30462 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMII'NO. J{ria O 4 ^2
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL Fl•`l
BUILDING PROJECT IDENTIFICATION
BUILDINGADDNESS: SANITARYNO. APPLICATION SUBMITTAL DATE
low-/+ 1�IblxV►�1y.� coin i $.2'2A6
OSVNERS AME: PHONE: N'I'RACfORS NAME: LIC NO
M NCa11'go.Mo0VN,�' �s`(Si6.A�55) C.. �. (,vim b. NIC coNrRy L#
dRCHITECT/ENC,INEER: LIC NO: ADDRESS: ❑
( J L NIBS ! dCl ! �ccc/ Zc nc
CONTACT. .,{l PHONE: BU ILDING PERMIT INFO
AV---T Vl� -log T�ogSco ❑ Consultant Fees Paid by Applicant(Initial) BLOGG ELECT PLUMB MECH
-1 ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm don 1 ant licensed miner Incoo,m flChapter 9 een�nmenemg JOB DESCRIPTION
�aZ th Section7")of Division 3 ofthe Business and Professions Code,mW my license is RESIDENTIAL,
in fail force and effect PERMIT ISSUANCE
UF; '" lFV � ❑STOW?. ❑KITCHEN REMODEL
�UU Licen.w Cl Lica APPLIANCES-RFSIDF.NTIAL ❑ADDITION [I PLUMBING RE-PIPF,
I-Q L Dam Co.".un fJ x= <<'"^�
+ ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
p.7 N PANELS
ZO°'Z I understand my plans shall he used as public records MODIFICATION
OZ 4—a UPT02MAMPS ❑INTERIOR [I CHIMNEY REPAIR
F•�.F7W Liatned Rafcsslonal 201-IBDIAMPS as, IMPROVEMENT
gy2:j OWNER-BUILDER D17CLARATION - OVER RNN)AMPS ❑RAI'H REMODEUREPAIR (]DEMOLITION
C C 6 I hereby from that I inn exempt hurrahs,Comraam's License Law for?M1e
�3 aa.U following reason.(Section 7031.5.Business and Professions Coda.Anv city or county SIGNS ELECTRICAL ❑OTHER
whicM1 requires a peri'm conmmn,alms improves Jemalieh,or repair any sinners
Fs�0 prior mils issomtee.also requites the applicant for such perms to file a signed statement SPECIAL CIRCUM'/MIS
SS QA ?hat he is licensedpurmannntheprovisiomof@e Cmu,c is License Law(Chapmr9
a�p0K (commencing with Section 7000)of Division 3ofthc Business and Professions Cade)or 'TEMP METE POI ST.
a 4 c LL than he,,exe,npt therefrom and the basis lies the alleged exemption.Any violmion of ?NEW BLDG/ADDITION ❑DEMOLITION
^H
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DE iS 11 ENANT []FOOD SERVICE
not mom than live hundred doll...(551X)).
F Z_Y - I PROVEMRNT
< n Laa nwnerof the propcny.or my employms wida wages as their sole compensation, SWIMMING I'OOLIiLF.CTRIC
will do the o'k.and the structure is nm intended cr offi,ed lin salc Sce.7I441 Businoss ❑OTHER
3 and Professions Code:The Commeots License Law does not apply to an owner of OUTLET:S-SWITCHP_S-PIXTURE.S
properly who builds or improve'thereon.mW who dues such work h imalf to hogs
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FE
sale.If,however,the building or improvement is sold within one yea ofamtpletimn,the 9@OAR NI y�V ESQ.FT
caner-bolder will have the burden of proving that he did not build m improve for pur- Yom' /iii
past of vestal.
