S 2148 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUItA1NC-F.LH(.TRIGL 11. °"° 2148
BUILDING DIVISION APPLICATIONAMERMIT rl.uhtBmG-bnEBAN1CAL
BUILDING PR(IJ 1!CT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'I'LU.DA'I'I
OWNER:SNAME: I IONEE / CO HA OR'SN ME: .1 0: ._
y N/C CON'I'ROLn
�1ARCHI'11iC1'/ENGINEVR., I.1' O:` AD It IIS: ❑
CONTACT': den ay Cle ///''',,,,,,,_��,...a, I'IIONE: BIl1LDING PERh1IT INFO
ITGe/ ^� ❑ Consultant Fees Pail 6y Applicant(Initiap ul❑DG ELECT Pu1M7y M TCCH
LICENSED CONTRACTOR'S DECLARATION Qry EI.IiCTRICPHRMIT rl:L rLIJI
1 hereby affirm that I am licensed tinder provisions of Chapter 9(commencing JOB DESCRIPTION
Metz with Section 7")of Ditmen Sof the Business and Professions Code.and my license is RESIDENTIAL:
Foo, in full force and eft PERMITISSIIANCE
�J ❑SPUWL ❑KITCHEN REMODEL
�UU Licunnc Clnrh Lied 72 APPLIANCES-RESIDEN'I'I Al. ❑ADDITION ❑PLUMPING R+LP[PH
til DaterCnnmmlm��
o,<a ❑MUUTFUNIT ❑STRUCTURAL
so, ARCHITECT DIiCLARATI N
FyZ I understand my plans.shall be used ns public records IANCIS MODIFICATION
UP TO 200 AMPS
OZ�� ❑INTERIOR El CHIMNEY REPAIR
r1fiej Licensed Professional NII-1000AMI'S IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DCCLAIIAHON I1VI3R IIIIl11AMl'S ❑BAIT k iMO +IlRll' IR DEMOLITIO'NJ
C 1 hemby affirm that I am exempt Into the Conlran a"License Law for the ❑RXIOff HR ON
X 3 a U following reason.(Section 7031.5.Busim—nd Professions Calc:Any dO a e...B, SIGNS F.LIif.TkICAL l �L
LL vFi which requires a permit m con arutt,alter,improve,demolish,or repair any.aacwre j a A Xy
prw,to in m terrace.also requires the applicant for such pknotto rile a signed statement SPECIAL CIRCUITIMISC. g��W�
Y`I Thal he ix liccnwsl pursunnnnthc provisinm nfthe Gmea.mr'a License l.aw(chapter 9
tfY� Q� (coo none ing with Semtan 7000)or Division 3 oldie Business and Professions Cadu)a TEM P.MH I'EIR OR POLE INSI'. COMMERCIAL:
that he is cscmpt here] band the basis Iia the alleged see Bide.Any vitalmic n of ❑NEW BLDG/ADDITION ❑DEMOLITION
IfilG LLrn• Section 9031.5 by any applicant for a Permit subjects the applicant to a civil penally of POWER DEVICES 0TONANT ❑FOOD SERVICE
not mare than five hundred dollars 1$501).
IMPROVEMENT
Q ❑ Lottie work,the theSley,annyemntendedwithwagesas[hcipose.mm,Hu,ionn, SWIMMING P(X)1.ELECTRIC
Q ad lo,work,Code.The C tis net intended Law
i...aloft, t,in littvinesa ❑O'fHl?k
m and
property
whians Cale:'rbc Contractors Lnit , Low anus nal apply m tat owner nI OUTLETS-SWITCHES-IlX'I'IJItES
�' .. property whp bulls,or improves t such ,and who does recti wnrk intended
or'or through
salown employees,the pmviJcJ that such mold i,cment are not im.1111 or tlfered for NEW RESIIlfNT1AL ELfCI'Ii SQ IT.
sale.If Nm'o'er.the huilJin6 nrimprovemem is sold within oncywr nfmmpldin4 the SQ.Fr.FLOOR AREA ASQ.lei'.
ensmer-budder will have the burden of proving that he did not build or improve for pur-
pose ofsale.).
E3 L ax owner of the pnsiwny,am cxdmivdy"atod"ln,with licensed cuntinier to IfIIAL:
construct the project(Sec 844,Business Emit Professitns Code:)The Commcmr's Li-
uLaw does not apply it)an owner of progeny who builds or improves increase,and QTY. PLUMBING PERMIT FIiF:
who nems,for such pmjats with a enntmmm(s)liccnud pursuant to me Contnemr's
Lica cLuw. PERMIT ISSUANCE
❑ Iran cxwnpt under Sec. .B&P C for this reason
Owner Dam AI.TP.R-GRAIN&VENT'-WR'I'ER(M) VN.UA'I'ION
.
