S 0186 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECIFRICAL PE511 No, O
186
BUILDING DIVISION APPLICATION/PERMIT PLOMBINC,-MECIIANICAI, s\�
BUILDING PROJECT IDRN'FIFICNFION
BUILDING ADDRESS: � SANITARY NO. AP//LIC++ATIO�NUIIMI'ITAL DAT(
0 e- U '' 'yJ
OWNER'S AMIi: r ♦"...(a5rNr5 PHONE CONI'RACTO 'S NAME, I,IC_NO:
NIC CON I'HOLp
tas
.goC IIECT/ENGINEER: LIC NO: ADDRESS �• sSaw Tc ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG %ELVU PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOEf DESCRIPTION
OW ZZO with Secllon7000)of Dlvlxinn3oflbe Buxincseznd Pmfexsiam Custe.andmPERMIT ISSISSUANCEy license is RESIDENTIAL
O
F.
in full farce and effect. OSFDWL ❑KITCHEN REN10DE1,
Is
License Class Lick APPLIANCES-RESIDENTIAL DADDITION 0PLUMBING RE-PIPE
FZZI Date Common
MULTI-UT Ow STRUCTURAL
,Doo ARCHITEC-S DIChARATION PANELS
MODIFICATION
__4_
zo.z I understand my plans shall he used as public records UP TO 21N0 AMPS
E3 INTERIOR ❑CHIMNEY REPAIR
I-�FTOi1 Licenwd Pmfaxional 201-1000AMPS IMPROVEMENT OSWIMMING POOLS
K C' 1 hereby aRnn thatN am exempt t fmER lm the Contractors License Lew Inn the OVER RKOAMCS ION D BATH REh10DEL/REPAIR D DEMOLITION
Q P
X3LLFfollowing reason.(Section 7031.5,Business and Prnfesomes Code:Any city or county SIGNS ELECTRICAL ❑OTHER
y which rtquires a permit m ctnawcl,alter,impmvc,demolish.or repair any SIm<turc
FNOj prior to its issuance,also mquires the applicant for such Permit o file a signed statement SPECIALCIRCUIT/MISC.
�ylY that he is licensed pursuant to the pmv+dunx of the Contractors licence"a(Chapter 9 COMMERCIAL'
w 0 (commencing with Section TOW)of Division 3 of the Business and Pnotbssions Code)or TliMl'.h1LTER OR MILG INS'
a a c C 'hat be is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION
❑DEMOLITION
ISmile.7031.5 by anyapplicam fora perrad objects the applicants anvil pet-IlY of IK)WI:R DEVICES 2 []TENANT ❑FOOD SERVICE
m mom than five hundred dollars ISSUE). IMPROVEbfE T
=O`01.as owner of me pmpeny,or my employees with wages as theirxo+lcinnnenxmion. SWIMMING IUOLEIS
p., will do the work.and the structure is not intended smothered for sale Phi 7OMI,Business [I OTHER
W 3 w and Pmfcxaiom Core:The Cnmranur's Limn-law does nm apply m an owner of OUTI.GTS-SWITCHES-FIXTUR' l
ea. property who builds or improves Iherenn,end who does such work himself or through
his awn employees,pmvidM that such impmvemems am not intended or offend for NEW RESIDENTIAL ELECTS -� FT.
FT.
sale.If.however,the building of improvement ix sold vithimon,yeaof con+pletion.mc SQ.14.FLOOR AREA SISQ,
ser-builder will hat the burden of proving that he did not build or improve for pur-
pou of sale.). OTA
1,as owner of the property am exclusively contracting with licensed contractors to
ansmct the project(Sec.7614,Bu.viacxs and Professions 1om:)Thc Comrecusr's Li- � '
c w law does not apply to an owner of pmpcny,who buildanor improves thereon.and QTY. PLUMBING PERMIT 'EE
who eonoacts for such projects with a centmmortOlicensed pursuanuo the Contramam
License Law. PERMIT ISSUANCE UAf 25
I am exempt under Sas .B A,P C for this leaum
N.TBR-DRAIN&VENT-WAI'ER(EA) gx' VALUATION
Owner Date la
Ty
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE Ur QUrCNIIIVU
dk hereby affirm under penally or perjury ono of the following decimations.
I have and Is ill maintain a Certificate of ConocnOn sell-insure for Workers Cooper- DRAINS-FLOOR,R00F.ARFA,COND. STORIES TYPE CONSTRUCTIOt
cation,as provided for by Section 3700 of the Labor Cade,for the performance of the
work for which this permit is issued.
