S 1869 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITV OF CUPERTINO BUILDING-ELRCTRICAL PE ITNO.
BUILDING DIVISION APPLICATION/PF,RMIT PLUMB ING-b1RCBANICAL 1869
ITUILDINI:1'RfIJP:CT IDEN'TIFICA'1'IDN
BUILDING ADDI213SS: SANT FARY N(I. AVPLICAI']ON SUBMITTAL DATE
les-S-41-1S a _ I -( X1 -`1
(W HR'S NAMI?:. CIA.",: CO "RACY k'S 7H:
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NIC CON'1'ROLN
• A I IECf/F C .I? T N A ORLSS: ^ ❑
4AVfwi
CONTACT: PHONR: - AUILDING PERMITINFO
• u-L� Y� 3 �JL
EI Consultant Fecs Paid by Applicant(Initial) Bliley ELL❑l PLUMB ME❑CH
�+ CJ
IJCF.NSIiD CONTRACT'OR'S DECLARATION QTY, I71.ECTRIC PERMIT FEE
1 hercny affirm that I our R,enaed under provnn.0 of Cham,!9(........arcing JOE DESCRIPTION
OIYZ with ScOi n'l0(Xn ofLovislon 3ofthh Business and Profesions CsNe.and my license is RESIDENTIAL
Fob in full tome anJ ellen. PFRMH`ISSUANCE
W� ❑SFDWL ❑KITCHIr.NRSdODHL
�UU I,iccmc Class Lic'M API'I,IANCF$-I<li$IDIiNTIAL ❑ADDITION El PLUMBING RE-PIPF,
N¢a Dae Contract.,
�H ARCHITECTS DECLARATION PANIi1S ❑MULD-UNIT ❑S'I'RUCIURAL
ZOO1Zz i understand my plans shall be used an public records MODRECA'1'ION
oz-O UP TO 200 AMPS ❑INT17RIOR ❑CHIMNHY REPAIR
I:.4 F-u1 Licenud PpdR,, m.I 201-1009AMPS IMPROVEMENT QSWIMMING POOLS
x St7, OWNER BUILDER DECLARATION OVER IOfN1AM1'S ❑BATH kF.MODF:IBEPAIR ❑DHMOLI'I'ION
C C� 1 hemhy nffmn dmt I.m seennpt front the Contrumor's License Law far the
xx� a U fallowing reason.(Stan,,.903[.5,11 are,,and rrnfeesions Code:Any city or county SIGNS RLECI'RICAL ❑DTI IIB
W O~ which requims a Permit m construct.alter,improve,demolish,or repair any structure �L.( I
priest it,i,rarccaka rcgmms lac npplicanl for such pc.iva Clc a signed Inurement SPECIAL CIR(UIUMISC.
a1W Thu he is licensed pit.sunm In the provisions of lbs Contrucmr'x Liccnsh Lnw(Chupt,r9
.5 (commencing with Section 700B of Division 3 ofnhe Business and Pmfessinns CMe)or '!EMI's MFit LIR POLI:INST. COMMERCIALL'
11 ry o C What he is oxmnpl darefrnnr and she nus.for rbc alleged exemption.Any violation of El NEW BLDG/ADDITION ❑OUNIo.1'rION
X II. Seelioll 91131 5 by any ap,lknm tarn pastil sunioms me applicant to a civil wndtty of POWER DF,VICHS ❑TCNAM ❑FOOD SERVICE
�..� nor more than five bendred dollar(E5Bo1.
FZ} OTIIhR I3MIiN'f
Q ❑Ido the werofmc property ormyemployees with wages
uaak(sole 044,13omes, SWIMMING I'(IOh ELECTRIC
cc
wall Jothework,ande he Contract t,Licensencerakd La doss,,,e(Seh.IIW4, wain of �GTIIHR
Ia]�� and 1'rofessinnrc CMC:The Cmm�mnnr's License Law docs nal apply m un owner of OU'I'1.13'I'S-SWI'I'CHHF-FIXTDItES
�"3 pmpcay who builds or improves thereon,and woo dies such work himself or mmugb
his own omployces,provided that such improvements are not intended nr offered for NEW RESIDEN'I'[AL CLI!CTR SQ It.
,dr.It.howev,,the building or oupr c,rent is sold within one year of ronnplelinn,tit, SQ.FT.FLOOR ARRA S/SQ.FF
er-builder will have the burden of proving than he did not build or improve far mr-
pwc of sale,).
❑ I,as owner of the properly,at,exduaivaly,thirsting ,In IlccnsM contractor In 'TOTAL:
Instruct Ise project(Sea.904,1,Business and professions Code:)The Contractor's I,i-
verse Law does not apply manraw net ofproperty who builds or improves thereon.and QTY. PL NC ERMIT FF.E
who contracts tor such projects with a contractors)licensed purnnnt m um Contractors
Lice.'r law. PERM II'ISSUANCE
❑1 am exempt under Sec. .B&P C far this reason
Owner DateALTIiR-DRAIN&VE W I?