WORKER:SCOMPf:NSAr,on DECeoul to ing HACK RDW PR(YTF.CT.IIiiVICO
1 hereby afBmt under pcnahy of Inrjury one of the 441twing tledaretiom:
❑ Ihaveprovidlm.inwinaCed 3700 of )onuntoCode,sate for Worker'ser or
DRAINS-FLOOR,ROOP,ARIiA,GOND. STORIES TYPE CONSTRUC'r1ON
' station,ii,provided far by Section AlN]of the Labor Code,ITrihe per[nrnwnue of the
Mer'which this l enrol is issued EI XTURFS-1'IA TRAP
heve anti will maintain Worker's C.ntpcnsal inn Insurance,as required by Section
t the LaborCoJe.on the peromtuneenf the work for which this Permit is issued. GAS-EA.SYSTEM-1 INCA OUTLETS OCC.GROUT' APN
Caymennui nlnsumrnrie�elmy Nv loftlteR/ GAS-EA.SYSTEM OVER 4(EAI
CEI TII+IC OFONINSURANCE
WfIItKEkS' GREASEINIBUS'FRL WASTli
CO(IMPENSAIA'1IN'I EIRCEI'TOIt
'ION B1111.U1NG IYIVI9111N NIiNS
(]hissection need not Be complGed if the permit is far one hundred dollars(51 can GRFASETRAI'
or less) PLANCIIECK PEI;
Icenify that int he arrmaninteof the work far whichthispermB it i....d.[,hall SEWER-SAN[PART-STORM I.A.200 Ff
not employ any person in any manner so its to become subject to the Workers'Compen- ENERGY 113E
zZ patine Lrws of Gdifnmia.Dasa WATER I IRATER WNP.N'r/ELCCTR
Applicant ` GRADING PEE
ISMICE'r0 APPLICANT.If,after making this Cenificale of Exemption,you should WATER SYS'11WOREA'1'INC,
I•-' becnme%object tothe Wokeek Compensation peavisltm of ate Ltbor Gale>tm must SOBS 19;13
Wfanhwith comply with such pnwwanwor this permitnholl be deemed revoked. WATER SERVICE
Q
z CONSTRUCTION LENDING AGENCY
agency
NIiW RESIDENTIAL PLMIi. SQ. °i', PAID Date I eeiplil
C.) l for by offirricwhich
that there is a j,med(Sec.30lending
uguney larthe perinrnr:mccof
the work I'a which This permit is issue)(Sec.3(191,Co.iv.CJ
fL h Lenders Name TOTAL:
Lenders Address 'fl 1'A Y
}�..r 1 .r ify that 1 have read this application and state that the above mo anemic is BUILDING F +
Lr
con c arae.l u,ree m comply with on city and county ordiotsccs and Stam laws relating to Q MECHANICAL.PERMIT FEE
V G buildo,,on,malim,and hembyamloriac rcpre,rccmavcanfthis city to soca upon the SEISMIC r?E
movcnuntimed property for lrupeetion purposes. 'ERMI CE(We)agree to.save,indemnify and keep ham the City of Copeman.,.Last ELECTRIC
Iiubilities,judginents.costs and expenses which may in any way acente against said City fAMMR OR ADIITO ME
If ZIJ
nscgnenceofthe,fantin,afthispannit. PLllMlfl F.
APPIACANI'UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT A �i)1. G N TO 10.1X1 C )
SOURCE.. J, '1'I(NS.1 MECHANICAL F:I,
NA'—' AIR HANDLING UN t 1 1 'FM) CONSTRUC I TAX
SignawnictfiApplmant/Comracem �)me lI EXHAUST HOOD OVMUCI'1 HOUSING"N
TION TLB
HAZARDOUS MATERIALS DISCLOSf1RB
Will the appliwnl(afume buildingoccumam srnunrhaatlle haa.rduna material 111? 00INTII II'TII)
as defined by the Cupertino Municipal Cada,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)4 HEATING UNI'I'(OVER I INI.( )
❑Yes E]No \'F.M'ILAI I I N FAN ISINGI.E RESID) PAID -
Irate Receipt M
Will the applicant ser future building nccupam use equipment or devices which
emit hanrdors or crok ;marls as delbmd by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1011.000 BTU) ,IGIAI.
District? BOILER-COMP(OVER J00jXXI BTU)
❑yes ❑Ne
I have rthe lumrdnus mamri.ls myuiremChapter
ents rosea b.YS of the Cali- AIR COND01 IONER ISSUANCE DA'I'I°
forma Ilread he
&Safety Cale,Sections 25505,25533 and 25534.1 understand 0mt if the NEW RESIDEN'T'IAL MECII, SQ.17K 4 ��
building d+ws nal cumwmly haven tenenl.lhal it ix my mspnnsihllity to notily the nrtntp int 1/
eche acquirements which must be and pria to issuance oI a Cenirwte ofCccupon,
Owner or authorized.agent Date TOTAL
g IssucD BY:
OFFICE