S 1902 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CFPY OF CUPERTINO BUILDING-ELECTRICAL. M ITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL {J 1902
BUILDING PROJECT IDENTIFICATION
BUH-DINGADDRESS,. jSANITARYNO. APPLICATION SUBMITTAL DATE
/o!/a Oe- AAzI 61 ,d - Z3� 9
OWNER'S NAME: PILON& COMM CTOR'Sgjr LIC NO: CONTROL+(
Jadillillb, a. l% Ck,,.k efcv . ?sir 7cn A22 s7�M P 33S I 2
AHCI{ITECr/ENGINEER: LIC NO: AOIIRESS:
0 C.)rbe// Avt Swq�+krkeistd 9 /
CONTACT: PHONE: BUILDING PERMIT INFO
—7c.?3 'S--:Ia ❑ Consultant Face Paid by Applicant(Initial) BLDG _ ELECT PLUMB MECCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMfr FEE pFf-I/ JOgDESCRIPTION
Q C z 1 hereby adult Nut 1 am licensed under provisions of Chapter 9(commencing
LLOO win,Section 7MEof Dolkinn 3 m fluo Business bad Professions Cadcund my license is PERMIT ISSUANCE. RESIDENTIAL:
CIz in fu11lisrce and eft L �� ❑SFUWL ❑KITCHEN RIiMODGL
aUV L¢cnse-J„ Lio'M APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING L PIPE
0-P. Date I Coamcto
NQ4 ARCIIITF.CTS DECLARATION ❑MULTI-UNIT []STRUCTURAL
z p=^ I understand my plans shall be used as public records PANELS MODIFICATION
Oz pp UPTO 200 AMPS C1 INTERIOR ❑CHIMNEY REPAIR
F��til Licensed Professional 201-1003AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER HIM AMPS ❑BATA RUMODEUREPAIR ❑DEMOLITION
Ya I hereby afros that I am exempt fbm the Contractor%License Law Ise the
O y V
following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECRICAC1 OTHER t
LLO rG� which requires a senna m cansuuc6 he,bamboo,demolish,or roped,any avucmre
C"mJ pnor to Its issuance,also requires theapplicam Bastilleperoml filo asignedsmtenten' SPECIAL CIRCUIT/MISC.
} that he is licensed pbmeb th
nnt epmvisica,of the Coor
ntract 's Liernu Law(Chep'er9
�(QQ oammuencing with Section pof Division 3m he Businessland l'mi—inns Code).,, TEMP: OR POLEINST. COMMERCIAL:
AkX
Ill.,he ix exempt therefrom and the basis fur the allegnl exemption.Any violation of ❑NIiW hDG/ADDITION C1 DEMOLITION
i� Section 9031.5 by anyapplicam torn permitsubjecis lheupplicam to a civil rapidly of POWER DEVICES NT ❑FOOD SERVICE
iy+ not ore than rise hundred dollars(85(70). IMPROVEMENT
m
F�G 1,aowneruf Nc m n,urm In ccs with wacs us their sole mm tion, SWIMMING POOL ELECTRIC
O ❑ p Ix y Yemp Y 6 lwnsa ❑0FHF.R
mandili Bothe work,and Nettie cuumCom is pots License Law ed does ade of apply 1D W,Business
and Professions Gsde:'The Compactor's Licence law Nes not apply to an owner of ` OUd'LL''TS-SNITCIIIS-PIXTURRS 1 0
propeny who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such int rrovemcut,am not intended or offered lot NEW I7S ' TIAL ELECTR SQ Fr.
sale lf.however,the building or improvement is sold within one your ofcoaplc'ied.the SQ.ET.FLOOR AREA VSQ.FT.
own ca-builder will have the burden of proving that he did not build or improve for pur-
pose of ode.).
UI
E]1.as owner of the praperry.um exclusively contracting with licensed conuacmm to LAI
instruct the project(See.RWq Business and Professions Cole:)The Contractor's la-
,ca.Law docs nourpply'nnr ownef of property who builds m improves 1111rama and QTY. PLI ,PER h IT FEF.
who contracts for such projects with a contractors)licensed pu wom to the Conubmoss
License Law. PERM I'r ISSUAN'
l am excrom ander See. ,B&P C I,,,'his rennin
ALTER-DRAIN& - ATER(EA) VALUA'T'ION
Owner Dale
WORKER'S COMPENSATION DECLARATION HACK FLOW I'R(DTCI'.Il VICE
1 hereby affirm under penalty of perjury one of the following deda.dion.c.