- R LEA) VALUAI[ON
WORKERS COMYENSA'1'ION DItCI,ARATION BACK FL 'NO SCI'.UIiV 'li
I hereby affirm under Penalty of perjury one of the following dam
ludrts
o :
❑ IhuvenadwiP sintmaCcuilichinafC...ocminxclf-inxuc La Waders Compen- DRAIN -FLOOR,RO KAREA,GOND. BTDk117F 'TYPE CONSTRUCTION
suits,as provided for by Section 391X1 of We Labor Code,for the peri'onnature of he
work for which nail pernal is issue, FIXvvRRS-P P
El 1 have and will maintain Wooers Compensation Insurance,an required by Sectio I
39!X1 of the Labor Code,no performance ofthe work for which this"no is issued. GAS-PA.SYS,11: '.401 'NETS OCC GROUP MIN
My W'orkces Compensation Insamace carrier and Policy naubcr a¢:
Carrier: Policy Nn.: GAS-EA.SYSIt l-OVER4(F )
CHKOFICA C,OF HXF.M II'ION FROM WORKERS'
COMPIiNSATiON INSURANCE GRHASI/INDUS'TRL WASTE IN'I'ERCEr1Uli
BUILDING DIVISION PEI?S
(This seninn creditor be nunplealBite Mnnit is!shine hundmldullars lSIPILL GRIiASE TRAP
nr lees.) I'LANCHI?CK FEE
I itudy that in lheperfonnarceofthc wmkforwhlch lblapnovit is Issued,l shall SFWiilt-SAN]VARY-STORM HA-200 FP.
nnl employ any person in any manner w as to beemne subject an the Wore
kr'Cnmpen- HNERGY FEE
zZ sant..Lawn dGalifomia.Dec WATI7R DEAL FR W/VIiNT/ELIiCTR
Apph,an GRADING FEB
N NOTICF TO APPLICANT:If,after making this Certificate of Esempnin I,you should WATIiR SYS'I17WMEAI'ING
-F become subject to the Workers Connpemmtion provisions of the I.ahor Cale,you imus SOILS ITF,
try firolwllhconnply with such pno,kinnxmlhlspemt,shall be deennedrev..kind, WALL HR SERVICH,
aQ
Z
CONSTRUCTION
ommNDING/sCENCY NIiW RISIDIiNf1AL PLM1I9. SQ,Fr PAID
� Iberal,y arrtrm tam ma
ere Ll , octnnanmeda.le.ai��g agency forme phrh,rnnan,e of Receipts
U 0 the wmk our which in,Permit is i...ed(See.3(199,Civ.C.)
0 � Lender.Name TOME:
L) Lender',AMrese TOTAL:y �-�-j n�i eertily d al I have read this ap,Iicatlnn and oboe Nm himubnva imormntiott is BUILDING IT ( V O
rn correct.i agree to comply with all city and county ordinances and snare laws relating to Q'I'Y. MECHANICAL PERMIT Illi
U Z building contraction,and hereby authorize representatives ofthis city roenterupun the SRISMIC PF.
above-mendosal Property far inslmmion purposes.
(We)ug.It save,indenmily and kccp.armless the Cltyof Cupertino again,, PEItMI'I'ISSIIANCP. I?LECfItIC FEC
liabilities.judgntens,cnasaadexpcnses which may in anywayaremeagainxr said City ALTHR OR ADD TOMECH,
nsegnench of Inc granting of this permit. PLUMBING FEE:
APPLICANT UNDFRS'I'ANDS AND WILL COMPLY WE 111 AL1,NON-POINT AIR HANDLING USE,(In 1(),111X)CPM)
SOURCE REGULATIONS. MECHANICAL FHI!
AIR IIANDLING UNIT(OVER 111,00X)CPM) CONSTRUCTION TAX
Signature of Applonat/Comaunr Date EXIIAOST HOOD(W/DUCT) HOUSING MITIGATION 193E
HAZARDOUS MATERIALS DISCLOSURE
Willrhe uppliOnlnr fumrc buildin,ov,uLan nem or huttdle haznnker,mmerld HEAPINGLIN r(TO 100.000 BTIB
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Hetdlh and Safety
CMG.Section 25532(,):' HHA'IINC,UNIT(OVER I do 000 BTU)
❑Yen 7N LAID
VI?N'I'IIATION PAN(SINGLE It13AID)
Uulc Iicccipltl
Will the applicant or future building ed by the
use equipment.ArQuor devices emich
emir hazardous an crmamtnants us de0ned by me linty Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) �O
DislrenI TOTAL
❑Yes ❑No NOII.RR-COMP(OVIER 100,000 BTU)
AIR CONDITIONER
I hath SafiC C(arduwmammdxrcga5533an under Chapter
rstadfthehat Call- ISSUANCE DATE
f.miagdnith octorSafety Cale.Salines255115,2553?and25514.1 natsmnd.hal if the NFW RLSIDENTIAI.MECH. SQ.F1'. �I i/
buildingdtesuent,which have a mnann,that,,iemymeponsbiliryronuifyccpceupnm ( 11 l/
of lite requiretnenta which most hit run prior to issumec nfa Cerrificnle of(Ieeup,ncy. _} .ynt
Owner or amharized agent Date TOTAL: ISSUHD BY:
OFFICE