S 0531 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELIOC"TR ICAL PKRMI'I'NO.
BUILDING DIVISION APPLICATION/PERMITPLUMnINc-51KCDANICAL
BUILDING PROJECT IOENTIFICA'1'ION
BUILDING ADDRESS: "71� 0531 .-
atis "pl Jr SANITARY NO, AYPLICAI'ION SUIfMI'I'q\L DAT
l ,41r `,/l L.oT f-3/7 /9 7
OWNER'S NAME: 7CON'I'RACIOR'S NAME. LIC NO:
NIC CY)NTHOLp
• ARCHITECTIENGINEER: LIC IbQ ADDRESS: ❑
BUILDING PHRMI'f INTO
CONTAC, PHONE:
I �' / ❑ Co.s.itant FMS Paid by Applicant(Initial) BLDG ELECT PLl1M MECH
vlu✓�a '1 4l� 41-5372
LICENSED CONTRACTOR'S DECLARATION Q'pY. ELECTRIC PERMIT FEE
1 hereby affirm tri I..licensed aadcr pnwi.donv nr chapter v Irmnmancing JOB DESCRIPTION
W 0CI with Section]fXl(paf Divi%inn3uflM Business and Prn(c%sians Ctde.and mylirona is R I�FN`I Y�L'.
M p YfiRMI"I'ISSUANCE T1,eYi
in full force and eft. FDWL ❑KITCHIiN REMODIiI,
QVV Licence Class Lic # APPLIANCILS-RESIDENTIAL [I ADDITION ❑PLUMBING RFPIPE
F z W Dae Commons
A. ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURAL
F,p co INNIi1S MODIFICATION
O Z to z I understand my plato shall be used as public records DPTO Mp AMCS
[I INTERIOR [I CHIMNEY REPAIR
D
Ful Licensed Pmfcscional 201d00AMPg IMPROVEMENT El SWIMMING I'(%)IS
�s1f; OWNER BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEf/REPAIR El DEMOLITION
C Q I hereby affirm Ibar 1 am enempt firm the Connote....'.Liomwe law for the
X 3 i V following mason.(Saban 7831.5,Business and Pmfe,,om,Cale:Any city Or county SIGNS ELECTRICAL ❑OTHER
W c'y which requires a permit In amamct,abcr,impmve,demalids Or repair any suvaure
Q prior to its issuance.also requires the applicant(orauch Permit file a signedstatnnent SPECIAL CIRCUITIMISC.
f�}' that he is licensed pumuanno the provision.Of the Conwcmrs License law(Chapter COMMERCIAL:
RW1000 (commencing with Secount]Up)of Division 3 of the Business and Protestors Code)Or TEMP.METER OR POLE INS
a a c Wthat he is exempt themboar and the lusis for the alleged exemption.Any violation Of ElNEW BLDG/ADDITION ❑DEMOLITION
U.
Section]831.5 by any applicant for a permit subjects the applicantin a civil penally Of POWER DEVICES ❑TENANT El FWD SERVICE
not more Ihun five hundred dollms($500). IMPROVEMENT
=opt.as Owner of the property.or my employees with wager as their side compcnwtion, SWIMMING POOI.FLECfR ❑OTHER
5L will dothe work.and the structureI%not intended or offered lot sale(Sec.BW.Busmners
6 3 m and Pmfessioe Code:The Cnmactor's License Law does not apply to an(wier of OUTLIiIS-SWITCHL•\-FI%TURI_
property who builds or impmve%thereon,and who does such work himself or through
his own employees.provided that such impmvemems are not intended or offered for NEW RESIDENTIAL R' 1
.sale.If.however,the building or lmpmvenent is sold within one year ofcompletion.the SQ FfFLOOR AREA SISQ.
L� II'.
owner-builder will have the burden of proving that he did ern build or improve for par 1 Q/ r ilt
Lose ofsaleJ. TOTAL TV\�!)-
I,as Owner of the property,am exclusively commaing with licensed contractor,to y L D
on.aruct the project(Sec.](W.Business and Pmhv. ions Cake)The Contractors Li-me Law does not apply vee an owner of pmpeny who builds or impmacs thereon.and QTY. PLUMBING PERA1IT -
who contracts for such projects wil aamtra Ilrl/(/pOwOnwal pursuannnlhc CrCo/m�m)a�or'..
