S 1152 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
"CITY OF CUPERTINO BUILDING-ELECTRICAL: P O'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J 1152
BUILDING PROJECT'IDENTIFICATION
BUILDING ASD/TURCS'5,: 1 �wr ' SANITARY NO, APPLICATIONQSUBMITTAL DATE
jt9is
O NEWS NAME: 1{ONE: CONTRACT OR'S NAME LIC NO: NIC CONI'ROLN
tits 94C ^a2 0 osa,4 s
CHITECI'A?NGINFER: L.ICNO: ADDRESS: ❑
A!t u - 6063 3GRG6o CAE C�� kAK
CONTACT. PHONE: - BUILDING PERMIT INFO
`�'�����' 'I�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MCH
/l
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby.matt Ill.(l ant Ilcensed under provisions of Ch.Pter 9(commearm, JOB DESCRIPTION
OW a'Z with Sation]qkB of❑ivision3ofthe Business unit Professions Cotte.and my license is RESIDENTIAL,
OW in PERMIT ISSUANCE: ,f
I-IyF License
Class deRmt. ❑SPDWL ITCHEN REMODEL
�UU Licenxc Class Lic.N APPLIANCES—RF.SIDEN'1'IAL ❑ADDITION ❑PLUMBING RE-1'll'I3
sk..ZW Date Contractor
yah' ARCHITECTS DECLARATION ❑MULTI-UNIT E)STRUCTURAL
P�p y> PANELS MODIFICATION
Z O h G 1 undeclared my,Inns shall heated.,public records
p=FO UP T0200 AMPS ❑INTCRIOR [I CHIMNEY REPAIR
is ❑❑- Licenced Professional 201-1000AMPS IMPROVEMENT SWI MM ING POOLS
�yda
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
CC CC 1 hereby mfimt that I em exempt from the Contractors License Law far the ❑OTHER
X a ped,U fNlowing reason.(Sectinn 7031.5,Business and Professions Code:Any city nr County SIGNS ELECTRICAL.
ul W which requlms a permit to carmen,otter,improve,demnllxh,or repair any structuru
prmrt,,i¢issuancc.also emprionflicapplicnd fnrxuch pe.iuo Ele asigned statement SPI?CIALCIRCUD'IMISC.
} that he islicensedpmmrion India rovivitnImfthe Carmelites License Ww(Chapter9 OMM R IA
�� (wmmm�cing with Section 9fq(i)nf Divixion3 nfthe Business and Pmfeasinns Cndcl nr TEMI'.MH'1'ER OR IK)LE INST.
6 a p�S' that he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^oe
Section 7031.5 by any applicant for a proton subjects the apPliesm m a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
manure than five hundred dollars($500). IMPROVEMb:N'1'
tSC
LI 1,as owner ofthe,mped,or my employees with wages as their sale compensation. SWIMMING POOL IiLECI'RIC
will Jo the work.and the suucturc is not intended or offered for sale(Sm.9DW,Business ❑OTHER
and Professions Cale:'The Counselors Lieense Low dues not.,Illy to un owner of OUTLETS—SWITCIIliS—FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements anet intended m offered far NEW RESIDENTIAL ELECTR SQ FT.
re
sole.Il'.however,the building or Improvement is sold within one year ideorapletion,the SQ.Ff.BOOR AREA S/SQ.II'.
