S0001B0494 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDVING-EL—
ME'H N[CA PE MIT No..,- 0 4 9 4
BUILDING DIVISION APPLICATION/PERMIT PING PwG.MEcu IJIFIC soot) i�•�(
- BUILDING PROJECI'IIINNU'UFIC' TION' t'
�� ) n� SANIT Y (1, APPLICATION SUBMITTAL)ATI
BUILDING ADDRESS: t(v
i I 61A/ yot4 oq-+r.
NIiR'S NApf!'SC 1 - 1'{GNI?: C(lN'1'RAC'I'OR'ti NAME LIC NO,
NIC (] CONgTRtILk
re
CHI FEC R: LIC N ADDRESS: E:1
CONTACT. PHONE: BUILDING PERMIT INFO t
�_ 0 ❑ Consultant Fees Paid by Applicant(Initial) BLDOi ELECT_. PLUMB_ MECH-
IC iNSEDC RACIORS DECLARATION QTY �j 'ELECFRIC,PBRMIT ( .r(��.IEE
I nereny:u rn mmlatn aer<ce I p na:rcnnpmr9'comm c g _ _ r., JOB DESCRIPTION
W'pQ with Senora J0lNB of 6i3l',Ilhelhelincerm C .andrayl censersPERMIT ISSUANCE :7 TfF-W- infullimcciumcmec sellml ❑KITCHEN REMODEL
1¢cnm Class Lic.p API'1 IANCES-RISIDr:NTIAL ��ADDITION ❑PLUMBING Rli-PIPITW Dote Conmactnr
+n6q - ❑MULTI-UNIT ❑,l''I'Rl1CTUliAI.TFCI'S DECLARA
Z O H z 1 understand m plats shall be used as public record,' PANELS MODIFICATION
CZ4- - UPT0100AMPS ❑INTERIOR C]CHIMNEY REPAIR
[=.4FW Licenmd Profeuional 201-1000AMPS IMPROVEMENT EjSWIMMING POOLS
OWNER-BUILDER DECLARATION
$f,'=� OVER Ia00AMP5 El BATH REM1IODEL/Rlil'AIR El DEMOLITION
CCG 1 hereby uRnn that I am exempt learn the Contractors C...Live,Law for the
3 W E-- following reason,1&.rico 763 L5.Ibiaincns and Pfnfesvo li Cod.:Any ar,or county SIGNS ELP,C'I'RICAL O OTHEH
LL C v1 which requires..permit ce con, he nlmc improve,demolish,o le',fig vl svunure
F.. ¢ prionoits ismunce.also mquimv the umpllcam lnr.wch permiuolileusigneJ e:uemcnt Sl'IiC1A1.CIRCUI r/MISC.
g;!(a Ne he is liecmdl purmunt mtM provisions of rhe Contracmra License Lrw(Chapter9
^^�� Icomntenc.cre,h freedman
and h basis
.11,cdrssand.a.A,kC,tinnur TIiMp.METIeR OR POLCINST'.
6 ca a e,
that he is 31.5 bl rain,apli and the pea Emma alleged,,emanon.Any viproakn of / NEW BLDGIADDITION ❑UEMOLI PION
W..m Section 7031.5 by any applicant fora permit subject.tha npplkum wuvivil punulty of POWER VCV10E5IiNANT
171 FOOD SERVICE:
to m thin Ove hundred dollars($50P IMPROVEMENT
i�F6 ❑I,as ownernflhemropcny,or my employees with wage,astheinnlecompvnsatlon, SWIMMING I'OOLEhCC'fIiIC
W�t. willilemewo k,und mestrucmro isnot imcnddlmoffcml faraala(Sec.70J4,[Usines ❑O'FHEk
m and Penfessiow Code:The Contractors license Law does nm apply m int owner of OI1T LIifS-SWI'I CIIIiS-FIXTURES ,
property who builds nr Improves Nuuom and who d m,such work himself m Shmngh I
his own employees,provided that such improvements am not intended or offered for NGIT
W RESIDENT IAL L' .1'k SO FC 7
sole.If,however,the building or improvement is sold within one year ofcompletion.the SO.FT.FLOOR AREA $/SQ.FC
ownerbolder will h her the burden of paving that he did not build or immense for pur-
pose of,ale.), L is - V / 3 -/
1,of owner of Ne Promeny,nm exclusively enmr Sing with lice,d ttmwmors m TOTAL:
construct the project(Sec.70PL Business and professions_: Code)I lie Contractors L `
- ,+ r
1 J not apply to an ownef ofm pay h builds or improves there d QTY- PWMBINO PERMIT r FEE
wn.ho mmmct-f r-ueh projects w th a contras Pier)licensed pursuant to the Commetoea
License I.nw. PIiRMIT ISSUANCE
1 em eacmpt under Sm. ..B&P C for this reason
1:1 ER K VENI'-WATER(EA) VA TION VAL
Dale �
WORKIiR;S COMPENSATION DGChARADON HACK PLOW PROTI?Cr.Of ICE
net
1 hereby affirm under penalty.,,,a,one of the following derlaraED
�
DIhavc and will mainmin aCcrtilieam of Consent nt sell-inawe for Worker's Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. :CUNSI'RUCTIOt
sation,as provided for by Section 17M of the Labra Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will antinion Workers Compensation Insurance,as required by Stiction
3700ofthe Labor CSdgf,hada Perla entt oftheworkforwhbhthispermilkismed CAS-EA.SYSI'P.M-1 INC 40UTLELS .GRU11P APN
My Work ,74 ensmio r Wer b+.ter r"
Canter: l GAS-13A.SYS'rGMOV HR 4(CA)
CEI FIFICATL OF HXENIPITON FROM WORKERS' GRF.ASFJINDl1SFRL WASTE INTfiRClil'IORis
PJCCOMMPPENd�SAATIONN1IIIN1'SSURANCE BUILDING DIVISION IErS
I I his mc or Im,.)IcrndyS pe-rfM1rm ice of tle wnrRl wInch lhisper nus forum, u �issocJ ollars1l shall GRCASCTHAP _.
