S 1752 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO BUILDINf.-I?LlitTl'RICAL PEti r NO
BUILDING DIVISION APPLICATION/PERMIT PLUl1BIAD-hI ECI IAN I CA 1, V � 1752
BUILDING PROJECT IDnbirr h'ICSFION
❑UILUMG ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ha Dr, Cuper-�� no Ca • 950/ L-J
OWNERS ME: - PRONE: NIRAC ORS NAME: LIC NO:
err ra.K e �1 W-y �"onc(��1 o reit a%� y / NIC CONTROL p
�ARCHI'I'I!C'f/F:NGIN LIC NO, A)1'R:'Stijy6 Gilman egLe Camp6 t( ❑
CnN'I'ACII /IPOONE: fsss//(((P���.-L�/1/W V BUILDING PERMIT I NFU
/}/ ichelle /�1�j -( 'l ❑ Consultant Fees Paid by Applicanl(Initial) BLDG ELECT PLUMB
MECCIU/
11 L (ter(li Ci V •J I ❑ ❑ UG 9
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERM IT FEE
1 hereby afforded I am Ifaemad radar provisions of chapter 9(commencing JOB DESCRIPTION
Don wish Section]BUB)ofDivisio Sof the Bucincssaad Professions Code.and my license is RESIDENTIAL:
W O p / � PERMIT ISSUANCE
W_i- in frme Cla anJ cRmLC�(� L 5 10 ❑SIUN'1. ❑KITCHEN REMODEL
QUU Licennc�C�lau�a�-�/�-�—LiC.N AI'1'LIANCES-RPSIDFiNTIAI, ❑ADDITION ❑PLUMBING RE-PIPE
• - nkC111TF.CTS DI!CLARATION ❑MUhTI-UNIT ❑MODIFI MODIFICATION Fpm PANELS MODIFICATION
ozmZ, land t dmy plan" liber uhli' c
4- UP T02W AMPS ❑INI'17RIOR ❑CHIMNEY Rh1'AIR
F.m. W LicawoJ l'rofcssl 201-1030AMPS IMPROVEMENT SWIMMING POOLS
OW I;an ex
ILDHR DECLARATION canTION OVER 000AMPS ❑IIA'TI I RIiMODEL/RkiPAIR �DEMOLI DON
CC a^<1 bemby alarm Thal 1 am exempt linin the Conuuctols 1 icense latw far the
p W V ❑OTI{ER
4 following rcmm�.(Section 7(13 L5,Buxinexs unit I'rnfen%ion,Cade:Any city or enunty SIGNS ELECTRICAL
WFv%1 which mobiles r permit to aorolrvm,alcor,improve,demolish,or repair any nmcture
< prior to itsi.manre,also require,,the applicant l iosnalo Wnnit In file a signed xtalabor, SPECIALCIRCUIT/MISC.
that he is licensed pursuant o the provisions of the Contractors License Law(Chapter 9 14 41 Oda 0
W�00 (commencing with Section Rpfpaffivisinn 3ofthe Rusinesand Prom,,ions Gde)or 1111,11r.METER OR MIX INST. '
4 4 DA
c K that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
�m Section 7031.5 by any applicant for a pennRauhmato the applicant to a civil penalty of POWER DEVICES
❑TIiNANT ❑FOOD SERVICE
ao
unorc'ban five hundred Milan($500).SQp Las owner of the property.or my employees with wage%us their sale compe ❑OF HERIiRnsation, SWIMM ING POOL ELECTRIC IMPROVEMENT
F- will do the work,:md the structure is not intended or offered tbrsale(Sec.91W.Business
L 3- and 1'rnfes%ion%Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHIiS-PIX'1'I1NIi5
propcny,who builds or improves thereon:Intl who does such work himself or through
his awn employees,provided tam such improvements am not intended or offered Int NEW RESIDENTIAL ELFCI'It SQ IT.
oda II hanxese,the Int Id'ng or incowairent is soldwtti year ofcomplellon,the - SQ.I f OOk $/SQ.
bdd 'll have the harden ofpot y0tl IPJ Ibdd p cforptn
. l I TOTAL: 21 999
Fl
t' t f the property,an nxclus ly connecting ithl' dcontractors to JUL
s utnat the pn9al(So ,7044,Bun nose unit 1 rof,s n is Cod,)U.Commmorx J.j_
cerro,Law does not apply to an owner of priTsorly will)builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who cinalm la for such projects with a comremnr(xl licensed pursuant to the Control
License Law. PERMIT ISSUANCE.
