S 2695—APPLICANI'TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUanINC. - ECEC i RICA].
RUILDIIG DIVISION APPLICATION/PERMIT PhUNIRING- VIECIIANICAC
BIRUDING I'ItQIECT IDENTIFICA'1'111N
PERIOD? NO,
S 2695
BUN.DINGADDIt
SANI'T'ARYNO.
AI'I'LICANONSUBMITI'AI.DA'I'I
o iy p
-// 9
OWNERS NAMP.: PHONE: `
J
C3LIa 1'RAC'fGH:S NAME: vLrlbs �"I"4(4ap,
�q
NIC
❑
CON'ILI,M
. RC HITF.C'1'111HIINGINP.ER: LIC NO:
ADDIi15S:
uKA cT- S•3 `1SUZ
CONTACT: PHONE:
RIJ I I.DING PERMIT INFO
G^ �T ^ C
❑ Consultant Fees Paid by Applicant (Initial)
BO LL❑ i I1 U I M❑ l
IrLi/
LICENSF,D CONTRACTOR'S DECLARATION
I hereby dim that I ma licensed under provisions of Chapter 9 (commeming
QTY. IiLECTRIC PF,RMI'T FLEE
JOB DESCRIPTION
1'IiRMI"f ISSUANCE
wow Sectio 9(NIH) of Divi,inn 3 of he lacamas and Profession, Cone. and my license is
I full farce and ftecl. O
Licen.ec Clare G Lich [ 44}�
Date�Cnntracmr
ARCHITECTS DECL
I understand my plans shall be used as publt curds
RESIDENTIAL
(]$IUWI. El KITCHEN REM(1DEL
[]ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
I ❑IN'1'IERIOR [I CHIMNEY REPAIR
IMPROVF.MF.NT (] SWIMMING POOLS
APPLIANCES - RESIDIENTIAI.
PANELS
Up TO HILI AMT'S
Licensed Professional
201-IDPIAMPS
OWNER-BUILDERCON
1 hereby affirm her 1 am exempt form thee Contractors Licenxc law fm the
following reason. (Section 7031.5, Business and Prnre%sions Cade: Any city or county
❑ BATH REMODEIJREPAIR ❑DEMOLITION
❑ OTHER
OVER 1000AMPS
SIGNS ELECTRICAL
which cammixis a permit to construct, alter, improve, demolish, or repair any structure
emi its issuance, also requires the applicant forsuch permit to file a signed statement
SPECIALCIRCUIT/MISC.
that he is licensed pummntto the provisions of the Connectors License I.aw (Chapter 9
(commencing with Seeticarl") of Division 341he Huours, al Professions Cnde)or
'f EMP. MISTER OR POI.IE INST.
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
POWER DEVICES
TENANT ❑ FOOD SERVICE
not more than Live hundred dollars ($500).
❑ Las owner or the popcny. or my employees with wage%as Meir sole a:mpensaion,
will do the work, and the swcture is not intended or offered (oral, (Sec. 7044, Business
IAIPROVCMFNT
❑ 0THI7R
r air
SWINPAINGP0(R.EI.ECTRIC
add Professions Code: The Contactors License law aides not apply to an owner of
OUT I.Fp1S-SWITCHES -FIXTURES
NEW RESIDENT [A]. EIACTR SQ ET.
popery who builds or impoves thereon, and who does such work himself or through
his own employees, provldaf that such improvements are not intended or offered for
sale. ILhoweve, the building or improvement issold within one yearofcomple,mn. the
SQ. FT. FLOOR AREA
VSQ. pT.
owner -builder will have the burden of moving thin he did not build or improve for put.
pose of ale.).
E]1, as owner of the property, am exclusively comrachng with licensed contractors to
"TOTAL:
o eorucuhe project (Sec. Z(IU, Business and Professions CNe:) The Contractor', Li-
cerve Caw does act apply to an owner of property who builds or improve, thrown, and
QT1'. PLUMBING PERNIIT FEE
who contracts for such project with a commensals) licensed pursuant to the Committees
License Law.
❑ 1 am exempt ander Sec. , B & P C far lis wason
PERMIT ISSUANCE r ��
Owner Doc
ALTER - DRAIN & VENT -NATER (RA)
VALUATION
WORKERS COMPENSATION DfdwfalATION
l thereby aRrm under penahy perjuryone or theinsum Fr diadmaWorkeetions:
HACK Fl.OW I'R(11'ECI'. DEVICE
to
❑(have Pro will far Section 37M of ConumwCod.for for Workers Compact,
sedan, as hick fid oar mi Section 3300 of the Irbnr CM,, for the perfonnance of the
wart far which Nis issued.
UNAINS- PIAOR, N(R)1,ANIEA, CONE).
