S 1206 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUHAING-ELECTRICAL PE tI NO.
BUILDING DIVISION APPLICNI]ON/PERMIT PLIIn11tINC-NIECIIANIC\L 1206
BUILDING PROJECT IIIEN'FIF'ICATION
BUILUINf ADDRESS: SANITARY NU, APPLICAI'IrIN SUBMI'1'PAh DATI3
Use I. ME: PIIUNIi: R'S NAME: LIC NO:
NIC CON'IHOLI
• RC 11'L 7INGIN eER: LIC N(1: ADDI BSS y„ ❑
�l lV
CONTACT: PHONE: �_..2�+ W � 40T BUILDING PERMIT INFO
❑ Consultant Fees Paid by A r cant(Initial) I. .E PLUMB NIECE
LICENSED CON IRACUR'S DECLARATION QTY. EIA:CI'RIC PERMIT 17FE JOB DESCRIPTION
1 hereby umrm that 1.m licensed under pruviniom of Chapter 9(utmmencinb
GKZ with Scetiun]IXpl of Division lof he Buzinecs and Pmfersium Ctdc.and my license is RESIDENTIAL:
W PERMIT ISSUANCE
� in full Lone and aired. + 2/� ❑SFDWI. ❑KITCHEN RIih10D1iL
aVV hiccnse Lien APPLIANCES-RESIDENIAL E]ADDITION C1 PLUMBING RI!-PIPE
H7j W Umc Cnmrnctm
'�-s A• RCHI ECI"S USCI A'0 ❑MDLTI-1191'1' ❑MODIFI MODIFICATION
~vz tont sand pia v0mll used ax tic I'ANlilti h10DIPICATION
1 Ozm- UP TO 200 AMPS [I INTERIOR 0CHIMNEY REPAIR
F�FW License)Prodessional 201-RMAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDS )ECLARATION OVER ItXX1AMP5 ❑BATH REMUDEIJRF.PAIR ❑DEMOR.ITION
J
q Iyq�Q I hereby nffno thin I um exempt front the Comraclor's Licrnee Law fur the
5L O L O following oras.....(Section 7031.5,limincn's not Professions Cn 1,Any city m'rou 1, SIGNS ELECI'HICN, ❑O'THIiR
ID 3 W N which requires a pemtit at construct,alter,improve,demolish,or repair any mrucmre
F�06 Prlomo iuiwaro ,at,.requirestbeapplicam Rnmch -,it Q)lilcasitoosTenancnt SPECIAL CIRCUIUMISC.
mat he is Ficemcdpursuannotneproviaons Orme Connacme,License taw(Cnnpmra COMMERCIAL�qp0 (commencing with Section 7(X%1)of Division 3 oftbe Business and Professions Code)or TEMP.METER OR POLE INST.
0.4 c at that he is exempt therefrom and the basis for the alleged eaotnpdon.An,ludmion or ❑NEW BLDG/ADDITION ❑DEMOLITION
W Section 70315 by vnyuppheant lin u penouvo,cats the appllcunuo u civil pendtl of POWHR DEVICES 0 ENAN'I' FOOD SERVICE
r w not more that five hundred dollars 1&51X11.
F Z'r IMPROVEMENT
W Sp DLas ownentf NC Pmpeny.ormyempinyceswith wages astheirsole compensation, SWIMMING MlO1.li1.hCTRIC
p- will Jothewon%Code:The Cln iormI I-menc Law does
otapec.'IUan Business ❑OTHIiR
Law and ProfohoICtde:the Cnmrerro License Law Jasnotrk human.through
OUTLETS-SWITCHP_l-FIXTUHEti
1r,o.n who bu11Js or improve,es thereon,and who dtcs such wed,himself or thrd for
l yc� 1 I thw such Im t t intended or oRcrcJ for NI1W HESIDEN'I'IAI.IILECTR SU PT. Q Q
his own run ac ue pnrvita of —dm s l m nu S PI'.11.00 REA YIS IT.
