S 2065 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO KUn.O{NG-ELEC`1 RICA[ rE ur No
BUILDING DIVISION APPLICATION/PERMIT r1.uNIRINc-MEcx,wlcA1' 2065
BUILDING PROJECT IDEN'1'IF'ICA]'ION
BUILDINGADDREyg ♦ SANITARY NO. APPLICNI'ION SUBMITRM,DAD
OW ER's N,MIE: PHO CON'I'RACI'OR'S NAME LIC NO:
!1J affil �e Q NRC COM1TROLN
•ARCHITEC'r/ENGWELR: . Llciso:l ADDRESS: ❑ V R -7 O
CONI'ALTc PHONE. BUILDING PPERMIIT INFO
J !�
DE,^ O ❑ Consukant Fees Paid by Applicant(Initial) it ElW 1'LUMIt/ h1ECll
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FLEE rL/K-r/
1 hereby alErnt teat Inn,li,tir+w ander promwiona ofchapmr 9(cotmttettaing JOB DESCRIPTION
a,CC)Z withSectlo.7000)of Division 3oOhe Buaine+.and Pndes+ians C,de.and mylirenm:is O RESIDENTIAL:
F,o in full farce:nd effect. PERMI I'ISSUANCE
[I[ISI DN'1, El KITCHEN'REMODELdUU LiClass omomnm APPLIANCIES-RISIDEN'IIAL EDITION [IPLUMBING R&PIPIE
F�W Dunx Com
Fpy AHCHI'rECFS DECLARATION PANELS ❑MULTI-UNIT C1 STRUCTURAL
OZ'i,Z [understand my plan+shall be ua�d I,.s puhlie rcmrM MODIFICATION
L= UP'r02fp AMPS El INTERIOR El CHIMNEY REPAIR
G,~W Licnued l'rofessinnet 201-1000AMPS IMPROVEMENT C)SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1(X10 AMT'S ❑pA'1'H RfiMODIiLIItIiPAlli ❑IJEMOLITION
,Y IY d 1 hereby aRrm that I am exempt from The Contractors Lice—Law far Inc
4 6 U IAlowlag mann.(Section 71315,[business and Profession%Code:Any city or county SIGNS ELECTRICAL. Cl OTHER
W 3
C,all which requires a permit to construct,alter,improve,demolish,or repair any.suction,
�d prion irslssuance,alsorequiresme applicant hasuch permit to file a signed statement SPECIAL CIRCUFUMISC.
fid>'. Thal he is licensed pursuvnt m the provisions of the Contractor's License Laos Chapn:r9
w C�02 (enmunemci ng w l In Section IlNNO u1'Dlvlainn 3 of the[Lines,and Podle,ons Cw4:)or TEMP.METER ORP LE INST. COMMERCIAL
to.X e Z that he is exempt therefrom and the basis for the alleged exemption.Any vlolarou of [I NEW BLDGIADDI'I'[ON [IUF,MOLI LION
Section][131.5 by any applieanl Fara peon,m,rc s the up,h,mu lou 6,li penally of POWER DEV
to^to []TENANT ❑Ir001)SERVICE.
SOn mire than five hundred dollars CS500L IMPROV[?MfiNT
Q I.nsowncrol rhe Is peny,nnnyunpluyces with wages as their sole aomlnnaation. SWIMMING LL "RIC
5�o will do the work,and theslmaum is not intended or offered for sale(See70t .Business ❑OTHER
413 ec ad P
nmfes+inur('ode.The Contmoor's Licmnu Law due+nal apply ,,m owner of OU'I LEI'S-SWI'rCHIFS- RES
L propeny whobuild+or improvesdiamimand whod,ws ach work himself or through
his own employees,provided that itch intprovenients on,not imummed or ortircd for NEW RESIDEN' [FLP SQ 14.
sale.11,however.the building or improvement is mileam
d wlWn onsyearorpletianJhc SQ.FE FLOOR AREA S/SQ.Pr.
