S 1681 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PUR UUMBINc-EIE6iA [CA P' ''I"" 1681
BUILDING DIVISION APPLICATION/PERMIT rINGRmUc IFCHANPGM.
nuu.uwr,rxo.utc'r IDRNrIFlcnrury
BUILDING A DURESS'. sANI'I'ARV N(1. AI'1'LICAI'ION SUIIMI'PI'NIi
,DAI
1! 03 V lo, Y1�. -
O 'NP :S NAME Y� � PHONE: CON'IKACTOR'S NAME LIC Nf� _/
2� X dW / L76 NIC �CIHULN
ARCHI)IiCf/IiNGIN13�N LIC NO. ADDRESS: 1� ❑
CONTACT: N PHONE: BUILDING PER\71'1 INFO
64ml. ) Z52`/TOM ❑ Consultant Fees Paid by Applicant(Initial) BLDG Iil.1,Cl' PU1MB MUCH
LICF SHD CONTRACTOR DECLARATION R QTY ELECTRIC PERMIT FEE DoH UEscRlrrloN
1 hereby million,btu I um licensed under provisions of Chapter 9(commencing
Z withsuunn'/aa)ofIrskinn l nfine Busineseand PmlcvslomC e.roomy license is RESIDENTIAL
❑ W- PeRMI'I'ISSUANCE
Fa, ,full force nnJ effect K ❑SI1riVL E]KITCHEN It[;PI EL
Q,UU License Cleo I.I,,N APPLIANCES-RESIDIiN'I'IAI. ❑ADDITION ❑I'IAMBING It[;
Fzlll Date Cnnlrocnn
rn 6 a RCHITECI'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAI.
1'"IAZ I unde.mod my plans,hall beuscdm public record,
PANELS MODIFICATION
ZOZy-, UP TO 200 AMPS ❑INTERIOR ❑CHIYINEY REPAIR
�4t:,) Liceavell Protessional 21H-ITX)AMPS IMPROVEMENT CjSWIMMING POOIS
y YOWNER-I3UILDIiK DECLAHA'll(INOVER INX)AMPS ❑HATH REMODEIJREPAIR 91)1?MOLITIUN
6 I hereby affirm that I am esenlpl Gam the Cnmmelnr's Lions Law for the
44x13 W F following mason.(Section 7031.5.Business grid Code:Professions Ce:Any city err county SIGNS 1:1.ECTRICAL DOTTER
A, which requires a perm,n)con,mov,alter,in,pmve,danolish,or repair any Ymemre
a'< prior tons warst. La y the pplic t for suchpermit t file a signed statement SPECIAI.CIRCUIT/MISC.
}; that, 1 1p mo II II p s Ill C t' I -i II 1LI prcr9
000 (coo g 'lihSmi 9(XX) fD i:1+ 1 fib B : dl I: C cigar 'f EMP MB'11ill OR POLE INST. COMMFRCIAI'
N
a a IY that he:s exempt therefrom anti the bass for the alleged examnp4on.Any v:alalion of ❑NEW BLDG/ADDITION ❑UEMOLII'ION
y(:2 Section 70315 by any a applicant fora t subjects the applicant to a civil penalt f POWER OIiVIC13
W w Pp Penni Yo ❑TENANT ❑FOODSERVICE
FL} not marc than five M1unlreddollarv(SWy. IMPROVEIdENT
=6 DLmuwncr of the propery.or my employees with wage%as their sole campcnsrtion, SWIMMING POOL IiLECfRIG
will Jo thewuak,and lo—anclone is nutl ,vudcJnraR,,rd fnrsulc(See 9044,1iusmeaa CH HER
to 3 w and I-one,,lous Code Ilm CanlmcKa,ikens,Law due,not apply u:un owner of OUTI,UI S-SWITCI I HS-1:1 X'IURES
a progeny vbo builds or improvers,hemm,and who does.such.,,,it himncif or through
his own employees,provided that such improvements am not intended to offered for NEW RESIDENTIAL ELECTR SQ Ff. SQ,FE FLf R)R AREA 5/SQ.FT.