donor-builder will have the burden of proving that he did not build or improve for put. �1 D
pace of sale.). T (lY—
❑ Las owner of the property,um exclusively contracting with licensed eomtmdors or
construct the project(Sec.20,14,Business and I'rofesslons Cade:)The Commctor'e Li- p
cense m A
Law does not apply an owner of property who builds or improves thereon, QTY. PLUMBING PERMIT FEE
who contracts far such pmjeces with a controctons)licensed rursumd to the Cmnmetors
License law T PERMIT ISSUANCE f
❑lam rapt antler Sey w/� l B&PCfnr thi nam
I /der1 /10 J/ a -� ALTER—DRAIN&VENT— ) TION
1 O 1
WOR KF.R:S COMPENSATION DECLARATION BACK FLOW PRDIBCT.D' CL• ITY OF (;l lr/'.1n 1pbtr)
I hereby affirm under penalty of perjury one ofthe following declarations: Y` Vf 1{LW
I haveand will maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS—FLOOR,ROOEAREA,GOND. STORIES TYPE CONSTRUCTIOt
Minn.as provided for by Section 3]q)of he Labor Code,for the performance of the
work III,which this pemtit is issued. FIX'I URES—E'ER TRAP
❑I have and will maintain Workers Compensation Insurance,as planned by Section
3Tf1(l ofthe Labor Gde,for the performance office work for which this permit is issued. GAS—
EA,SYSTEM-1 INC.40117HArI OCC GROUT' AI'N
My Worker's Compensation Insurance currier and Policy dumber arc: GAS—EA.SYSTEM-OVER 4(EA)
Cartier. Policy No.:
CERTIFICATE OF EXIEVEMON FROM WOR
KI?RS' GREASE/1NDUSTRI.WASTE?INTEHCF.PB)R
COMPENSATION INSURANCE BUILDING L ON FEES
(This section need notbe completed ifthepermit isfmonehundrtddollars(S I(XB GREASE TRAP
or less.) PLANCHECK FBG
certify that in rhe performance of the work for which this permit is issued,l shall SEWI7R—SANITARY—STORM EA.201 FT.
no,employ any pnssm in any manner so as to became subject to the Worker'Compen- ENERGY H.S.
sation Laws of California.Date WATER HUNTER WNENI'/ELFCTR
z GRADING FEL:
Applicant
NOTICE TO APPLICANT.IL ober making this Certificate of Esemption,you should WATER SYSEEWREATING
rAl
become subject to the Worker's Compensation provisions of the Luber Code,you must SOILS 1'E
Lkl .rat forthwith comply with such provisions or this pennitshall he deemed revoked. WATER SERVICE.
Q ['AID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAI.PLMB. SQ.Pit [)u
construction lending
Q Ihereby affirm that there is a consction lending agency far the performance of
U Lw he wnet far which this permit is issued(Sec.JDA,Civ.C.) TOTAL:
p ULenders Name
k1 Letalm.Address
As certify that L have read this application unit state than the above information is BUILDING Bi
rn correct.I agree to comply with all city and county unbalances and state laws eclotingm QTY. MECHANICAL PERMIT FEESEISMIC/EE
U is building consameatn,and hereby authorize representatives of this city to enter upon rhe
above.mentioned property for ballerina purposes. PERM IT ISSUANCE ELECT CFEB
(We)agree to save,indemnify and kee,harmless The City of Clipenino against
liabilities,judgments,costs and expenses which may in my way accrue against said City ALT ER OR ADDTO MECH.
PLUME NG FET;
in consequence affair granting of thixpemtin. is
APPLICANI I iNDERSTANDS6ND VLL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO II),(MII)CIM) III ECIIA
SO iREGULA (WS.
1 A/ AIR HANDLING UNIT(OVI:R 10.000CFA) CONSTRUCTION TA
of Applielatu
ig are naor O e EXHAUST LIOOU(W/[)UC'I'1 HOUSING ME I'[CATION 'E
HAZARDOUS MATERIALS DISCLOSURE
Will rbc applicxm or fumrc building wcupam store nrbundle huzsNnus martriui HEAI'1NGIINIT(TO 100,00 BTU)
as defined by the Colombo Municipal Cede,Chapter 9.12,land the Health and Safety HBATING UNIT(OVER 100,000 B RB
Code,Section 255320)?
❑Yes ❑NnVEN'I'I LA'I ION PAN(SINGLE REST U) I'AIU
Dam Rccc t N
Will the applicant or future building occupant use equipment or devices which BOILER—COMP(1HP OR IW,gIB BTU)
it Imzmmr Aair matuddrusek as refined by the Bay Are.Air Quality Management OTAI.:
tawist^ BOILER—COMP(OVER 100.000 BTU)
El yes E]No
I havereadthe hearadousnutcrials requilementsundm Cho,teti.95ofthe Cull- AIN L'ONUI'f10NER ISSUANCE DATE
fomis health&Safety Code,Sariuns 255115,25533 attd 25534.I understand that tribe NEW RESIDENTIAL MECII. SQ.FT.
h dding does not currently have.tenon,thct if is Illy respmsibility m notify Bm oricnpunt
of the naimments which most he at prior to kilear a of a Cerificme of Occuparay.
Owner or aulhodzed.,do[ [)ate L' ISSUE 1)BY.
Ajp�
OFFICE