S0001 B0169 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL I'13RMo.�016 9
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOOI
BUILDING PROJECT IDEN'OFICA'1'ION
IIUILDINGADDRE.SS: iNICIHARYNO. APPLICATION SUBMITTAL DAT-
/ ((01 444" GRov6 �1 �
0,10 2�3 Z7 `�� fie-'L'+�t�
OWNER'S NAME: 1'IIONI 'S NAME LIC NO:
N VAS I% NANI kO U1 CON'IROLX
ARCHII'ECI'IENGINEA LIC NO'. ADDRESS:
I LfU A"417I eIS68b oS. 1 J6SE cA.
CONTACT'. 1111ONR: 15101"(E 7,11 1If 5113 BUILDING PERMIT INFO
km
lE , `I O ❑ Consultant Focus[laid by Applicant(Initial) B.sec ELECT' Pt.Untu n CII
WS94R4 El
LICCNSIiU CONIRACTOR:S DIiChAR6UON QTY, ' 13LECTRIC PERMIT FEE
I hereby affirm Nat E o licensed mmea provlxloras nI chat",,,9(cam.nm,nia, JOB DESCRIPTION
OUZO with Salina 7(X10)of Division 3 ofthe Business and Prof sinnv'Code.and my licence is RESIDENTIAL
PERM]I'ISSIJANCIi
CF in but force and cffcem, ❑SFUWL ❑KI'I'CUEN RIiMODIiI.
ULicense Class Lic.M
Q ea APPLIANCES—H[SIDENi'IAL �VMUITION ,51RUCURAL 'll'Ii
N Q 6 Uale TISCarDECLARATION
AHCHIT[CTS DECfARATION h1ULT1-0NIT ❑STRDCICATIO
FvZ I understand my plans shall he used as public becords PANELS h10UIFlCATION
OZ 4O UPT0200AMPS [_I INTERIOR ❑CHIMNEY RI?PAIR
[. W Loc,pfwJ Profesmmaal 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNIIR-BUILDER DECLARATION OVER 11X0 AMPS [D BALL RE;MODELIREPAIR ❑DEMUTH ION
C CLQ 1 hereby aftin l khat I no exempt from the Convactor's Liccn.se Law 0mr[lie
X O 4 U following reason.(Section 01131 S,Businss and Poll essians Cmule:Any city or In. SIGNS HLECI'RICA[, ❑EYE HER
413
LLi which quires a permit Im,nnm'tmet,alley.improve,demolish.nr repair any ameure
IOJ piano it,issuance.also requims the applicant for such lemur to file a signed statement SPECIAL CIRCUT/MISC.
f } that he is licensed puts uanOnthefunwi,ma, fine Camracmrs License Law(Chapter 9 COMMERCIAL:
W 0 (commencing with Section 1000)of Division 3 of the Business and Professions Code)or TEMP.MITER OR POLE REST.
TION
a a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NOW BLDG/ADDITION ❑FOOL)DEMSERVE
x�mSection]WLS by any upplicant for a permit subjects the applicant a civil penulty of POWER DEV ICES DTENANI' ❑FOOD SERVICE
not more Ilia.five hundred dnllurs($501). IMPROVEMENT
FZQ ❑I an owner of the pampl or my employees with wugo,sas their Into,compensation, SWIMMI I LELEiCIIC
will Aa lh,work.onA lhevhvnurc is nw imm�dcJ nr nlicrtvl sur x:Jc lScc9194.Blorwvs ❑O'fI IIiR
a� and Professions Cola'Due Control License Low,docs not apply to an owner of OUTLETS—SW P 'D12E5
pmpeny who builds nr improves thereon,and who does such work himself or through
his own employees,pmvideE thin.such improvements arc nm intended or offered for NEW RESIDE IN TIAL EL
sale If,laoevcntho,building or improvement is sold within ane year mcomplelon,the SQ FI'.FLOOR AREA USQ.PI'.