sale.It,however,the building or imprivemmat is sold within one year of completion.the
err-hullder will have r11c molso of proving that he dial nor build or improve for par-
,,,eof one.). 'TOTAL:
❑i.:u varier of the ph,,ry,nm evelloively cumnclis,with liectnod ormcon,In
onswcl they ject(See.7(Wf.Business and Professions Code:)ine Gntnaara lb
ce haw does not apply Lo
+an wner of progeny who bulldsor improves thereon.and QTY. PLUMBING PFR FEE
stage
Gusuch pnajccts withacoturtt I,)licenced pu.uern the Conlnnor'>
Licence I,nw. PERMIT ISSUANCE
LJ I ant uscmplunJcr Sec .II k PC has 1111,team,
ALTER-DRAIN&VENT-WAT ' VAI.UA'1'ION
Owner [)ale
WORKER'S COMPENSATION DECLARATION IAC'FLOW PROTECT DEVICE 700
I hereby rdirm under Penalty of perjury one of the following Jeelvrariun,
I have mal will anuLuuill .'emlicamnl'Cnn,cm rose B-m%urehn WurkO,Cnanpem D \IN -MOOR,ROOT(AREA.COND. STO IIIc "1'YPH CON51'HUCI'ION
,union,us pnrvided I by Section 191X)of the LaMrClde,for the pclfnrnuoce A Wh
woo.]or whiclidis permit is issued Us-PB RAI'
n 1 have and will maintain Worker's Compensation Insurance,a require)by Section
370hal the laMU Code.for,he perfonmoccof the work for which this Pa.all is issued. GAS-1:. .TEM-1 C.4OUTLITS OCC.GROUP AI'N
My Worker's Compensation Insurance carrier and Policy number an, GAS-EA.. -OVIiR 4(EA)
Cnrriee Policy No.:
CFRTIFICA'I'17 OFEXEMPfION FROM WORKERS' GREASIA is AST It INIERCEP[OR
COMPENSAI ION INSURANCIi BUILDING DMS IN FEES
IThissectlon need not be completed ifthe Wornilo,furrow hundred dolt..IS IBB) GREASI7TRAP \
or jus.) i'LANCItECK TLE �
I certify that to the performance ofthc work for which Ibis Permit is issued.,shall SEWER-SANITARY-STORM 1!A.20017.
noI mnpiny an>')u.ntLA �0 ti�aBer makinJgl�this Ceyn�ihycays of E%emplion,yCo1 tpcn- I!NURGY FFII
III i.: Clean UI /]b /yy{clmHtc WuAcr, t
O uwtsl 'e iI )alc -g WATER IIIiA'IGR W/VIiN I'/Ii1.liCfR GRADING FE13
z OTIA,fiCI �b A C. ou should
q N(ITICI WATIiR SYSTIiM/I'RBA'ING SOII S FEE
F" become suhjm m the Worker's Compensation provisions of the Lahr Colic,you mus'
aiH lonhwim cmnply winssoh pmvisiaiv or biyermil dull be themed revoked. WATER SERVICE ..
y Q
CONSTRUCTION LIiNDING AGENCY NEW KTSIDEM1'I'IAL PLMIL SUFT. i'AIU
= z T hereby rlfimnhvnhere is a construction leadingngency bombe perurmm�cell Dare HecciprN
{UL- the work far which This Penni,is issued(Sce,3039],Civ,C.) TOTAL:
O U Lender's Name IGIAL
L,rulhr's AdJrus HOILDING FHE
>i LLIO. 1 ceirty Ilia I huva read This uppHcaunn end sum thuuhe rlv"I InlLrtnunon Is0-14
F' In correct,l same m comply xirh all city and cosmic ordinance%and sum laws refining to QTY, MECHANICAL PERMIT 17FE SEISMIC ITE
U z building Congmmion.and hercbY uuthorire mpreaenm,iro of thin city newer upon,he
aMrvomenrioned property far inspeminn purposes. j'(W/DUCT)
UANCE FL[CTRIC FEE
(We)agree nr rove,indemnify and keep harmless he Cayof Cupemnn uguina
litigious,iot"arnr,,envLe andaxphnscs w11el,Tray rn any wary accrue rgaina said City ADD TO MSCI I. PIAMIIING FI ?
in
e of the
A PELICANT UNDERS'PANDS AND WII
gn pcnn LL COMPLY WITH AL1.NON-POINT JNG UNIT('I'U 10.(XOCFM) MIiC11ANICA.ILII
SOU r EGULAfION.'
LING UNIT RIVER W."CFNU CONSTRUCT )N'FAX
Ser auamuf�ppllonpG�mmcmr Um 1I00D(W/DUCT) HOUSINGMI' GnfION FIiI!
HAZARDOUS NIXI ERIALS DISCLOSURE
Will lbC applicam nr furore building recupanumrc nr handle Im.acs,material NII'(TO Ra.SX)Ba%defined by the Cupvnino Municipal Code.Chapter 9.12.and the Health and Safety NIT(QVEH 11X).T D
Colo Section 25532(a)^
[:1 Yes [I No VEM'ILAHONFAN(SINGQ41 Y PAID
Dano Hcccipt p
Willdw vpPlienlor future building usen1vrl u,e aquipmemor device,which BOILER-COMPOIWOR 111o.UWBIM
mit havardous air canmminatnv as,defined by,he Bay Area Air Quality Management T
District? Yes El No BOILER-COMP(OVER 11X1100BTU) 1„
111nvc ruJ 111c hn'rardno mvteri;rlvm kr'Chr G9$ollhc Culi- AIRCONDI'HONBR ISSUANC.DATH','
yutrmnnnn um per
hernia Health A Safety Gels Sections 255115,25533:rod 25534 1 underslmd that if the NEW RESIUENTIAU MUCH. SQ FT.
building
of the mgJntio rsermcvuwhich obmasate e¢mneatnoprDioatno Issuance
suance(Lno C eial frm mrmtify the uecupam
of(kcupancy.
Owner or awhorisJ ugcm
Date 'I(yl'AL: ISSIAID BY:
OFFICE