S2656 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPER'1'INO nuu.ulNcELecrxlc,)1, PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT vLOnuRNG-MED NTIFIC S 2656'
ItIIII,DIN6 PROJECT IDENTIFICATION
BUILDING ADDRESS: ,/AA I,ry�p� SANITARY NO. AI'1'LICATION SUItMITTAL DATIi
l t l D L.fr P LDV M 1 1 — Cep PE2T�N O SO I Z a �/
OWNE R'S NAME: 1'HONqF,'� CONTRACTOR'S NAME; LIC NO:
N 0��✓— ��w� NIC CON'fR(IhN
ARCIIH ECT/ENGINEER: LIC NO: ADDRESS: ❑
6 NAr L E 9
CONTAC'P: PHONE: BUILDING PERMIT INFO
— ❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT' PLUMB MELD
AR 6 ❑ ❑ K ❑
ucENSFO coNTRncroRs DPc A RAT ION QTY ELECTRIC PERNIT' FEE
I hereby affirm that mf e. 1 1 provisions of chapter 9(u,nnedng _ JOB DIESCRIPTION
w,,hS,,, 7000)dDiew i3ofthe Buser di f"na"Codc col tyl'ee,c iz RESIDENTIAL:
W00 iq PERMIT ISSUANCE
F��F infullforecanJ 1 "'1 ❑SFDWI. ❑KITCHEN REMODEL
QUU Licemc Cla_ Lic.p APPLI,INCES-RF_SIDIiNI'IAL ❑ADDI'T'ION ❑PLUh1BING RE-PIPE
F z u] Date Contra
way ❑MULTUUNIT ❑STRUCTURAL
ARCHITECTS UPAhARATION
r.7 oe UP 10 ti MODIFICATION
Z p y Z unJcrxnad my plans shall M1c used us public rccnrdr
I Oz-'� UY'IY)2(IIIAMPS ❑INTGRIOR ❑CHIMNIiY REPAIR
Eisenson Prafce,fond 2014000AMPS IMPROVEMENT C SWIMMING POOLS
OWNER-PUILDER DECLARATION OVER 1000AMPS El BATH REh10DEf/REI'AIR ❑DEh101,ITlT
C z Q I hereby affect that 1 am exempt from the Contmoors License Law for the
'a pu:U []OTHER
k U. fourl,ng,norm.(Sruen 7031.5,Business and Poe,demur Coln Any city nr county SIGNS IiLI!CTRICAI.
w 3 to yQ which requites u pernN et construct,nlmr,in9nove,Jemnlixh,or repot,any xtnemre
FA prior to its issuance.also requires thcapplicant for such permit to file asi,c(Chapter
statement SPECIAL CIRCUIT/S11SC,
Eerythat he is licensed pursuant m the provisions of the Comment Licemelaw lChapter9
�tyCp (commencing with Section]000)of UivisianJof the Business and Pmlcssiom Code)or TEhIf.MIH'ER OR P01,1?INST. COMMERCIAL
y y e C that he is exempt therefrom and the basis for the a11c,c'J exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
Yx]�m
Section 7031.5 by anyapplieant for a permit subjects thcapplicant to ac,,it penalty of POWER DEVICES ❑TENANT ❑FOODSIiItVICE
not omre than fr,i,humbed dollars($500). IMPROVP,MEN7
❑i.as ownea ofmc propcny,nr myentplaycc.with wags as theirsole compensation. SWIMMING POOL ELkCI'RIC
will do the work,and thexwcwmis not imcnded orolicmJ far sale(Sec Raciness El OTHER
W m and End..tons Code:The Commcmr'e license Law does not apply to an mune,of OUTLET'S-SWITCHES-19XTURIS
pmpeny who builds or improve,thereon,and who Joe,such ,,,it himself or through
his ower wnployees,provided that suchTrout—vcmmats arc n, NEW RUSIDENTIAI,11I.It.CTR SQ FI
sale.If.however the building or improvement is sold within one yew ofunapletion.the SQ.FI'.17LOOR AREA S/SQ.UP
er-huilder will have the burden of proving that he did not build or improve for pur-
pn.a of soled.
Ej 1,o owns,of the pmpeny,am exclusively commum,with licensed contmaors to TOTAL:
msmmt the project(See.](44,Business and Professions Codr:)The Comesours Li-
st taw docs not vpplym an ownand pmpeny who builds or rep v,thereon,and (YTY. PLUMBING PERMIT FEE
who contracts for such projects with a ennvacmns)licensed pursuam to the Contractor's
License Law. PERMITISSUANCE
I an nxempt under Sn. .B E P C for this reason
ALTER-TRAIN k VENT-WATER(EA) VALUNI ION
Owner Date
.i WORKER'S oadyofNlmesno DECLARATION HACK MAW PROfEC"I'.DF.VICF, 550 , OL
I hand waffect under penalty M perjuryoneof Nefellow ing Worker's o v
�Ihave and will maintain aCenifca¢of Conxenuoself-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA GOND. STORIES TIRLCONSTRUCTION
smirk,as provided far by$,,otos 3]W of the Labor Calc,[or 0c pcnbrntanec o[the
work for which ll pcnnilis orker FIX'IVRI?S-PER IRAI'
❑ I hathand will ore.fon Wmkm's mance of mew work for
eh,h required by clued.