sale.ILLnwer%itheve tie burin of pnvio ivhathwithinoneycnrofolumveorapictlor a-
ofw1c.crwill have the nunlcn of paving that he did not buil)or impmve for Pur-
owner
u s owner
'FOTA L:
❑ 1,as owner of project
Socia(,,B exclusively professions
With licensed comrahm to
n,c La me , c, (See. rto Businessand
oy.no In
CtdaJTheCootmeror'sui-
aconwdtsfrnolapplijock with
a cofpmPeny woeosed fom,.;t Uoves mereon,nnd QTY. PLUMB .RMIT FEE
who consorts l'ooucM1 projcdx withummmctnrrs)IiccnscJ Pun'uanUothe Cnnlmaor'e
Licemc ww. 1'ERMI'T ISSUANCE
I am evempt under Sec. ,B k P C for this mason
ALTER-URAINd VIiN I!KI. VALUATION
Owner Dae r
WORKI!R$COMPENSATION DECLARATION BACK FLOW LEE I[ ?VI
I wrebyalbrnt under frinalty ofperporyune of the 4dluwingdeclaratious
�IM1vvmu¢Iwill maiomm u CenilrcaleofCiroso, necll-Town for Worker's Cumlxm- DRAINS-FLOOR.kIA)Ih.ARIA, pqSTORIES IYPE CONS'I'RUC'I'ION
.vtion,us provided[or by Section 37M of the LaMn Code,for the perfomtunm of the r A � D
work hn which this permit is issued. Iq%TURES-PER*1 R/
I have uad will maimmo Wo me,Cumpenvtinn Inmmnce.as merimal by Section �(y�1
3.(XhdtheLuhrt Cale,ILrme performanccof the work for which this permit is ivued. GAS-IiA.SYS'1IiM-I INC.4011TL1i1'ti FEBf'�` '°Of ANN
My Worker'fs�C',nlm cnmhiun�In�.yrw�a�cu�rrier ni 1 'nlicy read tb /,//�(
Cnnicr��(L�f�'�mcJA)1{q� YN°- ��•t, GAS-Eh SYSTEMUVIiR4fl!AI
CERTIIICA'Oi OF GXEMI'10 PROM WUHKERS T GHfiASI%INUUS'I'RI.WASTE INI'IiHCli1'roR
CiIMPLNSATIONINSUHtWCB �-
WOW I G R'ISIUN FEES
(This section nceJnot he completed if the lemhit is fonmc huadnN dnllan(51 W) ilRl!ASE TRAP
ar Icss) I'LANCHECK FIJi
cenlfy lbw in the purlurmnnu:ul the werk finwhich thisPrnnil isissuul,Ishull gIIW HR-SANI'T'ARY-STORM I!A.2IX11°I'.
nm employ unY Penn..In any ntvnncr m m m Ixcnmc mhjeq m the WnrkcrK❑nnlsom IINI!NGV plies
Q z sminn Lnws of Cabfnrnia.Umc N'AI'I?R HEA'I'IiR WNEN'1'/ELECI'K (TRADING 198!
z 0 APPlicam
N NOTICE TO AYPLICAN]':IL alar making this CcrOBcae of Exemption,you should WATER SYSTEM/fR13ATING SOILS FEE
F' bon ods, b.... mthe workers Cnmpemaion provision.of the who cafe Ynu must
ni � lonhwith nmtply with such provisions ter this pcnnit shall hJcetncA rcvoknl. WAII!R SERVICIi
Q
CONS] LENDING AGENCY NEW RESIDEN'RA,IT.MB. SQ.FI. PAID
U Z I hemhratlinntM1a mnaa
en is.en:eSoo leading agencype
till the rfl-mo-of Dnlc Rceuptp
1 ILL - the work for which this permit is ismcal(Sce.3097,Ci,C)
TOTAL:
Q ULenders Name TOTAL:
W I LenJcr' AJJrcss BUILDING ITh! L
certify that I have mud it 11 e..p...I c un and star Ih:n the above inlornimion is
Val snccl.lugrcc In comply oh allciry anA votuny nrJmvnccand wxm lawsrdamgbt QTY. MECHANICAL PERMIT FEF. SEISMIC FIJI
U Z building construction.and hereby aulhorom mprocntatives ofthocityit)anter apm the
Mmentioned ar."fur irmpectinn purpoe.. PERMIT ISSUANCE ELECTRIC hili
(We)agree move.indemnify and mep nanntess the City of Cupertino against
I'hbilitics,judgmenu,cos nW expcnseswhich inay in any way:meam ag.inst said City ALTER ORADD'rO MECII. PLUMBING FEE
wcopmncc of the ti nytf this l>ennil.
APP 'I'UNIJE I'A )S AND WILT.COMPLY WI'I'll ALL NON-POINT AIR HANDLING ONH(10 0,000CFM) MECHANICAL FEE
LIt-
SOU :k1;GULA N .
AIK HANDLING UND(OVER 10.001 CFM) CONSTRUCIION'1'AX
a
Si• marc nLAppi aoIA'onasctor faro f:%HAUS'f HOURIWIDUCp I ROUSING MITIGATION FEE
IIARDOUS MATERIALS DISCLOSURE
Willtheapilicent or futonbQddngnseupant uunorbundle M1aettrJnus material 1117.A 11NG ON]T('1U 00.00I[11'Or
vs defined by the Cupeninn Municipal Code.Chapter 9.12,and the health and Safety HHATING UNIT(OVEB loo,XIB RED)
Cale,Section 25532(.)' ,•
0YcsL�yNo VIiNTILATION I-AN(SINGLE REST[)) PARD
D:nc Receipt p
WIII the upPlicant ter more building no:cupnnt um ugnlpmcnl ur)wires which HUR,fik-COMP(3111'OR Ial.0 h BTU)
c
mit hmarolous.n a oloolonanb as defined by the Bay Arca Air Qualhy Munagnmml 'UVEAL
D'otriut7 BOILER-COMP(OVER ROOM It'I'U)
❑Yes Aj No
I have null the hazardous materialsrequirements,253an under .1 and rca of the Call- AIR CONDI'UON[R ISSUAN DATE
fomia Ilcuh k Salcey Cod See Satin 155115,25533 and 25531.1 onJentand mut if the NEW RIiSIDGN'flAh MliCll. SQ.Irl'.
M1uild'u ootntrnnt auk that it is my msponsibility o-0 notify mcoecuPnm
oft ryirumenls area Prior In issuuncc of a Cenilicvtc lof}]cc icy.
Ox' •r .gem -!•U to TOTAL: ISSUED BY:
OFFICE