Decirla%mincc 'ovm iU�R 'I� `� "/fL n+sePp^e IIFIfYt PERMIT'ISSUANCE
AL11S-DRAIN&VENT-NATER H1G VA UAT2)
Owner
Dare
W RKER:SCOMPILNSATIONDLCIARATION HACK PLOW PROTECT DEVICE OTO Ur Durso I INU
. erebyaffinnurric"ahy idKijmy are id the to lowing daluottiun%:
❑I have and will maintain a CmifcateofCnro, osell-insum liar Worker%Compco- DRAINS-FLOOR.ROOF,AREA.COND. STORIES 'IYET CONS'In UCOO[
cation,us provided for by Section 3701 of the Latae Code,for the Niformancc of the
work for which this permit is issued. FIXTURES-I117R TRAP
❑I have and will maintain Workers Compensation Insurance.to required by Section
3700 ofthe Labor Cale,forlee perfonrmncof the work far which this permit is issued. GAS-G.SYS'1"EM-I INCA OUTI.17'1 S OCCGROUP Al'N
My WOrker%Conapoasatinn Insurance sumer and Policy norms,Ore:
Camcn Policy Nal GAS-1?A.SY$TIiMOVER4(IiAI
CER1 IRCATIi OF EXEMPTION FROM WORKERS' GREASE(INUUS'I RL WASH:IN'I'ERCHYIDR
COMPENSA'HON INSURANCE BUILDING DIVISION IAMB
TlMsscaionncadnotbccnmplaedit the PrIart is fnnnwbundreddolbarvlSKgp CREASE'I IOAV
or lesxd YhANCHECK FF.B
Iccnily Iota in the Fu,fOonnneofshe work lbrwliebthis purnlltl%issued,Islndl SIIW Iik-SANI'fARV-STOKM HA.21X1 hL
nal employ any POm may no nu saasm hecnme IMIN't to the Wmkco Cn open ENERGY FT?E7
m in rIn - .
Z cation Lewsof Calihania.Dutc WATER HHAI ER WIVE N'I'IELECrIR
GRADING F
z0 Applicant
(A
NOTICE 10 APPLICANT:11,rfferamkingthl,a Ccnilicaaof lioran'io 0'you should WATIiR SYS'I'IiM/I'RIiAI'INC, SOILS FEE
a ; basnnesuhj...a the Wmke-CaaMvM,mlun Pra,m..ns al the Lubar Ctdc,Yon nnnl
W r forthwith comply with such provi or-sr Ibis pernnl shall hcdccondo,,Acd. WAI'HR SERVICE
0
CONSTRUCTION LENDING AGENCY NIiW RIiSIUIiNTIALI'hMH, SQ.ITT. PAID Date Reccipt#
V O Thereby Off mat there is ucunxwainn lending agency fins the perliununee of
[toe the work for which this pcmait i,,,,.cd Sec.3097,Civ.C.) 'I OFAL
O h Lender's Nunn 0TOMIECK,
IyTAL:
U Cradr,,Address BUILDING FEE
0. 1 certify that I have mad this application and state that the above inforomi nt is
FN camas,l agree mei iply with all city and county ordinance unit state laws relating m HANICAL PERMIT FEE SEISMIC FEE
U building construction,and hereby umhod>e represcmmivesonhisaitymenterupontha
above-mentioned pmpeny for inspection purpovex. CE ELECTRIC FEE
(We)agree m save,indemnify and keep I nates,the City of Cupertino against
liabilities.ju Ic.ms(c and capcnxs which may in any.ay acetas against said City ADD TO h1 F.CH. PWMBING FEE
cose fte gra LO in Mon'. X/�� ��q�/'AYPLIC ^D LT'/a'c"� " UNIT LTO 10,11(p CFM) M[CHANICALFEE
SOUR.�q0 )AUNI'1'(OVER L0Y0CFM) CONSTRUC13NTAX
/ p ic�anl] rarincto/r a/-I%1 '7T li%HAUST HOOD(WIUUCq HOUSING MITIGATION FEE
HA9ARCOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant store Or handle hauaNnu%material REAPING UNIT(TO 100.000HTU)
an Jelled by the Cupeminn Municipal Code,Chapter 9.12 and the Health rod Safely HPA'TING UNI I'IOVT:R 100.000 BTU)
Code.Section 255321a1'
p Yes ❑No VENT II.ATION RAN(SINGLE RES ID) PAID Date Receipt#
Will the applicant or future building acupant use equipment or devices which BOILER SHP OR I(Xho110 BTU)
emit hazardous air cnnmminanis as defined by the Hay Arca Air Quality Management TOTAL:
•
Normal BOILER-COMP(OVER 100.000 HTE)
❑Ycs ONO,
AIR CONDITIONER ISSUANCE DATE
I have read the hazmtRmvamtaials rcyuirements under Chapter 695 of the Cali
forma Health&Safety Crde.Sations 25505,25533 and 25531.1 understand that tithe NI7.W RESIDENTIAL MECH. SQ.PC
building does no currently have a tenant.that it is MY mrrymsibility In notify the acupOnl
of the requiaments which must M and poor to%,cnce of a Cendicalc of(kcupaacy.
Owner or aomm;zed agent Date TOTAL'° ISSUED BY:
OFFICE