PIXTURIiS-1'EH'1'RAP
❑1 have and will maintain Worker's Compensation Insurance,rex required by Section
171X1 oflhe Labor Cade,Indic perfomsom of the work far which fT
flu,permit is issued. GAS-EA.SYSIN I INC.4 OUTLISTS OCC.GROUP APN
My Warkc�,CCOlt W'm!two
Policy-Iqam
``�Jrrllll Pohn, Na.: 2 GAS-EA.SYS TEM-OVER411?AI
CERTIFICAI E OF EXEMPTION FROM WOR HRSGREASIANDUS'IIn.WAST Ii INI ItRCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION ITES
(Thi,wetinn needoot hccninpincd il'thepem+it ix In amehundml dullars($10 ) GREASE THAI'
PLANCIIIiCK FEE
or less)
Toy am,lhmin@can.a..msnceo(tbcwork Enwblcr,r no froThe Wlxixa Comf+nll SHWIiH-SANT'I'AHV-S'T'ORM EA.2011zP.
not employ nny poseurs nny manner en is ps bcamm suhjmnothe Wnrkcrd C.antpnr ENERGY FP.Ii r,
,Z, xmium lawn of Califoma.Una, WATER 1117A)ER W/VEN'I1ELECTR
z =
GRADING
NG FIA;
O Applicant I
Ufl NOTICE 10 APPLICANT:IL often nmHng this Cendicate of Exemi,irn,you vhould WAI'17R SYSTUM/TRFAIIN(; SOILS FEE -�
�t yountr subjeo to that Worker's Cntnpensatit)n provisions t)I the Labor Cndu,you sena
CSI �y forthwith comply with such provisions orihie permit shall he docmed revoked. WATT;RSHRVICE
� Z CONSTRUCTION LENDING AGENCY NEW RIiSIU1iNTIAI.I'I.MB. SQ.IT. PND
Thereby uffim that there isuennetmcllnn lending agency for the pmlommann,of Dau 1 H \
Q gle work for which this pemil is Issued Xm.3U97.Civ.C.) TOTAL:
0 (~ Lenders Name V Lender's Address TOTAL:
lS�a {g7 I certify that 1 have read this application und state That do,above alumna....is BUILDING FEE
it V0.) correct lagree mco+nply with all oily and awnryomdinances aialume laws relating u' QTY. MECHANICAL PERMIT FEF. M
C.) Z, building construction,and hereby authorize repre.wmatives oDa,city to cnmrurym the
above-mentioned properly iia inspemion purposes, FERMI I'ISSUANCE E
(We)-goes re,save,indemnify and keep hmmless'the City of Cupcnino against
IiahilifiesludgmcnE mcuOnd eapersex whichro,many way occurs,against said City ALTER OR AIID TO MECII. E
in onsequm me of the granting of this pemit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 100)OCIN) FEE
SOURCF EGUI IONS.
_ 9 AIH HANDLING UNIT(OVER III,INXI CPM) ON TAX
ala
Si nature of App m ICunnacmr Ilam EXHAUST(FOD IWNUC) IGATION
A%ARDOUS MATERIAIS IIISCLOSURIi
Will tM1e applicant err fu am building occupvmsnte nu mor lc M1aznNous material HEATING UNTT(l'G 101,INMI BTU)
as def red by the Cupertino Municipal Code.Chapter 9.13,and the Health and"Tory HEATING UNIT(OVER L00,000 BTU)
Core.Seetion 25532(al't
❑Yes ❑No VENTILATION PAN ISI NGLE RCSIDI PAID
Date Remind N
Will to applicant or future Wilding occupant use cv,ipmenl or devices which OERCOMP OHP OR 1(10,010 BTU)
ail harmclous air canmminams a defiocsl by the Bay Area Air Quality Management TOTAL:
istriet? 0.(1(11 BTU)
❑Yes ❑No
I have read the hazaNsws materials mgoimtmnu um4r C'hapmr 6.95 ofthe Cull- j5NEWRNSIDE�IALENIECILSQ
ISSUANCE DATE
fomie Health&Safety Code,Sations 25505.25533 and 25SN.1 understand that tribe . SQ.FC
(wilding does not currently have a mnam,that it is my rcsp+msibilty h+notify the occupant
of the r;uirememx which must W met poor to issuance ata Certificate of Occupancy.
Owner or aathutned agent Dam TOTAL: ISSUED BY:
OFFICE
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