S 0849 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO - BUDDING-ELELT'RICAL PERMIT FO.
BUILDING DIVISION APPLICATIONITERNIrr IsCUNIBiNG-MECHANICAL S 0849
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
lea ich6004d
OWNER' PHONIC CONA E: N(
NIC CUN ROhp
ARCHITECIIENGINF:ER: LIC NO: glll]RF / `f, /� /f a ❑
CONTACT: pen of Pll�o` ` lJL J V '`—• BUILDING PERMIT INFO
-Y�✓ _*'0J/4 ❑ Consultant Fees Paid by Applicant(Initial) BLDG EL?CI PLUMB HCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT FEE
I harchy abrin mat I am BeenserP under provisions r.r enapter 9 mr:mnendng JOB DESCRIPTION
OOO with Seetion]("Bud Divfsmn 3ofthe Bnsinessand Professions Cmleandmy licenseln RESIDENTIAL:
WOO PERMIT ISSUANCE
10 in full force and chem � ❑SPI3WL ❑KITCHI'N REMODEL
�Vp Liccnse Clt hiep APPLIANCES-RESIDER I'IAI. ❑ADDITION ❑PLUMBING RHPIPE
F W Dme- Cnmmmtur
FOh .a, hall he
DECLARATION PANELS ❑MULTI-UNIT ❑MODIFIURAO
Z I undcmanJ my plain shall be u.a•J as hlic records CHIMNEY
REPAIR Zz'y+ pa UP TO
OZI.p ❑IN'I'IiRiOR ❑CHIMNL'Y RI?PAIR
F-.,-I",4! Licensed Pmfezzional 201-10(g)AMPS IMPROVEMENT 0SWIMMING POOLS
t65 ,J OWNER-BUILDER DECLARATION OVER IINXIAMPS ❑HA'I'R REMODIiURIiI'Alk �DEMOhITIf1N
Q I hereby uflinn that I am exempt from the Contractor's License law Lor the
pe,C 6 U following momr.(Section]W 15,Bun imess find Professions Code:Any city or county SIGNS HLEM RICAL ❑OTHER
W 3 W Fa which requires u permit to construct,after,Improve,demolkh,fir repair any zunemrc
0� prior to ib issuance,al.so require,the applicant for such Peoria o file a signed statement SPECIAL CIRCUIT/MISC.
� that he i,licensed pursuant to the provisions ofele Comemon`s license law(ChapterY
,gx (commencing with Scene.7001u,f Division 3ofthe Businersand Professions C<xJGor TEMP.MILDER OR POLE INS1'. COMMERCIAL
III a dx c n that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW HLDG/ADDITION ❑DEMOLITION
W^m
Section 7031.5 by any applicant for a perant subjects the applicant n a civil Penalty of POWER DEVICES
F. not more ❑TIiNANT ❑FOOD SERVICE
than live hundred dollars($500),
d ❑ I,as ownn ofthcpmpeny,nrmyctnpleywxwithwugmnxthcirsalecnmpcnsuninn, SWIMMING POOL ELECT RIC IMPROVEMENT'
wHE Jo the work,and the ameture is not intmtded oroffemd ha vale(Sce.70,14,Business 0 0'1111?k
W3 and Professions Code:The Contractor's License law does not upply to an owner at OUGANS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his awn employees,pmvidcd that such an,rum menu arc not intended lar GTercd far NEW RESIDENTIAL ELEC R S
sale.If,however.the building orimprovement is soldwithin one year ofcompletiout the SQ.FT FLOOR AREA b/SQ.FE
neebuilder will have the burden of proving that he did not build or impose for pur.
pose of sale).
❑I,us owner al the property,am exclusively contracting with licensed cnntracous nn 1i
instruct the pojccl(Sec.7W4.Dunincss n ld i'n mourn,Code:)The Contractors Ll- - '
use Law aces not apply¢swowner nf progeny who nom.nrimproves Neunn,ane QTY PLUMBING 11I3RMIT 'E
who contracts for such projects with a eontmetons)licensed Panama to the Contractor s
License Law. PERMIT ISSUANCE.
I am exempt under Sec. .B&P C fortis reason
ALTER-DRAIN&VENT-WATER(EA7 6—VAI CATION
Owner Dom ✓ J,
WORKE'R'S COMPENSATION DECLARATION BACK FLAW PROTECT'.DEVICE !�2q'
/UO
I hereby aBirn under penalty of l mPaq one of the fallowing declarations:
Fj I have and will maintain a Certificate of Consen0o self-insure for Worker's Compcn- DRAINS-FLOOR,ROORAREA,GOND. STORIES TYPHCONS'1'RUCT10!
