S 1080 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
NG-EL
BUILD
CITY OF CUPERTINO IF.CI'RICAL PF IT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANIctL 1 o Q V o
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANI'IAkYNO. APPLICATION SUBMITTAL DATE
2� c, b /
W v d �
OWN 'S NAME; I HONE: CO RACTOR' 1Ii: LIC NO.
NIC CONTROLM
ARC I ECT/ENGIN.E LICNO, )URFSS ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT PEG JOB DESCRIPTION
1 hereby union that 1 am licensed under provisions of Chapter 9(commencing
"ZO with Section 7")if Division Sof the Business and Professions Cadc.md my license is RESIDENTIAL:
F PERMIT ISSUANCE
I— in full force and effect. ❑SFOWI. F1 KITCHEN REMODF.1.
�UZI_) License Class Lie.# APPLIANCES-RHSIDENI'I Al, ]ADDI'T'ION ]PLUMBING RE.PI'li
P G W Dace C...trnnor
y 0. ❑MULIT-UNl'1' ]sl RUCTURAL
ARCHITECT'S DIiCLARATION
I,-,p y PANELS MODIFICATION
ZOZv-Z 1 understand my plans shall he used as public records
..� UP T02W AMPS ]INTERIOR El CHIMNEY REPAIR
F leveled Profeuional 201-IMMAMPS IMPROVEMENT 0SWIMMING M)OIS
OWNER-BUILDER DECLARATION
hC � OVER IOW AMPS ❑BKfII RI(MODEI/RF.PAIR ❑DEM110LITION
ti k 6 1 hereby.(firm that 1 1. exempt from the Contractor's License Law for the
ip5t a,U which res reason(Scotian]OJ LA t,alm,n.nd P e.defonx Code:Any city os county SIGNS ELGCI'RICAh ❑Oflll?N
W WO F' which requircr a pemtit to eonxlnmt,.tear,improve,Jenwlixh,of rcPnir wry structure
prior to its issuance,also requires the applicant fenuch permit,,lilea,ilond smtemcnl SPECIAL CIItClll l'/h1ISC.
p^�^�m} that he is licensed pursuant to theprovl,.mnsfma Cmunich 's Lactose I..(Chapter 9
p^C�C (commencing with Section 7")of Division 3 of the Business and Professions Care)or TEMP.MITI?R OR POLE INS'I'. COMMERCIAL:
ay oy that he is exempt therefrom and the basic for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
y(^LL
Section?031.5 byany applicant for a peembsubjects the applicant bt a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
W not mom than five hundred dollars(251X).
�Z� I] 1. owner ofthe prepeny,or my employees with wages its their sole compensation, SWIMMING POOI,ELECTRIC IMPROVEMENT
F.MENT
u
will do the work.und thestructure is mulnue ladnr,,Beed for ace(Sea9044.Boxall,, ❑0r
fHEk
and Profession.,Coale:Thu Contractor.,License Law does not apply to an owner oiOUTLETS-SWI"ICHES-FIX'T'URE
n' .. properly who builds or improves thereon,and who does such work himself or through
his own employees,provided that.such improvements am not intended or offered for NEW RESIDENTIAL ELECTSQ FT
sale.If.however the building or improvement is sold within one your of completion,the SQ.FI'.FLryOOR AREA 5/SG.14.
ner-builder will have the burden of proving that he did.nt Wild or improve r for put- A I D
pose c f sale.). /
❑1.u owner of the property,am exclusively contracting with licensed contractors to l'
ns14,
numeral,the pmjact(Sec.7W4,11....assault Profession,".1,the Cnntr.cl,,r's LI- OCT ^8 REC
see Law does notapply m an owner of proPcny who huuds or improves thereon,and QTY. PLUMBING PER I' - E
who commcts-for such projects with a emarecnnr(s)licensed pursuant to the Contactor,
License Luw. PERMUISSUANCG
I CI-fY Ur wrthlINC
am exempt under Sec. .B&P C foris rcaen
tho
ALTER-DRAIN&VENT-WA'IT,R(EA) VALUATION
Owner Dum
WORKER'SCOMPI?NSA'I'ION DECLARATION BACK FLOW PROI'ECP.DEVICE
I hereby aRnn under penalty of perjury one of the following dcclmadons:
❑I have anti will mumemn a Certificate of Consent oself-i.mre for Workers Compel- DRAINS-FLOOR,BOOPARE&COND, STORIES TYPECONSTRUCHON
,mien,a,provided for by See,...37 W of the Labor Code,for the performance of the
r w
work fohich thin permit is issued. FIXTURES-PER TRAP
❑I have and will.min tin Wallace,Cnmpcnaatinn lot...an,ax mgeired by Section
37M of the labor Cn e,for the peffonn...of the work for whichihik ois i. trod GAS-EA.SYSTEM-1 INC.J OUTLETS OCC.GROUP APNI
My Wnrk<' n e t ,u cel nd Policy or to O AS-EA.SYS'IEM-OVER4(EA)
r, m' h cPolicy Na:
CERTIFICATE :(EMITION FROM WORK:R ' OREASEIINDUSTkh WASTE IN]INCEPTOR COMPENSATION INSURANCE —,' BUILDING ITIS"
GB,isseetion neWnotbeeompleted iftheparmit is fotmehu maddollacs15lo0) GREASE'I'RAP PL
orleu.) PfANCHECK Pule
I lenity that in the performance of the work for which this pemtit is isoed,lshall SEWER-SANITARY-STORM HA.210 FT.
