S 2946 (2) 'APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUP
BUILDING-ELEC I RIC,AL PI7RNI IT NO,
BUILDING DIVISION APPLICNI'10NIPF.RMIf PLUMBINGR ,ECTIVIESUICAI.
IfllI1.DINC PItO.I I?CT IUICN'1'IN'IOA'1'If1N
BUILDINGADDREy'S: " ��� �f� . I �I�� I �9 SANITARY NO. APPLICAI'IONSUBMI'9'A.DAI'E
l0 633-� 1` �-->/� —t 9
OWNERS�A ZF • 5diitf P,%tAb lON fl) Tit C r S NAh11i: LIC NO'.
DK NIC ///C```ONTRROOL...#ffs
ARCHITE Ti ENGINEER: LIC NII: ADDRESS: ❑ ��✓/�
CONTACT; PHONE - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MUCH
LDC
❑ ❑ ❑
LICENSED CONTRACTOR DECLARATION QTY. ELECTRIC PERMIT FEE
1 herehy iffimn mm I am licensed under prosidous of chapter 9(commencingDFSCRIPTION
Ortiz with Sermon](Nq)ofDivi,inn3nfthe❑usinesa trod Professions Code,and my license is ESIDENTIAL:
W p PERMIT ISSUANCE
F-Iy= infullforecandeffca. ❑SFDWL ❑KITCHEN REMODEL
aUU License Class Lic.# APPLANCP_S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F-ZW Dale Commerce
m¢a ❑MULTI-UNIT ❑STRUCTURAL
ARCHIT[CI'S DECLARATION
ZONZ Irude cnand myplansshall be used aspuhlie records IANLIS MODIFICATION
O Z=—a UPTO 200AMPS El INTERIOR ❑CHIMNEY REPAIR
F 4 F W Licensed Professional 201-1000AMPS IMPROVEMENT S 4MMING POO(S
akF.-� OWNER-BUILDHR DECLARATION OVER ItXN1Ah11'S ❑BATH RE.MODF.IIREPAIR Ii?MMITION
tY tY C Q I hereby ufGrm thin 1 am exempt from the Corrosion's Livenm Law tart the
x3LLFfolluu'ingre,con.(Smfitn]03).5,Havinessand l'mfexsions Gxle:AnY<Iry nr cru^tY SIGNS ELECTRICAL ❑OTHER
y which require,a .it to convect,alter,improve demolish,or repair any hwemre
F-�ot prior m its issuance,aLmnouire,,he applicant for..ch prow in file a simicillatamem SPECIAL Cl RCUI I''/MISC.
}' at he is licensed purream to the provisions of the Commcmrs License low¢:haper'1
th
ai�.^�]�O (commencing with Section7")ofDi,vion 3ofthe Busines,and Profession,Gale)or TE MP.Miel ER OR Pi INST. � COMMERC AI:
a a C C that hen exempt therefrom and the basis for the alleged contlabr.Any thdru o of ❑NEE'BLDG/ADDITION ❑DEMOLITION
ac Section]031.5 by any applicant for a permiisubjece the applicant toa civil penalty of POWER DEVICES ❑TENAN'T ❑FOOD SERVICE
t ore than fisc hundred delta.($500). IMPROVEMENT
f=O Fl nor
as owner of the property,or my employaes with wage.%as their sale contpcnsmion. SWIMMING POOL ELECTRIC DOTTER
a,F-m will do the work,and the structure is not recorded or offered for sale(Sm.9014.1fusiness
W and Professions Critic:The Contmcmis License Law does not apply at an owner of OU'I LETS-SWITCHES-FIXTURES
progeny who builds,or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECT SQ FT. �-R
sale.If,hnweveu the building or impermanent is sold within one year ofcuntpidion,the I r 'ET EA rwo'�'
-builder will have the harden of proving that he did not huild or improve for par. u 011
pot of tele.). TOTAL. APR 2 7
❑ 1,as owner of the property,ata e,clusivi ly contracting with licensed commcmm at 199
construct the project(Sec.]f W,Business and Pmressiom Caere)The Conn:ltor's Li-
uLaw dm%not apply to an owner of property who huilds or improves Estonia,are QTY. PLUMBI r MIT FEE
who contracts for such projects with a enmraemr(s)licensed pursuant as the Contractor's
License Low. i'li ANCE ey
❑ I amexentptunder Sec. ,B&PCgafhisrcaam
ALTHR-URA &VP 'ATER(f3A VAL
Owner Date- 7,, 70
WORKER'S COMPENSATION DECLARATION RACK 19AW 1'R(Tf: )IiVICE O
I hereby affirm under penalty of perjury one of the fo lowing declarations
❑ Ihuvc and will mninmin aCmiticaram COnscnuu,elf-inwve tin Worker's Cnmpen- DRAINS-pLDGR, Op, REA,COND. STORIES "I'YPF.CONSTRUCTION
senior,a,provided for by Seetion 3900 ofthe Labor Gx1o,for the perhamanc.of the
work far which this pi is issued. FIX,ORES-PER TRAP
❑ 1 hove and will maintain Worker's Cenivilitlnn I;ewrnncu,us mquimd it,Secrion
3900 of the Labor Code,for the perfanuarm of the work for which this permit is issued. GAS-PA.SYSTEM-1 INC.4 OU'ILEIS OCC.GROUP CAPN
My Workers Caron ion Insure.e currier and Vold number um: n
Carrier: Policy No, [IAS-1',A.SYS'HMOVER 4(EA)
CIBOVICATE Op EXRMPI'ION FROM WORKERS (iltliASIJINDIJS'GtI.WASEIN'TIiRCEI'IOR
COMPENSA'T'ION INSURANCE BUILDING DIVISION It
('I'hissmrlonnwlnut he campincd if t hepennit lx l'orunu hundreddelia"S100) OIt13A51!TItAP
or co.) LANCHECK FEE
Iecru("]het in the perfannutecollhn work far whhh this#reit is issued,I shall SI?WI3R-SANI'I'AItV,-S'IORM13A,2(q Ff.
