S 1146 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY�P CUPF,RTINO BUILDING.IU,ECTRICA], 1'IyyNff NO. 1146
BUILDING DIVISION APPLICATIONIPERMIT PING pRoxcr ICDANICAI, J
ItI111.BINf.1'NOJEC'I'IIINMI'IF'ICATION
SANT 1'ARY NO. N'I'I,ICA'IION$1111M1"PI'Ah DATE
BUILDING ADDRESS:
OW NAME: ,PHONE:J_^� COIT CNMSNAI:: s LIC NO: SIC CONG KOLA
l/JI IV "{/ Q
ARCHTF EFRLIC roo RFSStE:1 JE Ioo
CONTACT. PHONE: /y I BUILDING PI7RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG F.CT PLUMB MECH
SS Js ,fib� 4 ZSI ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I heathy affirm that I am licarcoad under provisions of Chapter 9(commencing
Oa1L with Satinn](JIN))nfDivisinn Ldthe Business and Pmfeszions Code,and my license is R ID NTIAL'
won PERMIT ISSUANCE
F,= in(ull fnnecundertecl. ❑SFDWI. ❑KITCHIiN REMODEL
FoFuU License Class Liwp APPLIANCES-RT:SIDFNTI Al. ❑ADDITION ❑PLUMBING RF.-PIPE
t Zul Data- Coamcor
lr.0y ARCHITECTS DECLARATION PANELS ❑MULTI-0NIT ❑MODIFI MODIFICATION
vJ>> l undetstumdmy pltens shall bameduspublicrecordx MODIFICATION
n50 G UPT0200AMPS
OR�J ,✓ ❑INTIiRIOR El CHIMNEY REPAIR
Fs.�1dFqz� Licensed PoWe"inal 1 201-I IXXI AMPS IMPROVEMENT C]SW I M MING POOLS
OWNER.DO LEER DECLARATIONElBATH REMODBUREVAIR O DEMOLITION
1 herehy of ori 11m1 I ten exempt Iron the Contractor's License Low for the OVlilt IIIOOAMI'4
i00i55��O y U following mason,(Suction 7131 5,Busirm,and Prnfossions Code:Any city or enuntYSIGNS EhI?CI'HICAL C]09'HL'R
E' which requires m permit to construct.alter,improve,demolish,or repair any structure
O prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIALCIRCUIVMISC.
�y striate licwsedpummnnnthcpravisiomafthaCnmrvcmr'sLicenmLaw(Chapter9 COMMERCIAL:
�IYQD (commencing with Section 7(XXnof Divisinn 3 of the Business and Professions Cartel or TEMP.METER OR POLE INST.
0,y e yv shut he is exempt rhere(rom and the taxis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLI'1'[ON
bull h Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT '' ,❑`FO,ODSERVICE
t mom than five hundred dollars D%fi. IMPROVEM�+l�KK1�T/
^=Q ❑I,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECf ❑OTHE`R
RIC �'J4
F-. will do the work,radiational..is not intendaro
deffered forsAle(Sca.7044,Business J y�
3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FI%TUR&S
property who buildx or improves thereon,and who doessuch work himself or through NEW RESIDENfIAI.ELELTR SQ Ff.
his own employees,provided that such introverted,art not intended or offered for SQ.FT.FLOOR AREA SISQ.14.
sale.If,however.the building or improvement is sold within one your of completion,the
owner-builder will have the burden of Moving that W did not Wild car improve for Pur-
Pact of ta]c.). TOTAL: r I D
❑I,as owner of the property,um exclusively connecting with licensed cuntracmn to
construct the project(Sec.7014,Business and professions Cade:)The Contractors Lk p/
cense law dies not apply to an owner of property who builds or improves thereon,end QTY. PL�YIBINC FERMI, FEE JAN .F "aa•, ��rD
who contracts for such projects with a contmctm(s)licensed pursuanOons,Comnnnr's l rl a `p
License I.a, FERMI' IS.j,ANq.