sation.as posmed for by Section 3]1X1 of the Labor Cede,for the performance of the
It far which this permit is issued. FECTURES-PI7R TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
00 orthe Labor Ciale.for perfnnnance of the work far which this permit is lssucd, GAS-fiA.SYST[M-I INC.401f1'LITS OCC.GROUP APN
My Werke C .aro n comer and Policy GAS-Iib SYSTEM-OVER Carrier: r n Policy Nn,L�6L111L1-1
CERTIFICATE OIs EXUMI'T'ION FROM WORKERS' CRI?ASI%INUUSTRL WASTEINTL3NCI?ETON
COMPENSATION INSURANCE BUILDING DIVISION PEES
( s union neednot tweamplvuW lithpe
e rmit is fat hundred do][.. GRE,SHTRAP
or IessJThiI'IANCHECK FF.FS
I certify that in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-S'I ORM FA.2W FE
not employ any potion in any manner so az to become subject to the Workers'Compcn- I.N17RGY FEE
0zi sation Laws of Califern Date WA'I'131t HEAFERWNEN'OELFC'1'11 GRAVING FEE
F47 O Applicant
NOTICE TcomTOn m APPLICANT:IP',after making this Cenllicam of faetnption,you should WATER SYS'IEMOREATING 5011 S ITE
h "N" bee subjethe Workersmpen
Cosation provisions of the Labor Cole,you must
foMwian comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
0
Z) z CONSTRUCTION LENDING AGENCY NEW RIiS1UENTIAL PLMO, SQ.FC PAID Data
Heccip M
V Thereby affirm that isacnnswction lending agency fanhe performance of
the work for which this permit is insneJ[gee.P09].Clv.Cd
F Lender's Name AL:
L) Lenders Address TOTAL:
'�•• y I certify that 1 have read this application and state thin fin, cove alinformation is BUILDING FEE
F
VE correct.l as.to comply with all cityand cauntymiinance,malmlichma Main,In QTY. MECHANICAL PERMIT FEE
V z building conaoctian,andncrebyumhodze reptesemativexafthis city memerupnnthe SEISMIC FEE
above-mentioned progeny for inspection purposes. PERMI"I'ISSUANCE .5
(Wed as=In save,indemnify and keep harmless the City of Cupertino aguimt ELECTRIC FEE
Iiabilitiez,judgmctns,costs and expenses which may in anyway accmc ugainst said Clay ALTERORADDTOMECIL
in oonsequmme of the ,,ailing of this permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WE LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I(ITS,CIM) MECHANICAL FEE �•
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of ApplicantsCantrector Data EXHAUST HOOD(WMULT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oceu,nmonma,a Ile hazardausmana ill HEATI NO It N IT(10 I W,IX01i'1'U)
as defined by Ina Cupertino Municipal Code,Chapter 9.12,send nhe lealth and SaIrm
Code,Section 2.5532(691 HEATING UNIT(OVER 100.00 BT1p
E3 Yea Nrvo VENTI LATION FAN(SINGLE REMIT) PAID -
Date Recital#
•
Will the applicant or future building occupant use equipment or devices which
emit hamrdous air contaminants as defined by the Bay Area Air Quality Manmgement BOILER-COMP(JHP OR 100,000 BTU) TOTAL:
Dlsaictl
❑Ye, JIN�n BOILIIIt-COME P(OVER 1110,1011 RTI])
I have mailthe nazvdous materials rcquiremenFc under Chapter CONDITIONERr 6.95 of the Coli- ISSUANCE AT,
forma Heahh&Se!ry Code.Sections 25505.25533 and 5534.I undcound Nat if the NEW RESIDENTIAL MECH. SQ.PT. /r Z4
building d«s nm yharcatenant.that it is my responsi1d1uymn flydn,Ncu t C
of the a hmust he t stn i'manceofa Cen' fOc
cairn � �
Owe uullhni agent Dam TOTAL:14/
O IS91JIiU ItY:(,r� _- O
OFFICE
or No j _._ ..
CITY OF CUPERTICAP. l++ 7.�
. 1
APPLICATION FOR BUILDING PERMIT 1111 EE
9e:ldmp De Notwo elm-/
AppLcalma is he.eby made for o permit to-_I�eyy'elr/e/r'
t a . 51ory _.�_ee-`�s,'r�'� " --Slru<ture
i�
t W to bE,orcmed only,as ;d�t.YM_ �-i�"'��� �---in accordance wdh
a .
.n1am.9peiih�alrogY�nnd,V1ot Plan.filed herewith.
Fsnrdered Mplve of lllt. 11sxnenis'S-�i� s
p O N p hr ef5y opfeµs rhos Jlte requlraments of the
l?.� erem ,d Zot>4dinaricm and all —�-'
e"a�htsr I - Ms_j J}f}a aensiioclton location,and Total Fee S,4
7. �,3Yre'I ' dl nhin the City of Cupertino.will be
� s
z tamp i iy�Ih/ r r , '
Y t�i �ST;NFR r {� PHCtJE
A NESS
AGENT
r WADING IN5PECTOe j
rN0'N�i - TAfEIICENSE
a `�•r i
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l:
Y '� tIl .. _� p�•a•aty.N�� — ..
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r: y`6i•Fv °+tsx,,&s 'u at c e
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ApplFcatbn ,a heTaby'tnajb toflue G+y ai Cuperltrw 6PE and
p MKwll wid
wiring assd)ar Fietwes ae liNwd all.tlse'1 Tlde r .
prlcb. 00 E1601
.iHt'.th�•ptoE1601" Csdo a{ Me
wiring and/or fixtures in Otxard
nbr and all other tams16
r
Addrw `
Stew 1W«.e rorT. -. _...- ,1WWP:•syd- ...-
A :eEe f vvtlt NOT vHCIAR 00 to I"*Ocd x P.1 Baer (f
��tMrrNSATtLri�I t"WS CO "" STAT'q 00tAtsPi�eNta f
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