S 1785 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPE'RTINO BUILDING-ELECTRICAL PE IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 1785
BUILDING PROJRCT IDF.NTIFICATIUN I : _
BUILDING ADDRESS'. SANITARVNO. APPI.ICATION SGBMI'I'll UA'f[
2� + ve11 creek (3
OWNERS NAME: ^ PHONE: CONTRACTOR'S NAME: ���hIC N36
Site. Qd D/ t_^1� K <a NIC CONTROLp
ARC,I)ITJeC'ULNGI HER: LIC NO'. ADDRESS
'. I ❑
I n _.... eq—,,r /(coo M Scalaear. �I`JOST7 CON''ACT PHONE: BUILDING PERMIT INFO
Fees Paid by
CH
I LICENSCOxED CON I AC ROB 19R7o 83oa ATION Q❑ ConeRltanI TY ELECTRIC PERMITn[(Initlapl FEE
pO ELECT
Fr" PLUMB MLl
1 hereby affirm that I licensed e p f Chapter 9( ae r, - JOB DESCRIPTION
won
❑
won with Sarbon 9000)of Division rth,Bt , tdProferAn �C I.andmylia ,els RESIDENTIAL•
WOO PERMIT ISSUANCE.
e,R]�, in lull force end afeen .j ❑SFDW L ❑KITCHEN REMODEL
dUV Lieratm Iasi,-�',q,(-����Lic.k APPLIANCES-RESIDENTIAL ❑ADDITION [_1 PLUMBING RE-PIPE
yW Dale ��r�T p Comma(,
GGA' ARCHITECT'S DECLARATI N ❑MULTI-IJNIT [],STRUCTURAL se m PANELS
Z O m Z [understand my plans snail he nsetl ns pnhlie records MODIFICATION
O�^Q UPTO 1-1000IAMPS C3 INTERIOR ❑SWCHIMNEY
NG POOL
Licensed Prol'es,ional 2111-I WU AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDERUECe RAI ION
Contin OVER INK)AMPS ❑BATH REMODEIJRFPAIR El DEMOLITION
I hereby uffrm Ihm 1 am caompl Som the Continent's License haw for Be
pe, C O following reason.(Seeinn 9031$,Bucinm,and Pmfc„ion,Code:Any any or county SIGNS ELECTRICAL ❑OTHER
W a Gr.y whien requires e permir m ronamt.alter,improve,demolish,or repair any sunemre
d pnnn,d,ie,vanee,also ox,iires the applicant for such pemtil m filo asigned sla¢man SPECIAL CIRCUIT/MISC. - 17�1�71g�
W '' thathc rs liecn,al pursuam mthe provision,of rheCnntmdnry Liwn,c Luw(Chvper9
WW
�O;� (commencing with Section 7000)of Division 3 ofthe futures and Professions Cale)or TEMP.METER OR POLE INST. 3�'.t7� COMMERCIAL'
di Ihm he is exentpl lherc[mm and 0c basis for Inc alleged exemption.Any
not LJ NEW BLDG/ADDITION ❑DEMOLITION
Ed Section 9031.5 by any applicant for a pemtil xuhjecta the applicant m a ei vi l penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
m morelhun five hundred dollar,(150@. - IMPROVEMENT
F)Las,waerof(he pfopauy,or any aneloyces with wa,rvr,U,irsole mmpertain, SWIMMING POOL ELECTRIC
all do Ihewnrk,and the,,...I a is notmended or aRered for sale(See.9044.Bn,iness ❑OTHER
Wand Profession,Core:The Convectors Licerec Low docs not apply to an nwncr of OUI LEI S-S W ITCHES-PIRU JRES
R' ..
property who build,or improves memun,and who docs such work himself or dinner f
his own employees provided that such improvements an,aol intended of oflchod for NEW RESIDENTIAL FLFCTR SQ BI'.
,.UeIf,howevnq the building or improvement is,old withinone yearofmmpliben,the SQ.FT.FLOOR AREA 1/SQ.FI'.
owner4ander will have the burden it proving that he did not bnlld or Improve ForPar-
pose of sale).