crhuilder will h:n'c me hurdea of proving that he did uta timid or improve fur,ur-
pm f. )
�nl nnppny 1 . ly t war .- Dram ,r, 'ro rnl ,�•�� �.se r 2a��
t Imp ) ep On, B al r.: carl)rnCommittees Li- •(
I t apply or fp p Ny n builds p thereon.and QTY. P BIND PERMIT FEE
Cerise
nlruCtt for wchp ojeasw lhucom t lU limnscdp II Ili Carl I,rs
Licanm Law, PERMIT[SSW CE S•JQ / ($ r/1/)
❑ lam exempt under Sec. ,BK PClisnhis reason (�6 `�J
AL'CIER-U AIN&VI?NI'-WA'IVR(EA) VALUATIO,
Owner DIO '�
WORKERLSC S\TION[ :1 following
li W PR(YO?C'I DEVICIi
I M1andwullinntain a eafficre, jurycrufit the itibu ingdeelam%C,,):
[have andwillm or by Sc Cenificme of the Later
ode,forth, NberamaCompthe )RNNS N.Ti S'IOk1ES TYPE CONSTRUCTION
sution.Ia provided fm by Suction 3]1X1 of the LOMr Cwle.for rev p:rmm�ance of the
work lot which Isis permit is i++ued. IS
I h,rvc and vad]mountain Worker's Conrpensarion Insurance.as required by Section
3]IXI OItM Labor Cale Ra the pertormance ofthe xvrk forwhich ren permit is irsunl, EA.SY 'EM- LITLLTSI )CC.CROUP AI'N
My Warkcr'n Congocnsmiun Imutancu cnvivr and Policy number era
Carrier: Policy No.: S- 91 I:,
CEIfrf PICATIZ OF[IN EM['TION FROM WORKERS'
so
COMPENSATION INSURANCE F,ASF/INI LWA NTIi
1This semen noel not becnmp[ned if the,...it,is bream hundred dollar($par) BUILDING DIVISION F
tar less.[ G S P LANCH
IcenirymorinmeperGnrnanceoOhc work fnrwhich inlet cWisi_+svcd,Ilio[[ SEWP 'ANI , -ST BA.N
not employ any person in any manner an as to become.subject to the Worker,Compere g Gt'PEI,
O ,� 'anon laws of Cod Eornia,Duro WA'1'Ek HE /'LECTR
z Applicant GRADING FEE
rN-r
NOTICE TO APPLICANT:If,after making this Ceniri ne 0 Bxcmption,you slim ld WATER hit , EATING
a > become subject to the Workers Compensation provisions of the Labor Cci e,you must )ILS FIJI
Forthwith comply with such pnorosmin onhi,permit,ball bedeeraad rcvnked. WATER SERVICE
a � sr��
z CONSTRUCT ION LENDING AGENCY NEW RLSIDIEN'I'IAL['LMB. SQ.EF J �.LL PAIL Q
U O l hereby affirm that mere is a enmsuucron Lending agency fm'mc pere,rmance of ores
IM1e work for which this pe,am is Issued(Sec.3097.Civ.C) 1 0
ULender's Name Q
Lenders Address TOTA
(r" S I earth, flat I have read,his applicmin.and sum that the aline inlormmion i+ BUILDING EFI 42n O C
Tn correct.I agree to comply with all city and county ordinurs-lad+tate law srelming no QJ y. MECHANICAL PERMIT FEE
U z buildingcnnstmnion.nW Lmehy amnodacrepresenmtives al'this city wenan,asulhe //11 SEISMIC 1 I' S
ohne-memionedproperty for inspection purposes. PIERMITISSUANC�: `x�/ `j7. �/�
(We,)egret no save,indemnify and ken,b innicss the City at Cupertino against • ELECTRIC T:' D
Liahilines,jud,ell cum and expenses which may in any w'.ay wer against said City ALTF:H OR ADU'TO MISCH.
in sepreaceof mag,all ingot in,permit. PLUMBIN F.F O �/
APPLICANT UNDIERSI'ANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CI'O III.(NIfI CPM[ O 4,
SOURCE REGULATIONS. MECHANICAL
AIR HANDLING UNIT(OVER 10.000 CFM[
CONSTRUCr1O TAX
HAZARD
Signature of Applicaor Date E%HAUST II(IOU IW/DIICTI HOUSING MITIGAT
HAZARDOUS MATERIALS DISCLOSURE NFIEE
Will the applicamorfnure Wilding occupant smrcorharnle huearbas material HEATING UNIT(10 100k0(0IFFU)
as deGnel by Inc Cal tin,Municipal Code,Clux,er 9,12,and the Ilcah o and Safety
Cala Section 25532(u)'! l o HEATING UNIT(OVER 100.008 BTU)
Yes
VENTILATION FAN IS[SUCH RES][)I [AID Date Receip,#
Will Bulms aircannm or nt%"romSaf6,
himdefinedfing by One B use ai Air Qu tar Manta which
•mit %air nvnaminanlem defined by IM1e Nay Arca Air Quality Management BOILER-COMP(3HPOR 100.000 BTU)
District? '1 OI'A L:
�o BUILL'R-COMP(OVFER IW.INIO BTU)
read the harxNous ntaluiul+ a under Chula 6.95 of the Cali- AIRCONEHIONEkre.L533a p IJSSUANCEIJA9'liFr Safely Code.Sermons 25505.8533 and 25534.1 unecanJ mm itme NEW RIi$IDENTIAI.MliCll�-Q� SQ.Irl'. 6r ` /_ /�not currentlyhavet utakthat it is my respromibilitym n,nify the ocapml 1 _ 4mems wiicM1 nn. ret priorissuance,nfa Cenidicale Ocucorenriaed agent Line TOTAL:
ISSUEDBY:
OFFICE