00050090 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q �QQQ n
CITY OF CUPERTINO BUILDING-ELECTRICAL T.iM,I NO 1I' n
APPLICA'f10N/IaF,RMIT PLUMBING-MECHANIGV, pppM
BUILDING DIVISION BUILDING PRf3JXPADENTIFICA'1'HIN
BUILDINGADDR1iSS,. SANITARY NO. APPLICATION SUBMITTAL DAO
Z (y' !. - 2-
OWNS 'S N ME; ONii CONTRA R'S NAME: I,IC NO:
kka NIC C/��CO/NI/ROLA
Cfll :CI'/ENGI 'ER L CSS: ❑ / y 3
C( A : •) 1 ,- BUILDING PERMIT INFO `fl
❑ Consullanl Fees Pail by Applicant(Initial) HLDG i'Lli(1 I'L13 MIi�CFI
VIJCB�NSIiU COM[NACIVOR,'S UECLARA'1'It)N QTS'. ELECTRIC PERMIT PEE 1DJ/ LJ LJ
I nenenr antrrn mat l ata Remn.ed ander pnwisiamx of chapter 9 e...... ting JOB DESCRIPTION
�d'OO Z withSection 700Tm Oivision 3ofthe Business and Professions Craft. PERMIT ISSUANCE e.and my license is ):Nf TIAI,,
W
�1 F' in full lirrce:nW effect. SPDWI, [IKITCIIIiN REMODELaUU License Class Lim.a pPPLIANCIS-RIiSIOENTIAL ❑A DITION El PLUMBING RI:PIPE
F�Z W Dae Commeun
m6a ARCHITECPS DECLARATION ❑h1Ul.Tl-UNIT ❑STRUCI'11RA1.
PANG S h10DHTcxTION
OZ=z I aodemmral my Plan Ball hewed:mpuhlierecnrdx
UP 10 200 AMPS
❑IN'ITPull ❑CIHMNEY REPAIR
Llcmhmd prom.....nul 201-1000AMPS IMPROVPMENT OSWIMMING POOLS
AYE; OWNER-BUILDER DECLARATION GVHR 1000AMPS ❑HATH RFMODFURITAIR ❑DEMOLITION
FC C Q I nearby a1Enn that 1 at,,exempt from the Con,annr's License Law handle
%OaU htbwir,orawn.,Section 7031.5.Busincsx and Pnnessions Carle:Any city or county SIGN5 ELECTRICAL. ❑OTHER
at 3 4 y which requires a permit to construct,altar,improve,demolish.or repair any xwclore
prior to it,isxmmcc.olso requires the uppl'mu Ilm,v,h parmino lileaaignedxtamnent SPECIAL CI RCOI'1'/M
CL y that he i%licensed Pursuant to the provisions of the Commetors Liceme Law(Chap,r9
DO (unnnhencing loath Smtion 7fNN11 of UivisiommJnbrie Business and Profuseinm Code)or TEM P.MILIIiR OH POLI?1 COMMERCIAL:
a m e C that he is exempt thmcfrom and the basis far the alleged!.tempora.Any violation of ❑NCW BLDG/ADDITION ❑Ill?MOLITION
Www Section 9031.5 byany applicant born permit subjects the applicant a civil unally.f POWER DHVICIi5 ❑TENANT ❑FOOD SBRVICE
not more than five hundred dollars(S5(0). IMI'ROVIiMIiN'1'
=Q �1,ax owner of the pmpeny.or mYcmployecz with wa8es as thcirmlccmnpcn%atit)n, SWIMMINGPOOLHLECTRIC
F will Jo the work and the shmcturu is not inicnJW ondTcmJ for xmJclSec.91114,1imxines% ❑OTHER
a 3 5E and Professions Code.Tim Contractor's License Law dues not apply to an owner of OUTLETS
propertywilt)built[%or impravca thereon,and who coax such work himself m thrt)ogh
his ownemployees,planned that such improvements ate not intended or aRcreJ for NCW RF_SIDFN'1"IAL IiLECI'R I .
sale.lhowever.the buildingorinpmscmoalx sold within one year o(c:mhpletit)n,the SQ.17.Fl.IIOR�ASR[:A IT.
S/SQ.
ownertmilder will have the burden of proving that he did not build or impose for pun-
pas sale., TOTAL: VVV VVV
s manor of the pmpeny,em exclusively amtmcting with Iiccn.aJ amaumna m
ms;to,,the protect(Sat,7044,Buxinc s and Padcssions Cade)The Cnmiaaors Li-
cense hwJoss nm apply to an owner of pnmrytny who huilds err improves thereon.and QTY I,IJMB ING PI3RMI FEB
who ronunnx far such projects with a conlracturl licensed pursuant to the Contractor's
Liver-Law. PBRM IT CF
lam exempt a Seca &P C tophi ream
'I) 01
ALI'HR-DRAIN&V -WATIiR(EAI VAL I%TION
Owner Dove ��j
WOR IBR I cGMP' SAT U[-IARATION BACK FLOW PRO'l DEVICT S VV`k
IM1ertbY aRrm pads ia�a ,perjury oneobthcft)llnwing Jwlaaionr. JJ
k]Ihavc unJ will maimnirx mticaIc of Comemtoself-insure for Weaker's Compen- DRAINS-FLOOR.ROOF,ARP.COND. STORMS 1"YI'Ii CONS"THIICIIO!
varum.as povided for b��m 3710 of the WMu Code,far the psolunproce of the
work far which this perhit i.issued. Fl%TURIS-1'ER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section GAS-EA.SYSTEM-I 1NC.40 E'.
