S 1288 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY l)P CCPERTINO BUILDING-ELECTRICAL PBR`�1•I'I'NO.
BUILDING DIVISION APPLICATION/PERMIT PING pRNO MECHANICAL. �J 1288
BUILDING i'ROJI?CI'IDF.NI'IFICA'1'ION
BALDINGADDRESS: tiANITARY NO. AI'1'LICATION SUBMITTAL DATL•
OWNER'S NAME: PHONE: CONTRACIOR'S NAME: LIC No.
,• AptfahnoO K ti A 409-2y571? NIC CON ROLA
ARCHITECTIENOI THE LIC NO', ADDRESS: ❑
CON TgCp; PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG CLf:C'r Lump MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q'rY ELECTRIC PERMIT FEE
1 hereby afferm Nm l am Ecensed under previsions of Chatter 9(csmmendng JOB DESCRIPTION
CIoz withSatiun9ll(MBofUivisinn3nftheliuxittassendl'mfcsnimnsCrxlC.tiadmyliccn ie PF,RMI'I'ISSUANCIi RESIDP.NTIAL:
Fcd. in full farce and effect. ❑SFDWL ❑KITCHEN REMODEL
aUU License Class Lica APPLIANCES-RESIDENIAL ❑ADDITION ❑PLUMBING Rr PIPE
F-z W Dmc Commcmr
m<m ❑M111,TIANIT [I STRUCTURAL
AltClll'1'LCrS DECLANATI(lN PANIiI S
zoia,z Iandcmlmod my plans shall he used uv public records MODIFICATION
Oz Uf TO 2W AMPS ❑INTERIOR []CHIMNEY REPAIR
F. Ez
Licensed Pmfeasional 20L100HAMPS IMPROVEMENT SWIMMING POOLS
li a� OWNER-BUILDER DECLARATION OVER I000AMPS lk ❑BATIIR' ODBIIREPAIR El DEMOLITION
I heme,infirm that I mm exempl Irons Lha Contractor's License Law future 1
a0.0.x5��O a U ZSCITiER
fallowing re.,m.(Semon]1131.5,Busincsa and Pmlessinnv Crate:An,cit,orcounty SIGNS ELECTRICAL ` -; A
Vo
which rewires a permit to construct.after,improve,demolish,or repair any structure, .
.u+O1 prior toits mucance,also requires the applicant far mach permino flcasignedsmmment SPECIALCIRCUII'/ 'TTf
�y that halsliunvedpursnmntouse Ep..kiansoflhaCnthicfnrsLienmuLaw(Clapter9
lannmencing wilb 5ec0oo 90lE IDlvisina3 of the anxioessund l'adessi...Cmle)m TF;MP.METER POLE INST COMMERCIAL:
d 6x e that he is exempt the.fram and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
tJ^m
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penally of POWER . ICI!S INANT ❑FOOD SERVICE
n inure than five hundred dollars($500). IMPROVP.MEN'r
Q ❑ 1,as owner of the propcny,or my employees with wages as their sale compensation, SW M1NG.P(HII.ELECTRIC
will do the work,undthe manure isoat immtidedmattered far ale(Sae JH Business 11
BOTHER
L w m and ltofessiom Code:The Contractors License law dces not apply 0 an owner of OUTLETS-SWI ILCHES-FIXTURES
property who bilds or improves thereon,and who diem retch work M1imttlf nr through
his awn employees.provided that such impoevemmrts arc me intended or offered for NEW R17SIDENI 1A1,ELECTIt SQ
sale.If,howevea the building or improvement is sold within one year ofcompletion.thecapressingSQ.FE FLOOR AREA $/SQ.IT.
