S 1988 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPF,RTINO BUau1NG.ELECT RICA], I'll I NO.
BUILDING DIVISION APPLICATION/PERMIT r1.UMBINC..MECHANICAL
J 1988
BUILDING PRO.IRLT IDENTIFICATION
BUILDING ADDRESS: 'SANITARY NO. APPLICATION SUBMITTAL DATE
Ave--- 8-- 1Z-%8
OWN R'S ME: i-' ( 'HONE CON'I'RAC'IY) ' NAME: ( LIC NO:
-amr 16Y IcI Ki y, HONE SI�-Z• M6 h� NIC CONTROL#
AR HITECTIENGINEER', LIC NO'. ADDRESS. - ❑
/la'a a
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
(cele- a S a o6t6 ❑ ❑ ifl-- ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby aRrm Out 1 am licensed under pmvisiom of Chapter 9(commencing JOB DESCRIPTION
O�Z witM1 Seaiun T000)of Division)af the Husincsa and Profcsxiom Crdc.wJ my licensa is RESIDENTIAL:
Ill: ISSUANCE
F B in full force and eRea. ❑SFDWL ❑KITCHEN REMODEL
�UV License Class LicConwetor,nti APPLIANCES-RESIDENTIAL ❑ADDITION ®RtUMBINGRE-PIPF.
F<I Date Co
'nQa ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS Ds public m'ION
E.D m 1'ANEIS MODIFICATION
Z O H Z 1 undersand my plans shall he used as public reauJs
UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�f"Yl Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
�C�Q t hereby aPimt
OWNERam exempt ffrrom the C nlomme,license Law for the OVER EXRAMPS ❑BATH REMODEVRF.PAIR DEMOLITION
:3 L V following reason.(Section 7031.5•Business and Pmfessinm Call Any city or county SIGNS ELECTRICAL. ❑OTHER
l H which requires a permit to construct,altar,improve,demolish,or repair any>tmmum
��-OQ prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
C2Q� that he is licensed pursuant to the provisions of the Contractors License Law
(Chapter 9 OMM $ IAL•
c4yp0 (commencing with Section AMM))of Division 3 ofthe Business and Professions Code)ar TEMP.MEI'F.R OR POLE INS'r.
W a c C and he is exempt therefrom and the basis for the alleged exemption.Any vinlatian of ❑NEW BLDGIADDITION ❑DP.MOLITION
W^m Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES 0TENANT ❑FOOD SERVICE
not more than five hundred dollars($500). IMPROVEMENT
F_ ❑I,as owner fthe properly,or my employeex with wage as theirsole compensation, SWIMMING POOL ELECTRIC
F- will do the work,and the structure,is not intended oraRered far sale(Sce.70D.Business ❑OTHER
IWARE and Professions Cade:The Cantmctars Lieense Law does an apply Ill an owner of OUTLETS-SWITCHES-FIXTURES
3 r properly tvhe builds or improves thereon,and who does such work himselfor through
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELECTR
sale.If,however,the building.,Improvement is wld withmmle ye.,.f,onadetion.the SQ.FL FLOOR ARG SISQ.FT.
ter-builder will have the burden of proving that he did not build or improve for put-
pom of sale.).
❑1,as owner of the pmpsnY•am exclusively consuming with licensed contractors IllTOTAL:
construct the project(Sec.7044,Business and I'adesla w Code:)The Contractors Li.
