S 2146 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-FLEC `v I'RICAI. PEI yITNO, 2146
BUILDING DIVISION' APPLICATION/PERMIT ILUNDIINC-MECIL\NJCAh
IIOILDING viarjECC]DEMO I P'ICA'I'[ON HU 11.IlONG AI>I)N IiS$: 1 y�.y _ — SANI'ITRY N(1. APPI,IGATI(1N 51111M1'1'I'AA'l li
PILO CONTRACTOR'S NAME; LIC NO:
NIC CONIROhM
I IN�t NI'LH' AUDRE55'. ❑ O
CONTACT, 'JV"IYJ—r;/X PH—O/NNE. BUILDING PERMIT INFO
Dv Jv ❑ Consultant Fees Paid by Applicant(Initial) BLDG— FERC[ I'LUh1y MF.C}y
LICENSED(ONTRACIORS DECLARATION QTY ELECTRIC PERMIT ITJI L.J! LD LrLI rL/J�
I nerchy alum that I a++licensed under provisions of Ch,ur,v(cormallo,,g JOB DESCRIPTION
Q=Z InSa,inn 7aUpdDivixion3of,nc Businuss aoJ l'mf lolls Gula wd my liaasl i. RISIDENTIAI:
w0t, i PERMITISSUANCE :3 rp
CWF inrullfmcetmde cost � ❑SPOWL ❑KITCHEN REMODEL
QUU Licence Class Lic.x AI'fhIANC[5-RES
TIAL ❑ADDITION El PLUMBING RE-PIPE
NQL IJate COnlraclm�
A(.11'1'FC-CS DECLARATION PANELS ❑M111,T1-UNIT ❑STRIICTURAL
Fay Z_ Iun Irish my plunsehull he used ux field lc mu+Ms M(]DIITCA'CION
O Z UPTO 21X1 AMPS IN I
❑JjodpHRIOROVE ❑CHIMNEY ING REPAIR
(=.,nFQ Licensed Prnfesei...I NII-100LAMPS IMI'RUVLMENT 0SN'Ih1MING 1'OOIS
CY C OWNER-BUILDER DECLARATION OVER H)BAMPS ❑BAT If REMODCLAITAIR El DEMOLITION
E:'1
d I hereby affmn that I an exempt from
from he Comemrs Licemfloor e Law r the
X 3 W U following maxno.(Suction 7031.5,Ib vincsx and Vroom sinus Code,Any city or county SIGNS I!1.FC1'RICAI. ❑(TfHER
y whin ratio...c,a ponan to sun,ammadier. denuflish,or relsair;any struchim
11-on print , c,cls y :th ppli II Ipermin 11 6 Ja mnem SPECIAL.CIRCUIT IISC.
Eby 'hat he is licensed pla, lt the prieniono,elite Contractors License to (Ch'ptery COMMERCIAL
fad C (commercial,with Sectio 7gX).f Division 3 of'he Business and Professions Code)or TEn11t MITER OR EIN '[
a t1 K that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW NLDG/AUfyl'I'ION ❑DFh101.IT10N
W^w Section 70315 hyaay applicant furl permit%objects lheapplicanl macivil Nenullyof POWER DEVICES TENANT ❑FOODSERVICE
Joe ,Itan twe hundred dollars(x500). IMPROVEMENT
I•ZQ 0I.asowar,ai thepmpcnY,nnny mnployccs will,wages as their role anmpemannn. SWI M M I NG POOL It LILC'I'R
0I{lik
will do the work.and the suoamm is not intended or offered fm sale(Sec.7144,Business ❑
aim and Professions Code The fomen'ter's License Law does not apply m an owner ul ODIl.E1S-SWITGI{CS-PIXY R
property who builds or improves thereon,and who does such work himulf or through
his own etndlycca,provided that such in+pmvnncnls arc not intended or offered for NEW RLSIOEIFUAL 121.Iif:fR SQ IT.
sale.It,however,the building or mprovemca,is sold within nneycarol'ormoviint,the SQ,FT.FLOOR ARBA x/SQ.lel'.