❑I have and will maintain u Cendicme orCousent to self-boon,for WnrAcr's Conipen- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPECONSTRUCTION
cation,as provided for by Section 3700 of the Lahor Code,for the performance of the
work for which this permit is issued. FIXTURM-PER TRAP
❑1 have and will maintain Warker.s Compensation brxtmnce,us required by Section
3700of the Labor Code,to,the play..ounce of the work fpr which Nis Nmi'is issued, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance scroll and Policy number art:
Carnes Italics No: =17A
TEM-(aVf!RJ(IiA)
CFEU IFICATH OI'EXEMPTION FROM WORKERS' ISTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCEBUILDING DIVISION FEES
('this section need not becomple¢d ifthe permit is foronchvndreddollars(SIW)
nr IcvsJ PIANCHECK PEC
I cinify that in the perfurnlm,of the work farwhieh,hi,pemtitis issued,I hall ITARY-STORMI!A.NM)FT.not employ any erson in any inanne��o�ctme kyFjso) I e'or ors Compcn- I?NERGY FIiErz cation Laws of faro" Da ER WNEN'VIRI-wTR GRADING FEE
Applicant NOTICE TO APPLICANT:11,after mrd ing this CeniGcato of Exemption,you should Elon B ATING SOILS FEE
abecome sabjem m he Workers Compensation provisions of the Latin Code,you bust
W forthwith comply with such provisions or his permit shall he dermal revoked. WATER SERVICE
0 PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPL I1. SQ,IT. Dam ReeciptM
V I hereby million that there is a construction lending agency fnrthe performance of
the work for which this permit is issued(Sec.NA7,Ci,CJ
OF Lenders Name Tll'I'AL:
V Leadetx Address 1NRlI OTA1.:
>" G I certify that I have read this application and stale that the above information is BUILDING EEE
tH TA coned,I agree to comply with all city and county ordinances and sone laws rela'in'tat QTY. MECHANICAL ERM IT FEE SEISMIC PEI!
U � budding causwenth .e
on,and hereby aundrerm reaconowsnf this city eatermpanthe
above-mentioned property for inspection purposes. PER IS,"�kq�E)'/1 ELECTRIC PEE
Al
(We)agree m save,indemnify and keep harmCanada-lesc'be City of Cameagainst RMIT ll
Habilities.judgments,costs and expenses which may in any way mccme against said City ALTER ORADD'Bat PLUMBING FEL!
in consequence of the'falling of this permit.
APPLICANT UNDERSTANDS AND W11.1.COMPLY WITH ALL NON-POI N'r AIR HANDLING ON]'T(To I(),IDB CFM) MECHANICAL ME
SOURCE REGO LATIONS.
AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
Signature of Apphwrmcontmetor Date EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant score or handle bavnrdoun material HEATING UN IT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Cole.Section 25532(u)7 BEATING UNIT(OVER 100.000 BTU)
[3 Yes ( VENTILATION FAN(SINGLE RESIU) PAID Date Receipt a
Will the applicmt or furore building occupant use equipment or devices which BOILER-COMP(3HP OR Madill BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOT
Owner? � BOILER-COMP(OVER HNa(00 BTU)
[-1 Visa QNo
I have rend the huabrdaus materials requirements under Chapter 6.95 nf'he Ceti- AIR CONDITIONER ISSUANCE DATE
Italia 1{cahh&Safety Axle.Sections 8505.23533 and 25534.1 undcon nd that if the NEW RESIDENTIAL MECH. SQ.ET. _ O C{'
handing dna edcome tly baveammul.'hall[is myms,emobilill to ready'he nccupant 7 > t
ofyrer'uit<ryQtec� list he melted ...'nsuaneenfacvaiticme`){fkcumnncY.
x yJ 7/>3/
Owner nr nmhorized agent I I�IIme�� TOTAL: ISSUED BY.
OFFICE •