nw employ any person in any nnttmcr sn nv m hmn;rte suhjcn to Om Wnrkurn'C'omm'a, ENERGY FEE
O satin.Lows of Cufdmniu.Date WA'I Fit IIHA'1'1!R W/VEN'1'fl!1.13CTIt GRADING FEE0 Applivom
NOTICE10 APPLICAN'1':II',alli,neking this CrniBcnm ni l!aompdon,you shouml WA'11312$YS'D:M/rN13ATING
F bounce suhj,v,rt d
the Waer's Congenxntian pmvl,i000ur the Echo,Code,You ,;nmSOILS Pee
I'othwilhcomplywdll'rel.ptuvisiuns nr this...unit but bedeened mvnked. W'At HIT SHIRVICE p
CU Q /l
CONS'I'It I1C1'ION 1,1?LADING AGENCY NEW R, G, PhMB. SQ.I'I'. PAID
'7 Z' (hereby alllnnthe,them tin ouoottetinn lending agency forthe lerformm�a of [—line Rm n#
Wthe work for which l In,#emit is issued(Svc.3097,Cie.C.)
Q U Lenders Nmne
W Lender's Addre,s TOTAL:
I certify that 1 have mud this uppliemin i and ante drat ole ain't ioforuntimt ix BUILDING FEB
rail comcct. agrct m comply with all city;vin county ordinances and nem Ines relating to QJ Y. MIiCI IANICAL PEkMIT FEE Q
UZ building tnmtromim,and hereby authnri'reopre..mmmise,of this city to cuter up on the SEISMIC FEE
above-mcntinnN property for imlx'ctino purples. 1'13RM1'1'ISSUANCE.
(We)egret to nave,Indemnity and keep harmless the City of Capon inn alai not ELECTRIC PEE
liahil hies,judgments.cosu and expenses which may many way uceme against said(:try ALIHR OR A DD'1'0 M HCH,
PLUMBING FEE
in consequence of the coming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NUN-POI N'I' AIH HANDLING ON I'1'(TO IB,ppo CFM)
MECHANICAL PEG
SOURCE REGULATIONS.
AIN HANDLING UNIT(OVER 10,0m)CPM) CONSTRUCTION TAX
Signature tr Applictmt/Contrecmr Date HXHAUSTHOOD ONMUC) HOUSING MITIGATION FEE
HAZARDOUS MA'I"ERIALS DISCLOSURE
_ Will the applicant or future buildingsccupam store or handle lmvardrnu material I]EXI'ING IINITf10 100.00)BTID
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilcalth and Snhty
Code,Section 25532(afl IlL]ATING UNIT IOVF,R Ent 000 BTU]
E]y" Fl No XT 'AN INGLH RISID) PAID Date Receipt#
s Will the applicant or future building occupant vu equipment or dm'iccs which
emit hamadous air coommirants as defined by the]toy Area An,Quality Management B(IILIiR-C(]MP pHP OR 100,000 BTU) TOTAL:
District? of
[3 Yes CIN. ROII.ER-COME'(OVER HEB,00 BTU)
I have red the hvrd
nnomer
sntfals ner,reemem,under Chanirfi95of the Cali- AIR CONDITIDNER ' ISSUANCE DATE
folia Health&Safety Cede,Sections 25505,'3533 and 25.5,N.1 undemmnd]hot it the NEW RESIDENTIAL MECH. SQ.Iir
building does not currently have a tenant.that it is my M%pnroibility as notify the omtsion
of The requirements which must he net prior to isswns'e or a Certificate of Occupancy.
Owner or authnorm!agent [)are TOTAL] ISSUED BY:
OFFICE