S 1158 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPF.RTINO BUn,D1Nf:-ELECI Rlcnl. PI RMI F No.
N• RUILDINCDIVISION - tiati PLICATIONAIFRMIT rLumBlNc.nu?cxnNlcM' S 1158
BUILDING PROJECT 1DEN'UIFICATION
SAN] NO, APPLICATION SUBMITTAL DA
11UILD1 U °'$:
0 2A,
OWNER'Sc6sts. PHONE. CONTRACTOR NAME: �LIC NO: NIC CON'TROL#
Trt
'ARCH TEcUENGINEER: LIC NO: ADDRESS:
CONT C1': PHONE: BUILDING PERMIT INTO
�AN P.S4:ACL 1 'L31 _TWT F-1 Consultant Fly Paid by Applicant(Initial) 1 ELL'C'IPLUMB MECH
LICENSED CON]RAURK'S DECLARATION QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that 1 am licrnsed under Provisions of Chapter 9(commencing
q0p with Sedion]IxN0l of Division Job the Im6aessand Pmfeseions Code.vod my license,, RESIDENTIAL' -
PERMIT ISSUANCE ;pqr{- ❑KITCHEN RUNIODEI
F .
OF, in full and coal
�UU 1.icnlsc Class 1.10.N APPLIANCES—RIiMDEN'TIA1, CADDITIDN []PLUMBING RLI'11'E
ZZM "I'—Contractor— ❑MULTI-UNIT ❑S'1'RUCTURM.
ARCHITECT'S DECLARATION PANELS, MODIFICATION
ZONZ I understand myplans shall focused as puhhe records UP TO 210 AMPS
Oz--Z El INTERIOR CHIMNEY REPAIR
F.�FuI
Licensedd[inclusiona] 2(1 AMPS IMPROVEMENT E]SW'IMMINGPO0IS
WOWNER-BUILDER DECLARATION OVER I000 AMPS ❑BATH RHMODEUREPAIR ❑DEMOLITION
C C'� 1 hereby af0rm that 1 am cocoon from Tho Cnn'ramor's License Law fur the _ ❑OTHER
X 6 U following mason.(Section 7031.5,liusim,o,and["mission,Cade:Any city m county SIGNS ELECTRICAL
W1 which 4 Permit t construct.alt P J 1',h p y structure f.=0g 'Bort I e 1: rey th PPI'c If suchpc l fl -, J.Iournal SPECIAL CIRCUI I'/MISC.
}
F.� but he is immostp . n th p frh Coca nowet L Lawr Ch Plert) COMMERCIAL;
16�ap�0 (commencing with Section 900lB ofDvlson J of the B. nc:a dl ,fessnm CaJe)or II:MI'.h1 E'I Irk 01(1'0LIo INST.
Ep:o e that he is exempt therefrom anti the basis for the alleged exemption.Any violation of ❑NhW BLDQ�'�IIN,ION ❑DEMOLITION
U..y Serino 7031.5 by any applicant fm u permit subjects thcapplicam in o elvll penWry Of POWHR DEVICES ❑TIiNANT �! f� aI�XYERVICB
o'neon,than five hundred J011ers(55U0, IMPRfTY 11iNT /lf�(�
=Q ❑L as Owner of the pmpnbonny employees with wage,as lheirsile con,penemion. SWIMMING POOL ELECTRIC ❑OTIIIiI�' I��
(_, will do the work,and flo,trvcmmis nut intended a offered for sale(Sm.AW.Business r lhllev't\
Ito
ec and Professions Code:The Coramla r'x Lieensu Law docs not apply In an owner of OUTLITfS-SWI'I'CH4S-FI%'rURlS
Misery who builds or improves Inertia,and who Jars such work himself or hmugh NEW RESIDENTIAL ELECTS SQ FT.
his own cotploym,s ,,,,adult that such loiprammen'u are not intended Or offered for SQ.Ira.FLOOR AREA SISQ.Irf.
sale.If,however,the building in improvement is sold within tine year of couple ion,the www
ovamo-hsaaddcr will have;he burden of proving that he did nm builA nr improve for par- ����
nom f. ). I'
Fl I as ownerf the P PcnY exclusively contracting with licensed ' I .to
Construct tta project(Sec o an B d Professions Cosec,11 r I ' and
must
s Iv J I ism.pply ss paywhatons p thereon. .- QTY. PLUMBING PERN41 F FEE
who convects for such Bolen with;%coni I r(%)licensed parstimatmi'heContractor'x .
License Law. PERMIT ISSUANCE
I am exempt under Set. B&P C For beck mawni
1' ALTER—DRAIN M VENT—WATER(CA) VALUATION
O !� \
W'ORKER'S CONIPENSATION DECLARATION— BACK FLOW PROTECT DEVICE '�(q ZQ.g0-1
�J 1 hcmby moral tinder penalty or perjury one Of the following declarations: JJJ��k�VV
I have and will maintains Cenificamof Comsu
no self-imvre fill Workep
rs Como- DRAINS—FLOOR.ROOF,AREA.CQND' STORIES 1'VI'Ii CONS'IRGLTI(
sauan.as provided for by Section 390x1 of the Lahr Code,for the performance of the
work for which this pond is issued. FI%TURES—PER'I'RAP
I have and will maintain Workers Compensation Insurance,as required by Section GAS—EA.SYSTEM-I INC.J OUTLETS
39W of the Labor Code.Bantu prtimnunmol''he work far which'his Hermit is'""I'J. OCC GROUP MIN
My Workers Cootpnwtion Ir;amace carrier and Policy number am: GAS—EA.SYS'I EM-OVER J(EA)
Camcr: Policy No.:
CERTIFICA'T'E OP EXEMPTION FROM WOR KERS' GRGASF/INDUSTRL WASTE INTESCT:YfOR
COMPIdIS sol]ON INSURANCE. BUILDING DIVISION I Ii1S
flbosatintteednnl been;nplem!Him .,it is bureau hamlmd dollars($100) GREASE TRAP PLANCHECK FTC
I cenifY that in lM1e performance of lM1e wad for which this Formal isissued.l shall SEWER—SANITARY—STORM EA.200 IT.