31(0 of the Labor Caie,for the performance of the walk for which mi%permit is issued. OCC.GROUT' MIN
My Worker'x Compansmion Inxaranc.cartel and Policy mother are:
Carrier. Policy No,
: GAS-CA.SYS'TEMOVIiN J(GAL
CIiRTIFICAI'HOFFXEMI?ION FROMWORKFRS' GRfASIJINUUSTHh WAS"1'IiINI'IiRCli14(l
COMPENSATION INSURANCE It 1. GI3I VISION I:L'i!S
IThissccdonnenl nn lure.... mA iHhe permit is for one hunJmd Jollvn(SIO(p GRIiASII'fRAP
a kss.) I'LANCIICC 'iii �
I certify that in the Nrfmmanee of the work for which thi%permit is i%sam.l shall SEWER-SANITARY-STORM HA.21X)FT. I
not employ uay pecan in my mnunner so as to beannc.,object to the Wnrkccd Compnt- ENRRGY I
Z srdion Lux,of Cul;mpnia.Data WAIF,R HEATIiR WNEhT/ELECfB UI E
ZApplicant _
y NOTICE TO APPLICANT.If,after making this Certifier,of ExemMmn,you should WATER SYSTEMYIRF.ATING SOI
a ? n aame xw,jceno the Worse.%Compensation pnwtnlons of the Labor Cale,you mart
r forthwith comply with such provisions or this permit shall be deems!revoked. WATER SERVICE
y O
CONSTRIICf10N hENDINGAGENCY NIiW HI151DIiNfIAt.PLMIi, sU n'' PAID Date Receipt#
UO ILcmhynffirm that there i.a construction lending agency for the Performance of
the work far which this permit B issued(Sec.3197,Cm C.) 'I O Al..
I
Q F-' Lemba,Name TOTAL:
LcnJcis AJd¢c% BUILDING FEE
P: 1 ccnify that 1 have read this applieaina and sate that the above information i,
.. to , reit.I agree to comply with all city ad caco,ordmorma%and srce laws muting it) QTY. MECHANICAL PERMIT FEE S171SMIC FEE
C,)'z, building mnnrvminn.and hereby authorise mpreacmmives of this citymrn,r upon the
nlervomemminal property far m1pemion parymsex. PI?HMI"[ISSUANCII ELECTRIC FCb
(We)agree to save,indemnify and keep hunches,the City of Cupertino ItIl
himilitiee,judgments,coxa andexpense%which may in any way scenic agami,sad City ALTER OR ADD TO MECH. PLUMBING FM 7.
in con"tacrce of me granting of this permit.
APPI-IC UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO 10.00 CFM) MECHANICAL FEE
SOU FRIx Ull IONS. /' J UV AIRHANDLINGUNIT(OVBRH)k00)CFM) CONSTRUCTION TAX
natu,o A ontmemr J Da U V E%HAUST HOOD(W/DUC[7 HOUSING MITIGATION FEE
HAZARDOUS MA'I FRiA 9 DISCLOSURE
Wi capplicatorfutumhuildingrccupanhs(cmorhanJ(chuallousmaterial IIEATINGUNI'rD I(XLIXNIB'TU)
us dapmeJ by the Copedina MI al Calc.Chapter 9.12,and the Health and Safety H:,APING UNI',(OVER 100,000 B U)
Cover Section 5532m)?
❑Yes ❑No VENI'lLATIONFAN(S1NGLERESIDI PAID Un, Heceipip
'y Will the applicant or floor.building occupant use equipment or devices which BOILER-COMP(311P OR 110,0X0 B'I'ID
a hacndouv ser conmminons as defined by the Be,Arca Air Quality Management 'TO3'N.:
Distinct f BOILER-COMP(OVER 100,000 BTU) O
❑Yes ❑Nu
I have awl the humdnue n odic s requiomente under Chapter 695 of'he.Cali- AIR C(INDITIONER ISSUANCIi ATI:
fornia Health&Safety Code.Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MI:CH. SQ.I71',
buildingd:np,, Ileaready hnvcn lc ant,that it it my respnnsibilitym notify the occupant64,
J ^(
of a ,JM1,ems nth mash et ,%a:mce of.emir 'r�c< c.
( ram/' agent
.S Dnt�c T(T[Ah: LtiSl1EU ItY:
�_� OFFICE