nse law does not apply to an owner of properly who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who mntracrs for such projects with a rommemr(s)licensed pursuam m the Contractors /^�
License Law. 1'ERMI'I'ISSUANCE ✓
❑I am exempt under Sec. .B&P C fur this reason
AUNER-DRAIN&VENT-WATER(G) VALUATION
Owner Date
WORKER'S COMPIWSA'1'ION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the lollow'ing declarations:
I have and will maintain a Certificate ar Consent.self-insure far Worker's Coopers DRAINS-FLOOR.ROOF,AREA,COND. STORI[S TYPE CONSTRUCT ION
satin.,as provided far by Section 3700of the LaMv Cale,for the pI...mrce or the O
walk for which this permit is issued -1'ER AP
TR
E] I have and will maintain Workers Compensation lour ave.as reqIIXI'URIS belittled by Section GAS-IiA.-11178 TR INCA OUTLETS
3700 of the Labor Code,for performance of the work for which this permit is issued. OCC.GROUP APN
Cn Worke♦♦r' Comp nsauo urmce cu Icr unA Policy nal
Carziera^,Zrp�'Polley MS-IiA.SYSTEM-OVER'' CERTIFI ATEOE EXE TION pRA W(lRK1iRs' GR17ASI-YINDLJSTRL WAS'T'E INTERCEPIUR
COMPENSATION INSURANCE BUILDING DIVISION PEES
(161,sectionnccA notbe,maideuedd thepcnnh is fit...tell u ndreddnllurs($1X1) GREASETRAP
or less) PGNCHECK FEE
I cealy that in the perfor.nmce of the work for which this permit is issued,l shall SEWER-SANI'I'A BY-STORM EA.21X1 FT.
not employ any labor,In any manner xa as to beconta suhlwt to the Workers'Camper- ENERGY FEE
Z nation Laws of California.Date W'A1 ER I IIiAH1R WNEN'I'IRLECFR
Q Applicantt GRADING FEE
NOTICE TO APPLICANT:IL after making this Cemill ne of Excaption,you should WNTER SYS'TIiM/IREAI'ING
H [^ bec.ma sahjed In he Worker.,Comlcnxminn Provtsoxe of the labor Code,you l nits SOILS PGBIf
WG fonhw,h,amply with such Provisions,,,I...permit shill hedecned revoked. WATER S17RVICI:
Q
CONSTRUCTION LENDING AGIINCY N17W RISIDEN'HAL PI ME SQ,FT. PALO
V Z I bcmby afllrnnha,them,,a camas dol lending agency for the armriance of
Oma milt#
he tvk for whlchthis Permit is issued(Sre.3007.Civ.C.) TOTAL:
Lenders Name
CU Lender's Address TO RUILDING FFE
C 1 clarify that 1 have read this application and state that the above ialarmmtinn is
wFs to corzed.l agmemcomply with all city ane county onlinunros and stem lawsrelutingm QTY. MECIIANICALPERMI'r FEE
U Z building eim,loahade
lon,and herebyame representatives of this city to emcruphe
a.tSEISMIC FEF.
above-memlored property for ispemio.purpls,e,. PERMIT ISSUANCE
(We)agree m cove, m
'indenify and keep hurinlcss the City of Culvrino again,+ ELECTRIC FEE
homilities.judgmmne,emsend caperocs which may in any way accmenguinl said City ALTHR OR ADD TO MUCH,
PLUMBING FEF.
in consequence of the granting of this emsit.
uen
APPLICANT DER ANDS WII ,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00MCFM) MECHANICAL FEE E3
OURCER IAT NS.
8 / Z'9p AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Date EXHAUST HOOD CSig pplic m or H 2 qE
rD
' HAZARDOUS MATERIAL_DISCLOSURE
Will the applicant or future building occupant wore or handle hervrJous material IIFAT]NG UNIT(TO I(May)BT UI
as Jefincl by the Cupertino Municipal Cele,Chapter 9.12•and the ITealth and Safety
Code,Section 25532bC IMATING UNIT(OVER 100,000 BTU) t
❑Yes ❑Nn PAID
VIiNI'II.ATION FAN(SINGLE RESIDE Date Receipt#
• Will the alplicam a,boom haddir,oveupant use equipntem nr devices which BOILER-COMP(31111 ,X1
OR 1000 BTU)
emit annotations air contaminantsW as defmby the Bay Area Air Quality Management TOTAL:
District, BOILER-COMP(OVER 100.0f1(1BTU)
❑Yes ON. — [�-O
I have readnhc ha�.us materials rryuimntems unJef Chapter 6.95ofnhe Cali AIRCONDITIONCR ISS NCEDATE
foods Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW REMDENf1AL MFCH. SQ.PIT •(f �f/ _ Gs D
building docs not currently have a accord.that it is my resrymslbility to notify aha«cupant
of the requirements which mum be met thin,to issuance of a CcniGcare.f Ock-Pooll
Owneroramh.tizN agent Dam TOTAL: ISSUED BY: �-
OFFICE