no;cmpluy ally pe nun m any co
,on hccootesabjecutiihe Worker Compn- ENCHGYIIiE
Z son".Lown of Cithfomia.Date WATER HI?ATER W/VI?NT/ELIC'IH GRADING IFE
OO Applicant
Z
NOTICE TO APPLICANT:If,after making this Cenifica'e of Exemption.you Should WATER SYSTEM/UREAHNG - SOILS FEE
a become subject to the Warmes Compensation positions of the Labor Axle,you must
fndhwith comply with such provisions or this Permit shall be decnted revoked. W'AI'ER SERVICE
a Q
CONSTRUCTION LENDING AGENCY N(?W RESIDF.MTIA1.PhMB. SQ.FL PAID
U Z Dem Be, p'p
UO kImwhich [a Permitstheis otedcon(Sm30lendin.agency for the Pedormanm of
IM1c workf rwhichrhisprmit lx iaxueAlSec.3097,Cis.C.1 � y '1'UTA L:
Q Lender,Name T, V<-
r CUl1 Lender's Address BUILDING
O. 1 agree Ihm 1 have with
all city
and county
sod diva Thal Ind starve sus relating is
m rs,rmm.I agree m cmnply who all city and Boom?nrdmnnce.and sale Incas refecting to QTY. MECHANICAL PERMIT FEE SeISMI Ir VMk�
U Z building construction.and hereby uuthonu representatives of this city to enter upon the _ ))
uhnvnmcn'ioncd Property for inspcona Purryixs. PER MR ISSUANCE ELECTRIC FEE �l
(We)agree ui save,indemnify and keep hufndexs the City of Cupenin,against
liabilities,Judgments.costs and expenses which may in anyway accrue again.o sail Cip' ALTER OR ADD TO MECIL PLUMBING PRE KI
in consequen.of the granting of'his Prom-
APPLICANT UNDERSTANDS AND WILL COMPLY WITPiALL NON-POINT AIR HANDLING UNIT(TO 50.000 CFM) MECHANICAL FEE
'OURCE REGULATIONS.
AIN HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
%
♦ Signature of APp .m �or
nun m )ate EXIIAUSI'll(RD W/UUCTI HOUSING MI'1lGAlIUN fill
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building aeupnumre or handle hazardous not IT MIT NO UN I'I'(TO I VIORx1 BI'0i
;is defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely HPA'RNG UNIT(OVER II1L0111 BTU)
Code.Section 25532(x)'
�Ycs FIN. VENTILATION FAN(SINGLE RESID) PAID
Date Receipt or
Will the applicant or future building acupant use equ ponat or devices which BOILER—COMP 131111 OR I(0,o10 BI TD
ten havrdoun air contaminants as defined by the Bay Area Air Quality Management 'IDEAL:
District? BOILER—COMP(OVER 100.110 B 11
❑Yes ❑Nn
AIS CONDITIONER ISSUANCE IJA'pE
I have mad the hauerdnusich,materials 2553mmx under Chapter695ofthe t fifth,
Gimiu health c Safely Code.Sections 55115.25533 and mil n.1 undemunh thin if'Im NEW RESIUIiNTIAI.MF:CH. SQ,tT.
building does nearswhicy hast si,fano',III,,'oix;ua responsibilitymeotifOc acnpom
,if the r,yuiomcnts which must be mel pnm m issuance of a Cmifimm of[Xcupuy. \
Owner or unhurried agent [)am ( f —`(/ ISSUED ItY
OFFICE
--- - - -----..---.__
m o >,
I(I - --- _ — - ,
File Ed[ view In er[ Forma[ gecwds Iools y#ndow tlelp
'IXC AV at� . .._-.
Input,Permit Number. 51158 ,�tu�`1 rI �p
PERMIT#: ARCHITECT: /ALUATION: 369298 1°I, rl.'1,
JCENSE#: 11111'6!"WIr y
APN: ISSDATE: 04101/98 I'
US STREET: ORCHARD 3USDATE: 94 91 96 CHKDONEIn IM1I P'IIl�td
h
r SITUS NONTYPECODEdE.CT,ST.RD: ,
IIIa J11PJ7�J4jIlY11
3LDGDEPT:
N,S,E.W: ESCRIPTION: SFDWL
:NGDEPT:
L CIN: CU EPT
'LCHKREO: YNDCMA fNlr�i ��111'i
d ZIP: 95014 ;ATEGORY: CTRFIRE: 1
-OT#: 0 )ATEDUE: 04 16 96 SANDIST: II�`Ir'i�f fliV��I�f�pl-
ID: ASKARI immercial -iLTHDEPT: �r6lfil11 i�IJ{'jet
OWNER SKAR CA-sdAf#: iTRTOTAL: 'iIf�f(�rr�,F
OWNER 10036 ORCHARD CT. CE-sq#ft#:
ADDRES CN-sa#ff#: INSPHOLD: It'i,jl + Il}IYl,
Y,STRE HONE; CUPERTINO C4 asidential �I♦ rl1. r I�.Iltf
t, 8 1 y
RN-sa#ft# F 383
I'j��Ii,i aillI IIi1!i
t I,
i r INTRACTOR: RE-sq#h#: I I
1I ,�.1 LIC#: -US-$Q#ft# 651 Search by
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