31388 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -PERMIT NO.
CITY OF CUPERTINO ATION/PERMIT PBmL.BING.ELECTRICAL
APPLICLUM1iii1NG-MECHANICAL. 388
WILDING VIVISION BUILDING PRO,IF.C'1'IDEMTIFICA'DON
SANIT=NOALICATION SU BMI'ITAL DATE
ILOING ADDRESS:
11141 S. src1,fn R� ` yp, .TeNO fel � �tG
I't10NF,: CONI'kACfOR'S NAME: IC O:
OWNER'S NAME: NIC CONTROLg
EMe IJ C t fG ' I LD Ccr:oSf 129
.ARCHITECT GINEER. LIC NO: ADDRESS ❑
jL mac+ LL q� si . qv �
CONTACT: Cryo 1[ 7E PHONE: JJy
75—Z7BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial)
C,u,/y �y.4 �' C:,16Y,nlr�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE )OB DESCRIPTION
1 herchy affirm that 1 an licensed under provisions of Ch.paer 9(commencing
Cas with Scene. of Division 3 of the Business..,[Professions Cole,and my licenmis PERMITISSUANCE
F O C in full force and effxl. , Z 97 WL 0 KITCHEN REMODEL
VU�'I License Class��- Ida p
FF 41 Dam Commcmr nils' AI'I'LIANCES—RESIUENTIAI. ❑ADDITION ❑PLUMBING RE-PIPE.
r!DL ARCHITECTS DECLARATION PANELS ❑MUf.T6UNIT ❑STRUCTURAL.
Z tun F. nJ my Tans ah 11 he publicreeords MODIFICATION
OZZrn [I INTERIOR El CHIMNEY REPAIR
G // �� � UI"I'02HU AMPS
��["-ttOyy Littnse a' I
2014"AMPS IMPROVEMENT
� � OWNER-BUILDER DE Ce Contractor's
ON OVER 1a00AMl'S OBATIi.REMODEIIRIiI'AIR [I DEMOLITION
1 hereby alTirm that 1 um exempt from the Cnnlmdor's License law for the []OTHER
%g W V following mason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECIRICAL
which requires a permit to consuyct,.lice improve,demolish,or repair any swnure
C�sJ Ja prior to its issuance,also requires the applicanlfor such peril to lilt a signed statement SPECIAL Cl RCU HIM I SC+
"y Na he is licensed pursuant the provisions of the Contractors License Low(Chapter 9 ,
z� 60 (commencing with Seclinnl0(HBofDiviuId3oflhe Business and Pmfessinns Ceade)ar TEMP..METIER OR POLE INST.
a y C that he Is exempt therefrom and the basis for the alleged exemption.Any vinliiinn of ❑NI:W BLDG/ADDITION ❑DEMOLITION
W..y
Section 7031.5 by any applicant far.permit subjects the applicant a civil penalty of POWER DEVICES OTENANT ❑FOODSERVICE
q
immune than five hundred dollars($500). IMPROVEMENT
2 C ❑ I:asowner of the property,or my empleyees with stages as their sale compensalon, 'SWIMMINGIPOOLHLECTRIC � EIOTHER
willdolhewoek,andlhearucarets not intended oroffeml fi.sale(Sec.](Fido Business OUTLETS—SWITCHES—FI%TURES
tail $ and Pmfessinns Code:The Contractors License Law does nod apply to an owner of
0, 'property who builds or improves thereon,and who does such work himself nr through NEW RESIDENTIAL ELECT it SQ p-L
his own employees,provided that such improvements am not intended or a fere,[foe SQ.FT.FLOOR AREA $ISQ.FT
sale.If,however,the building or ideparement is sold within one year of Completion.the .