Imnexemptuoder Sec. ,B&PCfimbismason By
ACfF.R-DRAIN&VENT-WATER(RA) VALUATION
Owner Dan IO
WORKER'S COMPf perjuIBON DECLARATION HACK FLOW PROTECT.DEVICE
thereby elan under Penalty eperjuryaneoftaefollowing Wmkaricm:
❑Ilmas andwill for h,Section
3700of fire Labor
Core,forme Worker's Compere DRAINS-FLOOR,ROOF,AREA.CONK STORIES TYPE CONSTRUCTION
notion,rte hick this
for by Section 3]IXI of the lahnr Calu,forme per4rcmance of the
19'k For which thin permit is Isnmd. FIXTURES-PER TRAP
,Iron and will maintain Work,,',Contpcn,,ndon Insrntnco,as required by Sodion
370a)l the Labor Code,loathe perfnraun,nst,,�r�or�ll'the will.t'oJtlwl�h,,h lhi%permit is ixsucAd. GAS-IM.SYSTEM-I INC.4 OU'I'LE'I'S OCC,GROUP AVN
My W[�1/.�t�n/Q..-Tvyy�ltrrllnl yNoY ur =6/5 t5nR CAS-EA.SYSTEM1I-OVI!R4IRA)
Currie B
CEN TIFICATE OE EXEM1 ION FROM WORKERS' GREASEANDUSTRI.WASTE INTERCEPTOR COMPENSATIONINSURANCE BUILDING DIVISION IB!1!y '
(This sionnaed not becumplamol ill),.pamin in fon ralabareddollan(Sl W) GREASETRAP
sir less) ectPLANCHECK PEE
I rankly the in,he pcnfannarma.fmc walksir whichthis permit is issued,Ishalf SEWER-SANITARY-S'1 FIRM EA.210 FT.
not employ any person in any manner no as to become sublcm to the Worker.,'Compere IiNFRGY FEE
Oz sutionlaw.uff California Date WA'I ER HEATER WNENT/ELECI'R GRADING FIT,
Z Q Applicant
NOTICE TO APPLICANT if,after making this Cenifica n of Exemption,ymt should WATER SYS'1'EM/1'RFA'TINC
tti SOBS PEI? bi
aIacono snhjcn to the Walker's Compensminn provlsinns of the lahar Cnde,you nun
LLL Ilmhwilh Imply with such provisions sir this,permit%hall he deemed revoked, WATER SERVICE
Q
pq,
CONSTRUCTION LENDING AGENCY NE W REgIDEN'f1A1.PLMB. gQ.Ff. PAID
✓ z Dul ReeeiplM
V p Iherchy rllirm tlta there isacnnevunion lending agency lnnbe performance of
I-t the work far whichthis permit is issue,](Sec.3091,Civ.CJ
Leader',Name TOTAL.
U Landcr,Adohus TOTAL: r
0. I sonify that 1 have read this application and state that me above information i. BUILDING PER
F" y cnrtwt.l agree awomply with all city and amity oNinunas and slate laws relatingm QT.Y. MECHANICAL PERMIT FEF.
U Z building construction,and hereby authorize repntxamadvea offlia city to enter upon the SEISMIC ITE
u@we-mentioned property for inspection purpase, PERM(T ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino again,, ELECTRIC FI!I
liabilities,judgments.cons and expenses which may in anyway name against said City ALT ER OR ADD TO MECIT
in nsv,,car a of the graming OF this pmalit. PLUMBING PEL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-f NT AIR HANDLING UNI'FITO
MECHANICAL1
SOURCE REGULATIONS ' O
( /r� x /`Q_ NtIIANDhNGUNT(DVER f,NIICPM) CONti'ftUCI'IDNIIAX
,I
Signature of ApplicantrConmemr [)am EXHAUST FOOD(W/DUCT} HOUSING MITIGATION FEE
HAZARDOUS MNI'ERIALS DISCLOSURE
Will theapplicant or faturc building occupant more sir handle hazedousmtanill HEATING UNIT(TO IINI ffil JUIC)
as defined by the Cupertino Municipal Cafe,Chaplar 9.12,and the Health and Safety
Code.Samuel 25532(x)1 HEATING UNIT(OVER 100.000 BTU)
C]Yes Fl No VENTILATION PAN IS INGLE RISIDI PAID
' Dam Receipt
eM
,* Will the applicant or future building occupant use equipment or devices which
mit haamdom air eontnminonls as deft ned by Area Air Quality Management TOTAL;
Ia),(XX)B'I'lll TOTAL:
District?
❑Yes 0N [TOILER-COMP(OVER 100.0iIll U)
^
I havcrwd the ba/aMeus mvmrluls...... tents under Chnpmr 695 Ofthe Culi AIR CGNDITIQNER V ISSUANCE DATE
I'nrnior llcullit&Safety Cala,Secimar,25505,25533and 25534.1 understand that if the NIiW RESIDENTIAL MECIL SQ.ITT. Z f/ � (y
building does not amcnlly have a Pearl,Plat It is my rcxpansihil'ny to notify the nceupnta /Y
.nf t rcynirc em%whir un Mnel prinnoi%,, � c tfu Cenificaeel Oce pane
a)
Owner mmnhodzul agent of ate TOT p ISSUED BY:
OFFICE