B 0295APPLICANTTOFILL' IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CONTACT: rnun oc
SEISMIC FEE .
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L&M%VL
CITY. OF CUVERTINO
❑ Consultant Fees Paid by Applicant (Initial) _
BUILDING. ELECTRICAL
PLUMBING -MECHANICAL
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm mut 1 am licenced under provisions of Chaper 9 (cr n Hent ng
with Seetitn]Uagof Divi,ma3ofthc Bnsmes,and Prfe 'my Inch. is
in albrn and, t_Z�j
Llcea' Class Lie
)ate Cnmracmr ✓
t
QTY . .1 " IPGRMiT
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PERMITNO #J 160295 ^ 5
f.
J1VISlON
APPLICATION/PERMIT
CHITEC'I"S OHCLA [Off=PANELS
r undmntund my plain sham he Hoed tin PnMi cords
50001
Q
3 Fp;
DUII,DINC
](11-11VOAMPS
j.'r,_.,)' 'BUILDING. PROJECT IDENTIFULAI
HIN-•i
OVER IINMIAMI'S
SIGNS F.LIfCfRICA1.
SPECIAL CIRCUD"MISC.
-
Y�
'RyyC a
N
Q[]I,
Fy
lammmensing with Smdon](KK)of Division Jufthe Holiness and Professions Cale)nr
that he is exempt therefrom and the bulls lin the alleged twern,amm. Any violation lir
Section 9031.5 by any applic.nt lin a permitsubjeetsthe applicant to it civil pvaskyof
nal ooc than live hundred duller, (S500).
its owner of the property, (it mycnydnyttswith wages for their Sec. cm{gmnsutinn
weer sv
will dothewons Code,HeCuntlxnots License Law does ousale t
and I'role.vsinns Cule: The Comrn:fr'x License Law doea not apply f an owner of
pv,wrty who builds aro improves thereon, and who does loch work binmelf lir through
his own employees, provided thatsuch impmvtmems are not intended m offered for
TEMP MCI'(?R OR POLE (NST.
POWER DEVICES
SANITARY NO.
NEW RESIDHN'TIAL BLEC'1'R SQ
APPLICATION SUBMITTAL DA'1'li
HI111,DING ADDRESS:
C
v
�D
1��
.
TOl'AL:
M 1 st of colo.). n
❑ as wner of the Sec.7peopmay, sinusineexclusivelynd Protracting with licensed amctors m
mamm the project (Sec. 9000, Business mA Professions Csror a The Contractor', 1.1-
cense law docs not apply m an owner of progeny who bullas or improves thereon. anA
-r y I
r.
QTY..4 t"t""P6l1MBING PF,RMIT
OWNERS N MIc
P O E:
CONT ACTOR' NAME:
I N
S3
NIC
CONTROL
Owner Dom
IezA
❑
WORKER'S COMI'I!NSA9'ION DECLARATION
RCIII'I'ECT/ENGINEER: LIC NO^
W \ d A?iiii , -rP1 '�1` "`,rJV
FEE
PERMIT INFO,
❑ ❑ ❑
1013 DESCRIP TION
CONTACT: rnun oc
SEISMIC FEE .
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L&M%VL
❑ KITCHEN REMODEL
❑ Consultant Fees Paid by Applicant (Initial) _
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YO
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W
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm mut 1 am licenced under provisions of Chaper 9 (cr n Hent ng
with Seetitn]Uagof Divi,ma3ofthc Bnsmes,and Prfe 'my Inch. is
in albrn and, t_Z�j
Llcea' Class Lie
)ate Cnmracmr ✓
t
QTY . .1 " IPGRMiT
. I.
PERMIT ISSUANCE
APPLIANCES—RESIp[iNTIAL
Q
V]
X277
CHITEC'I"S OHCLA [Off=PANELS
r undmntund my plain sham he Hoed tin PnMi cords
UP T02()1]AMI'S
Q
3 Fp;
Licensed Pnde"on al
](11-11VOAMPS
dA
4%Q
01 u
O y
ythat
OWNER BUILDER DECLARATION
1 hereby affirm that 1 um exmapl from the Contractor's License Law for the
followin6 reason. (Section ]031.5, Business and Professions Cade: Any city or county
which requires a permit to consumer, alcor, improve, demolish. lir repair any structure
prion -to its issuance, also requires the applicant morsubpennu to file a signed statement
he is licensed pursuant to the proveions of the Contractors License taw Chapter
OVER IINMIAMI'S
SIGNS F.LIfCfRICA1.
