsale l 5ec.]0.41.nosiness ()Of
LM S-SWI'I CITES-FI\TURES
ku 3 m and Professions Coot:The Contractor's hicenw Law does not apply to an owner Of
pmpeny whit huild,Or improves Thomson,and who dues such work himself m through NEW RI?tiID1iNl'IAh❑LIiCTR SQ Fr.
his own employees,pmviJul that such improvements am not intended or offered for SO.Fr.FLOOR AREA 9SQ.14.
.sale.IL however the loading or impmvatrcnt is sold within One year ofcompletion,the I 1
m,builder will have The harden of proving that he did not build ur Improve for par- ` 2
1 a.t r or he grorcnX at e.ewsmelr emmmetmg with licensed emmre<tna t.
:mI of mi
tmct the project(Sec.91144,nuslness and Professions Cale:)The Contractors Li- FEE
cense Law does not apply m an owner or property who builds or improves lhcreon,and QTS'. PLUMBING PERMIT g.g
who common for such projects with v emarxmgsl licensed To
to the Contractors P
License Law. PERMIT ISSUANCE
I
p�ium See. B&PCJI thi�re'usol At:I Iik-GRAIN&VIiNT-WATER(LA) \A IY SOON`
Data
WORKER'S C( PIiNSATION DECLARATION BACK II.OW PRITTCI'.DENIER (jR
I hereby affirm under lmnalf,al'P,,imY One of the following declarations:
L71huvc unJ will nwinminnCcrtilicnlc ill Conscm a:sof-ireurc for Wnrkor'x Cnmgmm DRAINS-FLOOR.ROOF,AREA.GOND. OR �S( I� 'I'YI'LCl1N5'TRUC'I'1(
sultan,ux gmviJcA f r by lection 391X1 of the Lahm C:dc,for the podormnnce nl'Ihe 17IX`I'URI:S-PER T RAI'
work for which Ihin permit is ismcJ.
1 have and will mdnmin Worker's Compenmllrn Insurance,as mocired by Section GAS-IiA.SYS'I'IiM-I INC 4 OU'TLII'15 OCT],UR(lllp AI'N
991X1.1'dm LnMm Code for the perlimnmlee allhe wad.for which Ihin permit is-„-all
My Workers Coulp,asroon lnsnnmce carrier and Polley number are: GAS-IiA.SYSI'IIM.OVHR 4 IIIA)
Cornier. Polley Na:
CERI'119CAI'I7 OF pxBMl4'ION FROM WORKERS' GRFASIUINDUS'I RI,WAS 11:INT IiRCEITOR
COMPENSATION INSURANCE 111 LNG ISION ILI!S
Ohisoction need not becomplmedlflhepennit is forms,hundred dollars(8I110) GREASE'FRAP PLANCHECK ill pie
.,less.)
Loy anylhatin the pedntmamemol s1work haromewobject to the Works'comued,I hall SIiW'IiR-SANITARY-S'IT)RM En.21X1FE IiN1eRGY 19]i _p
nm employ any pemm in any manner sa m m become subjcm ns the Workers'Compen-
,Z moon laws of California.Duca WA'I'17R BEAT F,WIV13Nl'l1iLro—I, GRADING I9ili
Z Q Applicant
NOTICE In APPLICANIT If,after making This Certificate of Exemption,you should WATHk SYS'I'IiM1VI'RIiATING sarn l roe
F•' 'N' become subject to the Workers Comm penmtinn pmvisioof The Labor Cafe,you most
forthwith comply with such prvi torn,this permit shall he deemed revoked. WATER SERVICE
} 3 PAID
CONSTRUCHON LENDING AGENCY NEW RESIDHNTIAI,PLMB, SQ.Fr. Data eeild a
L) 01herehya(firm th tdr,re iso connmction lendingagency for the performance of
the work for which this permit is issued(Sec.3191 Civ.C.) TOTAL:
�' (•” Laro s Name TOTAL:
WLeralch AdJrcsn BUILDING ITEE
. I cmam
ify that I have mad this application and summit the atawe info,mmion:s
F 6p) mimed.l agree to comply with all city and county ordinances and sum laws refining In QTY. MECH ANICA I,PER M IT FEE SEISM IC FEE
V z building conslmction,and hereby all turn,mpoesentadves of this city to enter upon the
uMne-mentioned progeny for inspection purposes, PERMIT ISSUANC17 ELECTRIC P
(Wel agree to save,indennify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way acetum against said City ALTER OR ADD T(1 M ECB. PLUMBING FF
an nmyuonce of the granting of this permit
APPLICANT UNDHRSTANDS AND WILL,COMPLY WITH ALL NON-POINT AIR HANOLINO UNI1'('10 lu,mMC17M) MECHANIC 1,Id:1i
SOURCH Rr:GO,A)'I(1N5.
T
AIR HANDLING UNIT B)VBR Id,IXX)GI'M) GDN$'1R C'IION'I'A%
Sig re ofApplicanUCentnmmr lam EXHAUST HOOD IW 11) CI') H(1U51.GMI'I'IGAfI(1N Plili
HAZARDOUS MA TRIALS DISCLOSURE IIIiAI'ING UNI'I'IID olonal.11TI
Will the upplieam or I'ubtre building occal om sura nr handle hseardous material
av relined by the Cupertino Municipal Cab,Clingier 9.12,and the Health and Safety BEATING ON I'I'(OVER ITS)(XX)IfI HE
Coe.Section 255)2m)'I PAID
C3 Yes F-1 No VIiNI'ILA'I'[ON FAN IS INGLE:ReSSIDI Dore Reeciptn
Will the applicant or furor.building ueoupam low cy.ipment nr devices which BOILER-Co Mp(3[111 OR 11X).001 BTU)
mit harvrJo.,air comminution,as defined hY the Bay Area Air Quality Management 'I OTA1.:
District! BOILER-C(IMP(OVIiR IIXLIXXI Ii'TUy
p Ye. ❑No
AIR CONDITIONER ISSUANCE DATE
1 have read the ba eiWous tnoedals r xg ircmems under Chapter 695 of the Cali-
fmmia Health&Safety C:de.Sections 25585.25533 and 255M.I understand Ihin if the NEW RESIDLNI'LAl.M11ECH, SQ,pT.
building does not currently have a unvnt,that it is my responsibility to notify the aeupied
mon,myvircmemn warn man to met roar to issuance ora c.tmmate aromeapmley.
ISSUHD BY:
Owner m amhmrizN agent
Date
OFFICE