nm mnploy any person in any manner In as m become subject to the Workers Counted- 5CWER-SANITARY-STURhU FB.2IX1 Pr. ENER FPy,In
OZ scion Laws of California.Date WATER HCATHR W/VENTIELITC'IR GRAVING FEC l�
Z Appllcvni -
a ; NOITCE TO APPLICANT:If,afar,making his Cerifie:ne of Esamption,you should WATER SYSTENIG RHATING
beemne subject m the Wnrkera Compensation pmvionns of)ter Labor Code,yon const SOILS RC
W
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SCRVICB
aQ
CON ST,I,.emNLENDINGAGENCY NEW ftFSIDENT1Al.PLh16. SQ.IT. PAID
U Q Iherehy affirm Win Nere iso eonslmclion lending agency l'unne Led nrmnnce of Dae Reccipp
F the work for which this pcmtit is issued(Sec.3097,Cih,CJ
Ixndce,Name
O V _ /L., TOTAL:
r Lender' tTOTAL.
Icrafty
certifyyt the 1 have read Nis application and stem that the above information, is _ Ii111LU1NG
�i % rearro. whit allcityand countyounveccaand cramlaws,upon
gto QTY. MECHANICAL PERMIT FIiE, —Q
U ,7�. building constmninn,and hereby amhorixt mpresenmtivas of this city tv enmr ulsmthe � - ,t � SGSMI
alsrvcmentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agree m savq indemnify and keep harmless the City of Cupertino against Ii1,F.C1'RIC Eli -9
Ii.diduiea.jadgmems,ocedaund expenses which may iti way arcmeugaimisaid City ALTER OR ADL 7n MECH.
mends, ce of the granting of this Permit. I UM GFRE
API' I F UNDCkS'FANDS AND WILh COMPLY WITIi AL Nl)N'''ii1'DINT AIR HANDLING UNIT(TUTU 16.IN10 CPM)
S( RCP t GULATIONS. �o /�� CONS R AON Ii
L // / AIR HANDLING UNIT(OVER IB,tl110 CI M) CONSI'HI1C'fION'1'A%
grature cf rcanucontr. am EXHAUST HOOD(WMUCr) HOUSING MI'1'IGA'1'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will She applicant or future building occupant stare or handle hazardous material HEATING UNIT UTO 100,116)BTU)
as defined by the Caft nino Municipal Code,Chapter 9.12,and the llcalth nud Surd,
Code,Section 255320)! HEATING UNIT(OVER Hatband BTU)
❑Ycs No VENTILATION FAN(SINGLE RESID) PAID Ume Receipts
Will the applicant or Rome building add and use equipment or devices which NOILER-COMP(7HP OR IIq,gXl BTU)
mit ha,mdous iii cuu minunt x defined by the Buy Arai Air Quality Management T
Timor,? At BOILER-COMP(OVER IM.00)BTID
Yee ,
I have re the arraNous n:nterids er,mr, cards under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomin He a ry Crack.Sections 255W,25533 and M534.1 under nJ Nal if the NEW RESIDENTIAL MECH. SQ.FT.
bo he
illy baster moan at tismy rtspon.,ihility ,no fy the: cumani
t of rhe yurtn hu a 'mance iter Cen' cam d v y
OwneIn fired pgcntIfme - TOTAL
ISSUED BY: �
OFFICE