I,as owner of the property,am exclusively a^mmefing with licensed contractors to APR 18 '8
entrance.the project(Sec.7x44,Business and IRofcsainns Code:)The Comracmr's I,u
cerise Law does not apply to an owner of property who builds or improves thereon,mid QTY. PL GPERMIT FEE
who conwasforinch projects with a commaor(s)licensed pursuant to the Contactors
License l.aw. PERMI FIS NCE ypie W Vada�"L•1
(]I um exempt under Sec. .B h P C for this reawo .. -
ACI ER-DR 'NT- 'A' Ili VALUATION
Owner Dam
WORKE'R'SCUMWPcrjm ION DE Ce folio ing BACK FLOW PRU 'VICIi W�
I herebyaffirmunder penaltyof perjuryoneof the following declaration
o
�Ihave and will main mina Ceni 37W)ofine LZduo od insurthe.for Workcr'a Compen- DRNNS-Iq.00R,R ,A ,GOND' STORIES 'IYi'Ii CONSTRUCTION
work ns Is
h his
for by Seams 3]INI of Ihe Luber Calc,for the performance oT the
work far which Isis permit is issued. FIXTURES-PEN TRAP
1 have and will maintain Worker's Conipensmion Imvmnce,as required by Section
37( the Lasa Code,far Ne peffurnance of the workfar
r'which this peril is iissssued. GAS-ISA.SYSTEM-I INC.4 DO LE'I'S OCC.GROUT' MIN
WcrWyy c /Nluaf "cc canis Zond Policy No.Poky7sma GAS-EA.SYS'TIiM-OVER4(EA)
Camierr f/-•�!/'iERI SFI T
CERI'IFICATEOFISATIO INSURANCE.
WOR KERS'
COMPENSATION INSURANCE GNIiASI'IINDUS"rRL WAS U1 I ERCEI'l'OR
lThissttn..necdnot be mit completed it the permitis hundred dollars(SIah BUILDING DMS NPEIS
or Icas.) GREASE TRAP PLANCHHCK FEE
I cenify that in the performance nflhe work far which this perm,,is issued,lahall X� FC
-STORMFA.20BFT.
nol mnplay any Penson m any a meet so as nt Mcmme subject In the Workers'Com en- ENERGY FEE
arm
Z O zzn Iacct roma.Data NENT/ELECTR GRADING FEE
ICE TO APPLIC ..for making this Cemfcme of P.acmptian,you should EATINGSOILS FEE
ocesubject to th er's Compen-ion provisions ofthe I.ahe,Code,you mustz CONSTRUCTION LENDING AGL'NCY PCMB. SQ.PL PAID Dam Receipt a
V ?hereby affirm Ron there iseamalmmimn lenJin6 agency for the periormancc of
W tice work fanwhlch this permit is issued(Sec.9197,Civ.C.) TOTAL:
E.,
ULase,Name
Lender's Address TOTAL:
} W 1 certify have reads appta
ify that 1 hthis and ste chat the above information is BUILDING FEE
ps
V
tail correct.l agree hs comply.,fit.11 city and mtmly nrmnanas and site laws relming"IQTY. MECHANICAL PERMIT FEE G baildingcsmcti
aon,and hemov
hyamte representatives of,hisci,y toenmtupon the SEISMIC PEE
7sm
above-mentioned pmpeny for impcotm putptse, 1-17RMIT ISSUANCE Q
(Wo)agree it)save,indemnify and keep harmless the City of Cupenino against ELECTRIC Ilili
liabilities,judgments.costs and expenses which may in any way accrue against said C'LY ALTER ON ADD IT)MECH.
PLUMBING ITE
in nsegncnceof the grnntintof this peril. I`
APPLIC NTIJ�IIh:RSTANUS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To IO,INIU CPM)
SOUIs.E L �� MECHANICAL FEE
� �� AIR HANDLING UNIT(OVER IB.1Xm CFM) CONS'TRUCTIONTAX
naonsZ.f ApplicanUCuntemor Data EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATIiRIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle launders material HEATING ON]'I(TO 100.000 BTU)
as delinod by the Cupertino Municipal Code.Chapter 9.12,and the Health and Satiety
Cal,Semon 25532(.)? / HEATING UNIT(OVER 100.000 BTU)
Yea ITNu
T VENTILATION PAN(SINGLE RE.SID) IAIU Date Receipts
Will the applicant ar foam building occupant use equipment or devices which BOILER OR IUILO00 BTU)
crit hwnrdous air cant tinana as defined by Ibe Bay Area Air Quality Managc'tnem f A :
DomclT �/ BOILER-COMP(OVER I W."BTU)
]Yez �d Nn
I have read the lausta smaterials mquircments under Chapter 695 of the Cali. AIR CONDITIONER ISSUANCE DATE
fnmin i with q Safety Code,Sections 25505,25533 and 255)4.1 understand that disc NEW RESIDENTIAL M17CH. SQ.ET.
buil ' g does nM curently have a tenant,that it is my respmsibdity m tmttly the tecupanl
s' rare enc: hichmusbemet riono issuance of.CetiO-.m of(Xcupaney.
neo m icam rimda nI Date ISSUED BY:
OFFICE