ner-builder will have the burden of pressing thin be did not Wild in improve for par- s,y,
pascoface.). v1. 'TOTAL:
1,as owner of the properly,am exchoi vel,contracting with licensed ennllecmrs to
nnamn the project(Sve.]0b4,Holmes,and pmfessiuns Cedn:)'Dle Conactor's Li-
censeLaw does not apply toanowner ofpropenywho builds a,milroves thermal,and QTY. _ PLUM LANG PERMIT FEE
who contractsI'oreach projects with a,nmaclor(a)licensed Earoman 1.the Cumuli
License law. PERM I'I'ISS DANCE '
❑ I am exempt tinder Sec. .R&Petal this reams
ALTER-DRAIN&VENT-WATER(CA) EVALUATION
Dam ee ^
r WOR KEEPS COMPENSATION DECLARAIION -- 13ACK FLOW 11411 ECT.DEVICE Ps'V
I hereby afile.under penally at perjury one of the following declarations:
Ihave and will maintain a CeniOcate of Consent to self-insure fur Workers Compen- DRAINS-FLOOR,ROOF AREA,CONED, STORIES' JTYPE CONSTRUCT ION
satins,as provided for by Section 3IW of the Labor Code.for the perfmmance of the /��� (� sn
work far which this permit is issued. FI%'TURES-PER'I'RAP (d {YD
❑ 1 have and will maintain Workers Co..l,mn icer Insumnco,ax reyaired by Section
371X1 of the labor Cods.for the performance of the work fill which this pewit is issued. GAS-EA.SYS'TFM�I INC.4 OUTLETS ,i DC p APN
My Workers Compenunumber
tion Insurance carrier and Policy um: •�O �f of uUt =h I BVU
Cartier: Policy No,: GAS-HA.SYSTIiM,(IVER 4(HA) L
CHKI'IFICRI'F OF EXEMPTION FROM WORKERS' GRLASIVINDUS'1'R.WAS'I'17 NIERCVVIOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thimsatia.aced..,he completal ifthe permit is forms,hundreddollars($IW) GREASETRAY
or Ices.) PLANCHECK FIJI
Ice ' that inthe perhumm�ceoflbe work lin which lhisperon is issual,I shall SEWER-SANITARY-S'FORM BA.200T. ENERGY FEF.
not it yany pumon In any mm�ner so its to become subject the Workers'Cump,n-
O r - n laws of Califomia.Date WATER HEATER WNENT/ELECTR GRAVING FEE
pPlicam
(TfICE TO APPLICAM':If.after making This CeniOcam of Haeulplim.you should WgTlilt SYSTIiMfI'REATING SOIL511giE
a Leonie suhjecl to the Worker's Compensation previsions lithe Lubar Cale,you must
forthwith complywith,mlipravilmornhis peail shall be deemed revoked. WATER SERVICE:
Q PAID
R' CONSTRUCTIONiolo LENDING AGENCY
agency NEW RESIUCNI'IAI.PLEBE. SQ.FT.
Ihueby ulna tMn lhme isnwnstmminn leading agency far the puforntunce o[ D' Rcaipta
LUL. H the work for which this permit is issued(See3097,Civ.C.) it
Lenders Name TOTAL:
kUil lenders Address BUIL'IOTA .
G o EE
1 senify That 1 have read this appliadiou and slate that the above infonuutinn in SEISMIC FNC. E
N erect.l agree mcamply with all city unit county ordinances and seam laws relating to Q'FY. MECIIANICAL PERMIT FEE SEISMIC FEE
U Z building construction,and hereby manhandle repr%entatives of this city to enter upon the
aMrve-mentioned propcny for inspection purpswca. PERMIT ISSUANCH ;LECI'R IC FEE
(We)ugau m save,indenmlfy.1111 kap hasnless the City of Caper iso againstar
liubilitiea,judgntemx,cnvta unJ expenses which may in any way neem,xgainxl said Cily AUHRORADDIYIMECB. PLUMBING FEE
I.cunoxamarce of the le aming of this permit.
APPLICANT UNDERSTANDS A ND WILL COMPLY W I'I'If ALL NON-POINT AIR HANDLING UNIT GO 10,000 CFM7 MECHANICAL FEL'
SOURCE REGULATIONS.
AIR I IANIILING ONE I'(OVER 10.000 CFM) CONSTRUCTION LAX
Signature of ApplicanJComolor Date EXHAUST HOOD tW/DUC) HOUSING MITIGATION FED:
HAZARDOUS MATERIALS DISCLOSURE
WIl}hMpRlicant or future building occupant store or handle lutaurdoux material HF.ATINGUNLT(TOI(IO,WO ' J)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ileallh and Safety HEATING UNIT(OVER ),IXq BTU)
Sect
5532(a)?
❑Ye, FNo VENTILATION P (SINGLE RESIT) PAID
P� Dale Raeipt p
Will the air comnuvfumre building by theBayAwee ea Air equipment or tIManaement ROLLER- MI'(3HP OR I(XldgXI BTU)
emir havallous air comaminams s defined by she Bay Area Air Quantity Managentem TOTAL:
District? BOI . -COME(OVER I(X)jXX)BTU)
Cl Yen ElNo
I have maul the haamdsus materials requirements tinder Chapter 6.95 of the Cali- IR CONDITIONER ISSU CE DATE
fare.Hea1N At Safety Cade,Sections 25505,25533 and 25534.I malloaand that if the NEW RESIDENTIAL.MECH. SQ.IT.
building does nal currently have u tenant,that it is my msptmsihility to Pray the tecupant
of the«qulrccents which must he met prior to issuance of it Cer ificam of Occupancy.
Owner or autbnrisd agent Dam TQTnL: ISSUED BY:
OFFICE