37W nfthh Labor Crile.for the performance of me workjfrn wb�icM1�this�pcnnil a[iu�uc/J��.S] CAS-EA.SYS'1'L'AhI INC.40U'11,Y.'lti OCC GROUP APN
CamcMy rSSa �tand POlcy No^'� ^' 101 GAS-IiA.SYSTEM-OVER 4(EA)
CIR'I'IFICATY,OFI?XI:MPfION FROM WORKERS' GRI?n51?IINUUS'1'NI.WASTE INTI?RCEI'TOR
COMP17NSAIION INSURANCE BUILDING DIVISION FEES
('This...tion mail not beca)mpluad il'the permit is tisane hondmd dollars(SI WI CRI?ASE"TRAP -
nr les..) PLANCHECK 117E
IceriNden irohe permormaceofthe x'orkf.rwhi,h an,,ermit is i...ed.i shall SEWER-SANITARY-STORM EA.21X117.
mot employ any person w any manner so m tohecnme wbject m the Wodons'Compen- I:NERG) FEE
sainn Laws of California.Date WAI His HEATER WIVENT/ELECI'R GRADING FEE
Z 2 Applkant
t-. NOTICE 10 APPLICAN I':IT alter making this Cenilica n of Exemption,you should WATER SYSTEMTREeM'ING
> becnmh s rhilectto the Worker',Comphnsmoon provisions of the Labor Cnow"ode,you uq SOILS FBI?
l+7 fonhwilh comply xithsuch provisions or this permit shallM deemed revoked. WATER SERVICE
iNhT0NLENDING AGENCY NEW R?SIDENTAIPLMIB, SQ.FTPAID Uac tucptk
U 0 briery allirntlnemce,it,atsmctnn
lending ngencyf nhe perfnnnwce or
I.L. I the work or which this permit is issued(Sea.3097.Civ.C.) TOTAL:
O U Lender,Name TOTAL:
U 1<ndee,Address
FOn I certify that I bve read this appi,alion amt m a tem the ahme{nfommtion I, nu�lAlb f,Cj
N ourv,l.I agree 11, on,d, j,lb rill ' y' tyI' da Loss cla Ing n QTY. MFCHANICAL.PERMI'P FEE $1:'5�a11 Illi
U z building cnstruction.and hereby a du r is rep i n col thiscity t enter upon the
abuve-menfoned property for inspection purposes. PERMIT ISSUANCE E ENilf:197E a
(We)agree to.ave,indemnify and keep harmless he City of Cupertino agwryl
liabilities,judgeraw,c tsond expenses whicb may in any way acerae against said City ALTER OR ADD TO MECH. I JYMBING I9il
„egnzi�P'ica
gramin .permit. 11II e _ .— aa..ff
APPLICARST )S ND WI OMPLY 'ITH ALL NON-POINT AIR HANDLING UNI'I'1'IA IQIAXICI'M) BXCHANICAI.11?E 1,7yV
SOURf.
941 AIR HANDLING ON[[(OVER 10.00007) `AYSTRUCI'ION TAX
Sip are of mmcmr Dae EXHAUST HOOD(W/DUCT) DODSren-m ]ION -E
HAZARDOUS MXI FRIALS DISCLOSURE
Will the applicant nr fmure huildingrecupent store or handle huraNnusmwerial HEATING UNIT(10100,00M B U)
as,defined by the Comedian Municipal Code.Chapter 9.12.and the Health and Safety
Cod,Section 255320)+ HEAPING UNIT(OVER 100.0100 B'1'UI
❑YcxVEN'TI[Al'ION FAN(SINGLE RFSI D) PAID Receipt
'�.e
Wilk Wealplienm or fnutrc building occupant use egnipmem ordevices which BOILIiIi-COMP(3111'OR 101.UW R'1'U)
mit learodous air contnmruunts as reined by the Bey Ares Air Quality Management 'I OPAL:
District? / BOILER-COMP(OVER 110,010 n 1'UI
0Yes 01
l have read the baltoth,nmerials is to under Chu 6.95 of the Cul i- AIR CONDITIONER ISSUANCE DATE
'g25533a Chapter
fomiu IICJN&SiRny Gde,Sectlotu 255115 25533 and 25534, unJersnnal ohm if the NEW Nli$IDENTIAI.MIiCH. SQ.PI'.
building does not naw c eatemen6 tit my nrsrymsibility to notify Me occupant
of We"i iremena which m t M met p ono c once of a Cvwdy wr of O cuP=ry.
If
�)
OwncrnrauNoriaa rot Dare TOTAL: ISSUED BY:
OFFICE