owner-builder will have the burden of proving that he did not build or improve for pur. _
poseofsale.). TOTAL: -yti
I,as owner of the property,ala exclusively conrcling with licensed cnnlr.cmrs m 6" p ,
e...met the project(Sea.9844,Facades,unit Prol'Ininn CcdeO The Gmlmemrx U. A
1 cense law does not applyor aowner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
whocrlmw
l.s forsuch projects with aconeromid licensed purman to Ne ContmctO_�
ars c
License Law. PERMIT ISSUANCE
0 1 am exempt under Sec. - ,B&P C for this mason
ALTER—DRAIN&VENT—WATER IPA) !,VA TION
4�,
Owner Dale I
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE. h`•((�A.,l
1 hereby afford under penalty of perjury one of the following declaration: rIVV
I ❑ I have and will maintain a Certificate orconsenuosel Ginsure for Workers Compen- DRAINS—FLOOR,ROOF,AREA,COND. - STORIES TYPE CONS'1'RUCI'ION
smioq as provided for by Section 3]00 of the labor Cock,for the performance of the FIXTURES
—PER TRAP
ak for which this permit is issued
❑ 1 have and will maintain Workers Compensation Insurance,m GAS—EA.required by Section SYSTEM-I IN OUTI, OCC GROUP
3]00 of rhe laWrCWeI for case performance of the work for which this peril is issued. APN
My Work m lion lyswen a ep�*er and Policy nnmberarc:�„' GAS—EA.$YSTLMOVER 41.
Cartier: tK' 1 -'c ! Policy No,.
CERTIFICATE
L. C
CERTIFICATE OF EXEMPTION FROM WORKERS' GRHASEBNDUSTRL WASTE INTER k
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thin section need not bemnapleted lfuap cid,is inrnne hundred dollar,($1 Gq GREASETRAP PLANCHECK FEE
orlew.)
Lany,[hada.lin ary.nranp-11'1w ad for which this I heWlsis'C-IPelll SEWER—SANITARY—STORM EA.200 Ff. ANERGY FLG
.oremployLa any person In any..inner sn nes to become subjun m the Workers'Compen- _
O ,0 Armon Lows of Califnmin.Date WATER BEATER W/VENTIELF.CTR GRADING FCC
Applicant
NO'urne TO APPLICANT:If,utter making this vi sine of of H imnptlon,you shoo-', Wq'I'13R SYS'fEM/TREATINO - FEE
F "� bcsmmeh comply
the Workers Compensation prat.Ions of the Limen GIIdo.you mad
W � (..heath comply with such provisions or Nis Permit shallMdeemc+l revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.FT. Dae Reapt M
V 0 I herehyaffr that therms.construction lending agency fortr
epsrfaantt of - -
LL. (ti the work for which tha perit Is board(See.309],Civ.C.) TO
Iepaides Name
U TOTAL:
Lcndcrs Address BUILDING PEI:
E1 canlfy and I hum read this application and visa,that the above ioronn don is
rh correct.I agree to comply Wada all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U building cont ion,and hereby amthoAze mpmsenmlives oflhis city to enter upon the
aMw,-mendinned pr.,,Iy for inspeainn apposes. PERMIT ISSUANCE ELECTRIC FEE
(We)ugrcc to save,indemnify and keep ha bless the City of Cupertino against
liabilities,judgments,nava and expenus which mayin any way accmeagainst said City ALTER OR ADD TO MECH. PLUMBING FEE
n consequence of the gearing of this permit.
6VMVANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00)CPM) MECHANICAL.FEE
OUR EIURH TIONS.
�D AIR HANDLING UNIT(OVER IQIImum) CONSTRUCTION TAX
naw��ApplicanV cm ) e� E
AUST IE
CU HOUSING,MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material ING U000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety 'ING U00,000 BTU)
Code,Sanit 25532(aft PAID
O Ycs Otho VENTILATION FAN(SINGLE RFSID) Date Receipt0
r WII1 dao applicant or future building occupant use equipment or devices which BOILER—COMP(3HPOR 1010,00013 TU) `
•emit hazardous air cnntaminanlx as defined by the Bay Arca Air Quality Management TOTAL:
District? BOILER—COMP(OVER❑0),(100 BTU)
E]Yes ON.
I have read the h a materials rcm
quireeno under Chapter 695 of the Cali-
AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Coda,ode,Sections,than 25533 not 2 ibifi understand that"Pare NI?W ftBSIUBNTIAI.MECIL SQ.Pf.
of thengdoas not currently which have a loner p that it is un ob ofasi cad m notify the Occupancy of dao mluirtmena which must he mel prior m issuonm of a Cenificne of Occupancy.
Owner or audaorizeJ.gent
Date TOTAL: ISSUED BY:
OFFICE