SPECIAL CIRCUD"MISC.
-
Y�
'RyyC a
N
Q[]I,
Fy
lammmensing with Smdon](KK)of Division Jufthe Holiness and Professions Cale)nr
that he is exempt therefrom and the bulls lin the alleged twern,amm. Any violation lir
Section 9031.5 by any applic.nt lin a permitsubjeetsthe applicant to it civil pvaskyof
nal ooc than live hundred duller, (S500).
its owner of the property, (it mycnydnyttswith wages for their Sec. cm{gmnsutinn
weer sv
will dothewons Code,HeCuntlxnots License Law does ousale t
and I'role.vsinns Cule: The Comrn:fr'x License Law doea not apply f an owner of
pv,wrty who builds aro improves thereon, and who does loch work binmelf lir through
his own employees, provided thatsuch impmvtmems are not intended m offered for
TEMP MCI'(?R OR POLE (NST.
POWER DEVICES
SWIMMING I'O(II. ELECTRIC
UUTLGI'S—SWI'TCIIIiS —Il%T
NEW RESIDHN'TIAL BLEC'1'R SQ
❑TENANT
sale. If, however, the building or improvement is sold within one year of completion, the
IMPROVEMENT'
own er,milder will have the burden of proving that he did num build lir imp ..w, loo, par-
.
TOl'AL:
M 1 st of colo.). n
❑ as wner of the Sec.7peopmay, sinusineexclusivelynd Protracting with licensed amctors m
mamm the project (Sec. 9000, Business mA Professions Csror a The Contractor', 1.1-
cense law docs not apply m an owner of progeny who bullas or improves thereon. anA
-r y I
r.
QTY..4 t"t""P6l1MBING PF,RMIT
who contracts for such projects with o connotations) licensed pursuant n the Contractor's
PERMIT ISSUANCEF:]I
Licensc Low.
mon txuntpt ander Sec. B d, P C for Thi. rasm
AL'1'HR—DRAIN & VIm,N'r— WATER Hi A)
Owner Dom
WORKER'S COMI'I!NSA9'ION DECLARATION
RACK FLOW PR(yfECT. IJI?VICH
1 hereby aRan under penally of perjury one of the following declarations:
,] I hove and will maintain a Cenificete of Consenno self-Insum for Workers Cmnpen-FGAS
FLOOR. BOOP, AREA. CONE.
sation. as provided for by Section 37M of the labor Cade, for the performance of the
work for which this permit is hostler.
—PER TRAP
Fl 1 have and will maintain Worker, Compensation Insurance, as requirel by Section
3](e, of the labor Code, mor the arform:mcc of the work for which this lmnnit in issued.SYS'CHM-I
INC. 4 OUTLETS
S YS'I HM-0VER 4(EA)
My Worker's Compensation Insurance currier and Policy number arc:
Cartier: Policy N.,
FL ST RL WAS' I'E INTERCEPT OR
CERTIFICATE OF E%EMVI[ON FROM WOR KERS'
COMPI INSAT](IN INSURANCE
Tfhi, co,linprod ma hat cvmnpHtmJ it thcpermi(is for one hundred dollars($FXb'RAI'
Icertiry Omar in the pmfonnenee of the work furwM1ich this Permitil ixaucd,lshullANITARY—
not employ any P,monm say mwmer... n. almor ni, irstil, ImQtheWorker,'Compen-
S'1'OkM EA. 200 FI�
WATER BEAT FIR W/VfiNT/C:LIiCTR
Z',Z
O
smion laws of Cal''doyy''�;�ry D � L�
Applicant
a;
fS.l
r n
NOTICE TO APPL .a ing this Certificate of Eserl you should
bcammc subjceno Wohers Compensation Provisions of me laMn Grade, you must
fanhwithcomply -th such provisions or this permit shall Is, deemed mvnkN.