.
owner-builder rill have the burden of proving that Is did not bund or improve for put- O /�
[3 1 a Blore. (/)
1,as owner of the pmpen,at.exclusively cammeming with licensed nmtmann m j/
Bernie'see project(Site.1194,Holiness and Professions Code:)The Courall
w Law does not apply[loan owner of property who on ANrinmpm el thereon,mn< "V. PI. ING PERMIT EE
who,cmmmnx forxuch projatowitou"nnae is)li"o,ed"nonnl la th mmvuan1,
Ltcensc Law. PERMIT . 'It CE
I atm exempt under Sec. .Ii Al P C for this
AL R—DRAI -VENT—W VALUATION
Owner Date I
WORKER:SCOMPENSATION DECLARATION BACK F W('ROTI: DEVICE �Mp r'
�❑ Thereby affirm under p,nalry of perjury omen(the fullmvim,kalaztiuns:
FI have and wiIII.umin a Certificate selfinsum for Worker's Corruption. D INS—Fl. R.ROOR EA.CO D. STORIES TYPECONSTRUCI'IOI
as provided for by Section 3110 of the I.uFor Cede,for the pedommance of the
work for which this lcrmitisi.ssued FIXTU I'IiR'I' P
I have and will mninlatn Workers Compensation Insnrantt.ss reconnect by See' I
j]lyd of N,Lnhar CnJ,.for the performance of the work for whish Nis permit is tooled. GAS—EA.S ."IIM-IE 40UTLR: OCCGROUP APN
My Warkc(s Compensation Insurance carrier and Policy nnmher arc'.
Camcc Palo,No.: GAS—G.SYS IC VEll )
CERTIPICATROF EXEMPTION FROM WORKERS' GREASUNDUSTRIL WA :INTE 'HTOR
COMPENSATION INSURANCE BUILDING DDE
SI(IN IEF_5
(This wvu..aced nal be completed lion,permit is for one hundred dollars(51(X1) GREATRAP SE
i aneas.J r.n -.e �
I cenify that in the porHamunc,ofthe work for which this permit is issued,naIaha11 SEWER-SANITARY-STORM IIA. IFT ENER ".'
I m emphny ony pcn many Bonner,ax rim became subject to the Workers'Csn open-
' Z nation Le,sof Callfomia.Dam WATERIIEAHPIt W/VCNDELBCTR ORAUING ETI?I?
Zo Applicata
h NOTICE TO APPLICANC IL mer making Nis Cernicam of Exemption,you should WATER SYSTCMO-RCATING
(-' hccsmme mbbem the Workers Com lion roof theural r CWa you must ILti PEE
J pcnsa pmvinio _
CL fnnhwilh comply with such pvmvizions.,,his permit shut[betlamed rcvokW. WATER SERVICE O,/1, Q
W ! J
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ.PC ID
7 zate Reniptp
L)QIhercby af0mmthat there isatamswnion lending agency for the perfommancc of
the work for which this permit is issued(Sec.3091,Civ.C) TOTAL:
O ULeadds Name
CLI Lender's Address It (.DING FEE IC
a ruff,that 1 have rad(Ills application amt all,Ihw the chose inGnnmtlnn is
ern , left.I agree to comply wiNaH day a ad county mahananaoil'fare laws retain,m QTY. MECHANICAL PERMIT FEE S17ISMIC IT
V Z huddingconstmetion.and hereby authorio,representatives oflhiscity to enterurym the
al.womcmion d pmpeny,for inspection pur mses. PERMIT ISSUANCE IiLECI'RI
(We)agree m save,indemnify and keep hmmkss the City of Cupenino against O
liabilities,judgments.costs and expenses which may in any way came againsosaid City ALTF.RORADDTOMECH. PLUMBING 'E
in mnxquence of the granting of this psormio.
APPLICANT UNDERS'I'AN US AND WILL COMPLY WITH ALL NON-POI N AIR HANDLE NO UNIT ITO 10.010 CPM) MECHANICFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONS'I'RUCTE TAX
Slgnamrcaf APplicunUCmdracNr Dam EXHAUST'IROU(WIDUCO HOUSING METEOR'ION THE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuwrenuildingoccupam noreorbandle hazan4us material HEATING ONE'I'(IO 100.010 BTU)
as defined by the C'upenion Municipal Cute.Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 000.000 BTU)
Cook.Section 25532m)'
❑Yes C)No VENTILATION PAN(SINGLE RESIDE PAID
Dale Raft' Ip
Will the applicant nor future building orcupant use equipment or devices which B
OILER
R I(0.Z11?E !
mit h:v.arduus air cnnurminnnts as defined by the Bay Area Air Qualay Management (f r
0isvia?❑Yes ❑No
1 have readmho,harrdous materials quinol anter Chapter 6.95of the CalmISSUANCE U/VTE
forma Health&Safety Cede,Sections 25505.25533 and 25534.1 undeneW that if the CH.
building does ant curmndyhave a mwnt,that it is my responsibility m notify the occupant
of the requirements which must he met prior as issuance of a Cenificate of Occupancy.
Owner or authnrizcJ agent Ilene :
OFFICE