❑ 1,a5 owner of propeny,am exclusively contracting with licensed contractors e TOTAL' r
mslmd the project(Sec.744,Business and Prnfe„inn,Code:)The Ommreors Li- -
nseLawdoesnotapplyroanownerofpropenywhobuildsorimprovesbarren,and QTY. PLUMBINGP-E P. Lu CC[I IIVCJ
who contracts for such projects with a eantraeterfs)licensed purswmt to the On n clots
License Law. PERMIT ISSUANCE
/y- ❑ I or exempt under Sec. ,B h P C for this reason
Owner Date A%GIR-DRAIN&VENT-WATER BEA) VALUATION
WOR Ki R'S COM PENSA'HON DECLARATION SACK FLOW PaOTECT.DEVICE G
1 hereby affirm under penalty of perjury one of the following declarations:
Ihavc vnd will maintain aCcniOcrrtu of Conserv to,elf-insure for Worker.Cnntpw- DRAINS-FLOOR,ROOF AREA,GOND.
entry,as provided for by Section 3700 of the Labor Code,for the parfon acture of the STORIES TYPE CONSTRUCTION
t
work for which this permit is Issnal. FIXTURES-PER TItAP
❑ 1 have and will maintain Worker',Compen,alinn Insurance,is required by Sonora
3700of lire Labor Code,for the part'ormanei the wank for as it],t his rebut ixinsuW. GAS-EA.SYS'I'HM-1 INC.4 OUTLETS OCC.GROUP APN
My Werk SConnpa¢vtionl eumnec carrier red Policy 076 GAS-EA.SYSTEM-OVER 4BEA)
Cartier: Policy Sell
EafIPICAfE OF GXBMP'i'ION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(fhisscei ar need net herompleed if the permit is forme hundred dollars(1 lot)) BUILDING DIVISION PEES
or le„) GREASE TRAP PLANCI ILCK FHP.
I comfy daunt the perfrrouanceofthe work for which this permit is"'"ad.Iehull SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any inner so as m become subject to the Worker”Otmpen- ENERGY FEE
melon Lave,ofc.lifomia Date WATER HEATER W/VENT/ELCCTR
Z. ci Applicant I GRADING PEG
0 NOTICE TO APPLICAN'G if,afar making this Cer ifone of P remplion,you should WA'I'17R SYSTEMOI HATING
henrme aobject to 0,Worker',Compensation provisions of the Labor Cade,you mast SOILS PEE
Wfonowith comply with such pmvisions or this pnmrilshull be dmmedmvoked. WATER SERVICE -
aQ
CONSTRUCTION LENDING AGENCY NEW RF.SIDENTIAI.PLMB. SQ.FT. PAID
wIneeby elf rte that there isamnstrvdion lending agenry fnrlheperfnmrvnce of Dam Receipt#P the work for which this permit Ix issued(Sec.3097.Cls.C) .
Lenders Nn
mo TOTAL'.
ULcaderu Address - TOTAL:
1 candy that I have read this upplicmion and sone that We above infonnmimn is - BUILDING FEE
rI"si fn correct.1 agree m earthly with all city and county ardim...ee and,tae laws reeling to QTY, MECHANICAL PERMIT - PEE
V,Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above mnnlloned property for inspection purposes. PERMI'U ISSUANCE _
(We)agree to save.Hall ad keep hamlas.,the City of Cupertino against PH.h:C'1'RIC FEE S"S
Iiabilites.judgmems.rosdand expeawswhich may in any wayacemnagain,tsaidCity ALTERORADDTOMECH.
in mwquene,of the gmnWtg of Ihi.,perm”. PLUMBING FEE
APPLI N UNDERSTANDS AND WILL IT LL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOU !CUL S. MECHANICAL PEE
//( 6_/0_ AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION'fAX
SI mmo App Co or Date EXHAUST HDGD(W/DUCT) HOUSING MITIGATION PEE.
HA OUS
'ERIALS DI SURE
dl the applies r finurehdainga....anl a or handle hmvrdoa,rnamrial HEATING ON]'T(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chap a 9.12,and the health and Safely
Code,Section 25532(u)'I HEATING UNIT'(OVER Iof1,000 B'UU)
❑Yes ❑No SUN"I[LAI ION PANS INCUR RES ID) PAID
Dam Britain a
Will the applicant or future building oeerpam use equipment or devices which BOILER COMP pHP OR100,000 BTU)
emit huvzNns ro
oair ntmninanta as defined by the Bay Area - ,
v Air Quality Munvgo
nnt '
OTAL: �e
DlgriclP BOILER-COMP.(OVER 100,000 BTU)
❑Vex � �No
I have read the hazardous materials re tsunderChu 6.95 ofnne Cali- AIR CONDITIONER ISSUANCE DATE
yar per
forma health&Safety Code,Sections 25505,25533 and 257.I undersland Wal if the NEW RESIDENTIAL.MECH. SQ.FL
buildin 1 e,norervc ate aspo ry ronad(y the eceupam
nfm na trust be 'colic�IOnJ�-'X
Owner nr ulhnrizal vg
Data TOTAL ISSOED BY' 0 �I
OFFICE