WATER SYSTEMO-REATING
WATERSF,RVICE
NEW RESIDT:NI'IAh1'LMp. SQ, FU
d Q
UO
CONSTRUCTION LENDING AGENCY
1 hereby affrm, that Nuc nor comma,lum lending agency for the pohmnance of
Ore work for which this perm,( is Noted (Sat: 3099. Civ. CJ
TOTAL:
W
Ctit
Uz,
Lender's Name
Lender, Address
I teddy that I have mud this appllallnn and ,lam that the nNoc oforn alum N
Prru.t I agree to comply with all city and county urbanites and state lawv relating un
building cnnstruoion, and hereby mulcts ene,or,mausexrfmm, city lo,for open the
Y '.
QTig I MECIIAMCAUPERMIT,
'
PERMIT ISSUANCE
ALTER ORADD'in ViLCH.
abovememoned property for inspection gorp:mex.
(We) agree to save, indemnify slid keep mail the City of Cupertino against
liahilities.judgmen(s, costs andmo co,cs which may in anywayaccre, against crid City
in communicate of the stenting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
AIR HANDLING UNIT (TO 10,000 CFM(
SOURCE REGULATIONS,
'
AIR HANDLING UNIT (OVER IOA00 CPM)
EXHAUST IIOOD(W/DUCT) -
Signature lir A,d,1,mUCrmmamr Dant
HAZARDOUS MATERIALS DISCLOSURE.
gnecupan( store ofhaue ha,i...u. raamrinl
Will the applicant orfutum houl.dl
HEATING UNI'I'1'101(ML001J BTU)a,
HIiATING UNIT (OVER 100.000 BTII)
defined by the Cupertino Municipal Cod, Chapter 9.12,'ad the Health and Safety
Gale. Section 25532nd?
VENTILATION PAN (SINGLE RESID)
E] Yes Cl No
will the vppliant lir (more building usub m nix equiptnem or device, which
nit horn ous air contaminants as defined by the Bay Area Air Quality Mi nagemem
BOILER (3HP OR RXL010 BTU)
BOILER -COMP (OVER 100,000 BTU)
Aklrin9 I
C] yes 7 N
AIR CONDI' I'IONER
I have read the hazardous materials requirement, under Chaplet 6,95 o1' the Call-
NEW RESIDENT ]At, 1,1I701, SQ. IT
'
furnir I caph At Safety Cade, Sector, 25505,25533..,125534. 1 nndoomend that it d1e
• a
of ydwsnrvpant
oI (Imm,movavre,,ntnlyhavc
lactfohalithmylerfe Corm lem
of IIIc rcquircmats which mux( M: rano prim m imm�ec of o Ccrtilicvm of Oavpnnry.
TOTAL:
Owner lir euthoriaed ager - Date
OFFICE
FEE
PERMIT INFO,
❑ ❑ ❑
1013 DESCRIP TION
RESIDENTIAL:
SEISMIC FEE .
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L&M%VL
❑ KITCHEN REMODEL
❑ADDITION
[I PLUMBING RIi-I'IPIi
❑MULTI.UNIT
[-1STRUCTURAL
41
MODIFICATION
❑ INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
E]SWIMMING POOLS
❑ BATH REMODEUREPAIR
Ll DEMOLITION ,
❑ OTHER
A
7 6
Spy 6t'yal—
COMMERCIAL:
❑ NEW BLDG/ADDITION
❑ DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT'
❑ OTI TER
$/SQ. 14.
PA
JUL 0 9 ANST
CITY vi- uurrnIINU
BUILDING DIVISION FEES
PhANCIIECK I�lili
ENERGY FEE
GRADING FEL'
SOILS FEE
PAID
Duce Receipt M
BUILDING FBI;
SEISMIC FEE .
ELECTRIC IFI;
PLUMBING ITE
MECHANICAL FEE
41
CONSTRUCTION TAX
HOUSING MI' I'IGAfION FEE
PAID
Ilam Rcv,'.
ISSUED