$'fURIiS
TYPE CONSTRUCTION
,3 O
FIXTURIiS- I'IER'fRAP
aintaiis
31 have add will maintain Workers compensation art hi as his exa i by Section
3700 of the labor Code. fur We perfannance of the worA fur which lhispermit is issued
GAS -IEA. SYSTEM INC. 4 OIJTLHI'S
—rr�C CR(UI'
APN
GAS - lib $YSTIiM OVER 411 1
My Workers Compensation fins tax carrier it Policy umbo qf�
Carie, Polley Nino
)
Q
HULLOING DIV
)N 1971
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRP.ASEiINDUSTRI. WASTE INTERCEPTOR
mpiniflhe permit is Ox one hundred dollars (Sled)
(This smtinn need not beroed
or less)
1 cenify that in the performance of the lark for which his permit ix issued, I shall
nal employ mannersoasm bccomenab¢Oalhe Woolens'
p y any person in any j P'll-
GRIEASIETRAI'
P ITh KFBR
11 !RCY FHE J
SIEWF.R- SANITARY - S'IYSRM Ii A. 20017.
WATER IIIEAI'IEH W/VENT'/ELIiCTR
NG Ffai
,ac
Applilaws of California. Doe
Applicant
NOTICE TO APPLICANT: If, site, making This Certificate of Exctmpfiov, you nhnuld
WATER SYS'I EMTRIEAI'INC,
become subject m the Worker% Compensation provision., of the labor Gide, you must
- -
fonhwdhcomplywithsuchprovisionsorthiswounishallBedeemed revoked.
WATER SERVICE
NEW RESIDIEN'1'IAI. 1'1.1011, SQ, IT.
CONSTRUCTION LENDING AGENCY
I hereby affinr chat hem is a construction lending agency for the performance of
PAID
Ile Receim#
the wnrk ha which This permit is issued (Sec. 315], Civ. CJ
Lender, Name
TOTAL:
TIT r
(.enders Address
IIUILUI P
1 cenify that 1 have mad this application and slate that the above information is
QTY. MSCI IANICAL PERMIT Flili
SEISMICH.
mrren. l agree to comply with all oily and county ordinances and core laws relating Ito
building construction, and hereby authorize representatives of this city to enter upon the
PERMIT ISSUANCES
IEI.FC1R CC
above-mentioned property for inspection purposes.
(Wc) age. trove, indemnify and keep harmless the City of Colum o ngainst
Iiabilities,judgmems, tests and expenses which may in any way acerae again,9 said City
in of the graining of this permit
consequence
ALTER OR ADD'I 0 N11 -CH
1'11110 Glgili 7,0
AIR HANDLING UNIT(TO 11.0X8 CFM)
MIECIrANI L FEE
APPLICANT UNDERSTANDS AND WILL COMPLY Wl'lll ACI, NON -POINT
,SOUR REGULATI NS.
AIRIIANDIANGUNH LOVER 10.00ICFM)
CONS'TRUC'I'I NTAX
�y
3-„-11
Soda re if AppliannUGmtoemr Date
IIAZARDOUSM 1'IERIAI.SDISCI.OSURE
EXHAUS'PIIOODIW/DUCT)
HOUSING MITIGATION FEE
III the applicant or future building occupant sorraorhandlc boznNoms munrial
HHATINGUNIT' TO 10(AD1(11TTU)
as defined by the Cupertino Municipal Code, Chapter 912, and the H,ultll send sola,
Code, Section m_5532(a)'!1117NI'INC.
UNIT' (OVER I0H,m#1 If I DO
VCN'fILKIION PAN GSINGLIE RES IDI
Yes iUNn
LAID pmt Rcccipl#
NOII ER -COM(' 13H1' ON IINI,IMI011'I'UI -
WIII Ole...Ituant e, fawn building mecuptat use equipment or devices Whicll
emit hamMoms our contaminants a defined by the no, Area Air Quality Manageumnt
'GFcrkN
0Yes Na
HO11.1NO- COM ('(OVER I OO,camif I' U)
A[ItC(INDI"I'IONI?It
I lwve read lhohuoNnus nmlaiuLs Is under Conner (r.95 of the Call
mpfvmmml 1
fomiu Hwlth&Saf,Iy C,xlc, Sceliam25505,25533 and 25534. I 0 fcamW tlwt it be
but doe nalrmrm, I hnveatmlwl,Ibpl it ie my mxpanxihi tywnnlify lhanenlpmn
ISSUANCE DATE
NEW RISIDEN'IIAl. MBCA. SQ. 1,1
r
of a uircm,nt msec he lnv�T' use snonm ofo Cc
ISSUHDIY
OIO
maDam
v OFFICE