not employ any person in any manner.sa as m bearme subject to the Workers'Compan- ENERGY ITH
Z section Lewsof C.lihmia.Data WATER HEATER WNIiNT/F.LECTR
7�C) A,harm 1 GRADING FEE
q NONCE TO APPLICANT:If,after making this Canticle of Exemption,you should WATER SYSTE tIkEAUNG
(ti became snhjccl m the Worker's Compematlon provisium o1'tlm I her Codd,you must SOILS Il?h
CaLI forthwith comply with such provisions or this permit shall he dcenredm,mk'& WATER SERVICE
d Q
7Z CONSTRUCT a'IONLtion lending agency
NEW RESIDIiNT1ALPI.MB. SQ,FT. PAID Date Receipt#
V 0 Ihereby ikhmi ponaulre issmrt(San.3n Ie. agency fonhe perfoemantt of
F the work for which this permh is issue)(Sec.409].Co.Civ.CJ
� Lenders Name TOTAL.
L) Lender's AJJms, TOTAL:
}ata i certify that I have read this application and stow that the above infnrnmJon Ls BUILDING FIFE
Fr V) correct.i agree In comply with all city and com.y oedinanaus and smta laws riming in QTY. MECHANICAL PERMIT FEE
V Z building constmmion and hereby authorize rtprenentatives ollhis city menwe upon the j SEISMIC FET?
shove"meminned pmpeery for inspection purposes. PERMIT ISSUANCE.
(We)agree to save,indemnify.nd keep h mnless the Cary of Cuptnino ugainv ELECTRIC Plili
res hahilide,,judgmers,costs and expenses which may in any way accme against said City ALTER OR ADD*10 MECH.
in consequence of the granting of this Fall . PLUMBING FEE
Lick
APPLIC T UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO VLSI)CFM)
MECHANICAL PGE
SOURC IF.GOLATIONS. /+
o Alk HANDLING UNI1(OVER 111,111111 CFM) CONSTRI1CfION TAX
LAOJOSI signature oT unl/Cnmamor Data GXIIAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
IIAZARDOUS MA'I ER1ALS DISCLOSURE
WI I t e applicant or future building occupant store or handle latallousmameial HEATING UNI'I'('f01(0.0nd BTU)
as defined by the Cupertino Municipal Code.Chapter 912,and the Health and Safety
Code,Section 25532(a)^ HEAPING UNIT(OVER IW.0%)H'TU)
7 Vex ]Nn PAID
VENTILA'T'ION IRAN(SINGLE It Ii51UT Date Itcceipt p
Will the applicant or furore building occupant use efmi nuent or devices which
emit bazancoos air conmminanta,defined by the Bay Area Air Quality Management BOILER-COMP 0HP OR 1110,000 BTU) ,IOI,AL.
E]yes FIN.OisWct? BOILER-COM V(OVER 100,00)HTU)
1 have read the hazardous materials requirement,under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE UNIT
forma Health&Safety Code,Sections 25505.25533 and 25534.1 mal,nWrd that o the NEW RES11OHNUAL MECIL SQ.EI'.
building does not currently have somal amt h is my responsiNlity nr nsnify the occ.nmt
of the rgaircnicnls which must be mat prior to issuance of a Cen ificum of Occupancy. ��.''',1_/�ryl/�
Ownerorro horiud agent Data TOTAL: ISSUED BY ' 'I
OFFICE