I am exempt under Sec. .B&P C for this reason
ALTER kgAINk VIi I A + rlips IDI
Owner Dater''� :z ap-
WORKER'SCOMPENSATIONDECLARATION BACK FLOW PRO[ECT D13VICE / ^ OAtiw�/
I hffi
ereby imunder uter panel(,of perjury one of the following dechroduns: LLJGN/
❑ Ihave andwill malntalnuCcrtilicateofCnnscntm saff.mute for Worker's Compen- DRAINS-PIAOR,NOOP,AHIIA,GOND. 4FEE
'I'VPI3 CONSTRUCTION
smion,as provided far by Section 37(X1 of Ilse huhm Code,far 0r.perfomtance of the
work for which this permit is is.menl, 1'I%'flJltl?S-I'131t'1'RAP
❑ I have and will maintain Worker's Compensation Invuranee,us requited by Section GAS-IIA.SYSTEM.I INC.40UTLETS
3700afthe calm,Cada,fortha performance afthe work far which this permit is issued. P APN
My Workers Compensation Lnsumnce corner and Policy number are: GAS-ITA.SYS'I'FM-OVER 4(HA)
Carrier: Policy Na:
CF.RT'IFICAFF OF EXEMPTION FROM WORKERS' GRCASE/INDUSTRL WASTE IN'fENCF.I'TOR
COMI'I,NSAFION INSURANCE. DI ,DMS )N PIAiS
This section need not be completed if the permit is forone humdondakirs(1100) GREASE TRAP
or lest)
Icertifythetinthe perfordderearOhework forwhich thispermit is issued,Ishtil SEWER-SANI'T'ARY-STORM EA.20(1 FT.
Out employ any person in any manner so as to beeome cAjceuo the Workers Compen-
Z ,anon Luws of Califam..Dam WAFER HEATER WNENTIELECTR
z 2 Applicant '
NOTICE TO APPLICANT:If,utter making this Certificate of Exemption,you should WATER SYSTEMRRHATING
(-' ^ become subject m the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. WATER S12RVICI:
PAID
CONSTRUCTION LENDING AGENCY NEW RP_SIDENHA1.PLMB. SQ.FT. pate Heccipt p
V0 Ihereby a(Brnthmthere iso construction lendingagency for tie performance of
the work for which this permit is issued(Sec.3o97.Civ.C.) TOTAL:
0F" Lenders Name TOTAL:
�a V Lenders AJJno BUILDING FEE
1 certify that I have rated this tepplicmian and sum that the Above information is
t..th correct.lus=to comply with all city and county ordinances andsmte laws relating to QTY. MECHANICAL.PERMIT FEE SHISMIC PER
LJ 4 building cnnswction.ind herebyuuthnriurepraeninivesofthis city to enter upon the
above-mentioned popery for inspection purposes. PERMIT ISSUANCE ELECTRIC PEE
(Wo)agree to cave,indemnify and keep harmless the City of Cupertino s against
liabilities,julurems,tests and Move,which"my in any way-came against said City A 1.1 HE OR ADD'I'0 M HCH, PLUMBING FEE
in consequence of the gmuar,of this permit.
APPLICANTUN B fA )S AND WILL COMPLY WITH ALL NON-POINT ABR HANDLING UNI'I'TO 100M CEM) MECHANICAL FIM
SOURCER I S
AIR HANDLING UNI'I'(OV13R 111,1X111 CPM) CONS'1'kUCTION'1'AX
Signa pMl' nm .ontmw,r Date EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FIiE
I AF.ARD1 . MATERIALS DISCLOSURE.
Will the applicant or future Wilting Occupant store or handle hazallous material LEAFING UNIT(TO I(X),IXXI ETC)
As defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.010 81 U)
Code.Section 25532m)'f
❑Yes V17NI II,AI'ION FAN(SINGLE RESID) PAID
Data Receiptp
Will the applicant or future building Occupant use equipment or devices which BOII F.H-COMP(JHF OR I Wpp BTU)
emit huzudntantamount,us air tantamo ,as defined by the Bay Area Air Quality Management TOTAL:
District? ���/// BOILER-COM P(OVERBill BTU)
❑Y's
NNa
I Wvc rad the Invention, requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE ,
fomite Health&Safety Gsle.Sections 25505,M533 aml 25531.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.Ff.
building drat not currently have u tenant.that it Ls my mspoostbility n nntify the Occupant
of the rgeireinents which must W met prior to issuers ofa Certificate of Occupancy.
Owner or authorized agent Data TOTAL: I ISSUED BY:
OFFICE