ur-bnllder w111 hall the burden relro
pving thus ha did not huild nr Intpro c lin pup
WeuI uh.). f' TAI
E]1.as in re,of Ire pmpcnX am exdusivdy contracting with licenced cnruachna to
construct the project(See.7(W.Business and Numo siurs Gari,rte-clu m o r s 1.i- (/ C
n,w law does not apply to an owner of pmpeny who builds orimprovcs lhemon.and QTY PLUMBING PERMIT FEE
e /
no contacts fur such Narlects won asmear mo i,)liwnsed pursuant e,the Commaor'x
Liccnsc Law, PERMIT'ISSUANCE t
O funl1yy��a unJy tics. li k i'C for ihir rrasun
XQIA ALI ER-IlRA1N&Vf:Ni'-Wn'TER(liq VAI.b\TION
Owner Dale ( O
WORKER'SCOb1PENSATION DECLARATION BACK IIAK'PR(ff1iCl'.DEVICE (/
1 Hereby affrtm under lewlty'of perjurynae b, the fn....to'Jcdarabom:
I �IhavcunJwill mmmmnnCer,iOwm of Convent tnxdf-irvwmbn Worker's Cntnirn- DRAINS-ILOOR.R(I(lI:.AREA.GDND' S'TO ES TYIll.C,INSTRUCI'If1N
motion,uv pmvlded for by Seel on 3700 of the Labor Coda lin the Ncr1'ornnmce rel the
wod for which Infix panni,k issued. FIXTURES-PER'L'RAP
0 1 have and will maintain Worker's ComNensati.n Insurance, rcyui ed -I INC.40lTfL[ffS OCC. APEby Sationisaued. GAS-FA.SYSTEM
E Id
3700 ofthe Luton Code,for the perfumunce of,he work for whicnu.tnis pcnius
n
My Workcr'sC+mNnsalionlnsumncecamerandl'(ilicynumMram: GAS-EA.SYSTEM-OVER 4(EA)
Casio: policy N..:
GERIIFICAIV OVI!X F-MPI'ION FROM WORKERS' CRICASI%INDUSTIi I.WASTE INTf!RCI!I'TUR
COMITI'SATION INSURANC1! It IN-1 DIVISION FI:IiA
1'Fhissec,i.n need not bevnmplegold Reformat is Intent hundrtddullars(SIIXU GRFASETRAPZ SO
er less) PLANC KP i
I certify that in the lerfnmence of the work for which this Format it issued.(%hall _ ANITARY-S'TORMEA.2IHIIT,
nolemNley+mY person in any moons'so us e+bttnnm suhjecn. cr. nn - � � F.NB E
2, swi.I Laws of California.Tollet +a 'I 17R 1 RW/VC N'DELL!CTR G G ill
C Q Applicant I 1
NOTICE'TO APPLICAN P.If.allcnnakin6,his CcniEcam oII inn.you should WA 1'17RS SI /1'BEATING 501
become subject m the Worker's Compeno
vun pmvi cered
as of the Ce,you must
IX foahwithcomplY with such provisions.,this Nennilshall toe de tnvdLIYU V 1 R IR t to t !
O Y PAIL
n' CONSTRUCTION LENDING AGENCY NEW RL, AL I'LMe. SQ.Pr'
U-
I nurcb 1'fim+thnnhoals ucnnxlmctinn lcndingugrne orlhc Nminnaacc"I me RccciplM
W E. me won.b+r whian ma Nm+n'n locoed[xa.nw7.civ.c.) .lt.
Lenders Name '1' 'FAL
LLUUri Address BUILDING BUILDING EE
Ty 1¢reify Ina 1 nave read This apNlicaunn unJ s'ae Ihm'be aMwe in6mtainn us
.H. V1 Ctmml.l agree m comply wimall city and county ordinances and slate laws mating in QTY MECIIANICALPERNIF1FEE SEE ,FEE
L) z huilding annlrvaian,and nenby aulnnrim rePrucnm,ivcs n(Ihia cltytecnmrugm the r
almvmnmrtloncd Nmpcny fret irm,Letiou Forsoos. PERMIT'ISSUANCE I l!I 'I IC IEE /g J
(We)agrcc In rove,I Bounty and keep farina,Ina Cil'ol'6upcninn against
liabdilie>ludgmcro.costs and capenses which may in any way acweagainsl wiJ City ACFERORAlIUTUMECII. A M IIEE
in .nseyuence of the granting of this pc.I'.
APPLICANT UNDERSTANDS AND WILL COMPLY WITII ALL NON-POINT ALR IIA N DLING UNIT'('to IRR nCFM) MI 'IIA CAL FEE
SOURCIi REGUfATI(INS. �y
N AIR IIANDLINGUN1'C(OVER 1010yICFM) CO 41'NI1CfION TA%
Signature of Applu,naCommeor Dale EXHAUST HOOD(W/UUCP BOOS 'G MITIGAL'ION PER
HA9ARDOUS MATERLAIS DISCLOSURE
Will the applicant or fntwe twildingrsenpamsmn or handle hwaN.usmamrial BRAI'INC,UNIT aO IgI,(XX)BTU)
as defined by the Cull—Municipal Cale,Chapter 9.12 and the Hcalln and Safay II FXI'I NO UNIT(OVER 100,000 BTU)
Cuda Satiun 25532(0)!
❑Ym 0 N V17N'IfiATION VAN(SINGLE RES]D) MID -
Date Receipts
Will the applicant or future building ovcupam use equipments devices which BOILER-COMP(31111OR 100.000 BI'U)
emit haardom air eonlamiwms as defined by the Bay'Arca Air Quality Management TOTAL:
District'! BOILER-COMP(OVER 110,0010 BT U)
�Ytx C]No
I has.muddle hamnlou,truejals rt Is under Chale,h95.f the Cali AIR CONDI'DONIIN ISSIJANCG DA'I'S
famia Hearth Safety GWe. a t n 25505,25513 and 25531.I umlerawh that it Inc Nliµ'R131DENTIAL MIiCI{, SQ.fel'.
minming dura ma currently have a¢taus,for o in myace ofa Certiy to notify the Occupancy.occupant
of the mquircnrn¢which mmlMmet prix,to issuvac oft Cenificam of OccuNncy. ,
Owner or:nnhoriaod.agnn Date 'LOYAL: ISSUED fly. l�• ��
OFFICE