S1745 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC,TRICtL PB ITNo
. BUILDING DrvItiION AI'1'LICATION/PERMIT PLUMBING-MECHANICAL 1745
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMI ITAL DATE
':2 10-7:5 h&k"ricNa
OWNERS NAME: \ PHONE: C N'I'RACT(IR:S NASIH LICNO:
1 NIC CO.VIHOLW
:i LA
RW ARCHITLCI ENGINEER: LIC NO'. DRESS � ❑
CONTACT: PHONE: iITTII 88 BUILDING PERMIT INFO
❑ Consultant Ems Paid by Applicanl(Imial) BLDG ELGCT PLUMB ME-CHH
Eltial- L�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that E am licensed under provisions of Ch inc,9 famunencin, JOB DESCRIPTION
❑aZ Ih Section IIMYJ)of Olvlsion3ofthe Business and Professions Enda and my license i,v RF F,NTIAI'
utop wt PERMIT ISSUANCE
Cu'!- n full force and effect. ��� ;EDl4'I. ❑K ITCHENREMODEL
aUU Liver,y(� 2 Lic.p APPLIANCEti-RBSIDIiNTIAL ADDITION ❑PLUMBING RE PIPE
tete, Ornc Dan1p-a- Cnmmcmr -
ARCHLTECI'SDECLARATION MULTI-UNIT ❑STRUCTURAL
Fn,z I understand my plans shall be used as public records PANELS AIUDIFICAI'ION
OZ4o UPTO200ANIPS El INTERIOR ❑CHIMNEYREPAIR
F'1.~u; Lfcenmd Professional 2)1-My)AMPS IMPROVEMENT E]SWIMMING POOLS
C -,+ OVER IW)OAMPS ❑BATH REMODEUREPAIR El DEMOLITION
OWNER-BUILDER DECLARATION
C C Q I hereby union Ihot I on awonpr In m the Conunnors License Law far the
k3 i U following recruit.(Section 7031.5.Business and Professions Code Any city or county SIGNS IiLECTRICAL OI ITER
W D.rn which requires a permit to construct,aper,improve,demolish,or repair any soncom y
o'i prise 1 t 'a.a1, 'q ' fi ppli ' tf hPeru...a fl I:Tacmcnt r SPECIAL CIRCUIT/MISE. ` t.
EWp— Ihalh licensed.... n th p sun. fill L I nor L La (Chepar0 -
�e[0� (wmmenang with Section Todd)of Division 3 atilt,Business and Profession Gdc)or TEMP.METER OR POLI?INST. COMMERCIAL'
d d e C chat hit is c,,fuq Ihav1'rar i and the Basi,ba the olle,vil cscmptlon.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Ixz'�m Section 70315 by any applicant for a pemtia subjects the applicantita it penaltyof POWER DEVICES ❑'TENANT El Pow SERVICEnal more Than live hundred dollars IMPROVEMENT
❑ Liu owncnn aha pngcny.ormyenpinycc with wngcsux lhnlr,ale,.ai,stxmion, SWIMMING POOL ELRC'PRIC
will Jo the work. it the saccons is not intended or offered for isale(Sec.714 'Britons
❑O'T'HER
43 ce and Professions Code:"Ute Commctors License Luw dne.s not apply to an owner of OUTLE:1'S-SWIPCIM -FIXTURES
pmpriy who hailds m improv,,Ili umt,and who does such work himself or Ihmogh
his own employees,provided t[in,such imprnvemens mu an,intended or offemd for NEW RESIDP.N'I]AL LLIiCTR SQ IT.
sale.If,however.the building or improvement isenld within one year ofeamplctiom.the SQ.IT.FLOOR AREA $/SQ.FI'.
r ct-holder will bine the burden.1',o my that he dol not haild nr improve for par
p roof sale). v
Fl 1,as ownet of the property,am exclusively contracting with licensed contractors[is
TOIAI..
construct the Tindal(Sec.7044.Ravines,and Pmfessim,Cade)The Con meter's I.i-
nseLaw docsnolapply ,,mowner of properly who bei ids or impnavea lhesnn,and QTY. PLUMBING PERMIT FEE
whacommeax mrxuchpvajecs with acommctims)hcerv¢d pursuant riathe Com arm's
License Law FERMI"T ISSUANCE
❑ lam exengn under See .B&1'C forlhis team..
Owner Dae ALTER-DRAIN&VENT-WATER IF) �Jr VALUATION /.
WORKER'SCOMPI?NSA'IlONUPOLAIIATION BACK IlAW PROTECT.DEVICE /
❑ I herebvaRmt under penal,of perjury one of the followingdecimations: V -> V
I have and w ill mtimain n Certificate of Convert to self-inure for Worker's Cooper- DRAINS-FLOOR,ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
section,as provided fur by Senior 3700 of F,Labor Code,for Ibe perlormm�c of rbc
work for which this permit is issued. FIXTURES-PER I RAP
have and will maintain Worker's Compensation Insurance,as required by Section INCA OIffLEI:S
Ilofthe Labor Code,I Gcf,tfamnance of the wark fm which this pcvmit is i.ssncd GAS-LA.SYSTEM- OCG GROUP MIN
My Work9 scamggms Inumnee conic onA Polie}nyyrnM1�a a k
Camee j�f,',) °"•4(I(Se�Pnlicy No 1'r4 hLI(9a GAS-G.St'SIF.M-OVERa(IiA)
CG IIIBC'AI'E(11 EI
FROM WORK171ZS' GRE;ASIYINDUSTRI.WASTE IN'1'ERCIJTOR
COMI'EPISAHON INSURANCE BUILDING DIVISION IT?P_S
(This section need not be completed iDhe permit is forint,hundred dollars(SIO() GRF.ASL'TRAP
or Ica,.) PLANCHECK FEE
I acridly that in lhensini,niancemf ahework bassinet lhisprmil isismad.Isha11 SEWER-SANITARY-SURM EA.200 IT.
a.,employ any Person in any manner so as to become subject to the Workeri Compen- ENERGY Bili
O z sation Laws of California.Data WAI'FIR IIF.AI FR W/VENTA:LI!CTR GRADING hili
Z
Applicant
y NOTICE lt)APPLICANT:If,after making this Cenificata of Exemption.you should WATER SYSI HMGMEATING SOILS FEF.
F; All
E-' la," 'novo a me W k C pens t pri ^s of he Labor Cade.you must
forthwith couni with suchf '.' xnr0at,pe I:hall a,d d akcd_ WAI1'R SERVICE
Jim Q S'D
z CONSTRUCTION LENDING AGENCY NEN'RESIDE NTIAL PIAIFL SQ.ET. PAID Dmc
U O ILt,rchy olid nn lhm there isnennalmcllnn knJasa cy iia the perfnnnantt of aurPl
f" arc work for whicb this pennil is is' (5cc.31to'm J
Lenders Nanta l� YTAlf: 1 111
O V Lender's Address TOTAL: f,IIY VC V�
r 1 cenify that 1 have read this a nation and intoe that the rhi infonndo m is
BUILDING 1'LE
F h enmvl.l agree in a". oy and countyordinacesandsme law,retain,to QTY. MECHANICAL PERMIT FEE
(JZ holdia,eansnmcain 1.rod he ryamharivcrepreacnmaivexof this city locno,r upon the ST:ISMIC FEE
above-mentioned prnpcny for im ove,im purposes. PERMIT ISSUANCE 5"
(Wee)agree m save,indemnify and keep harri the Ciay of Cupertino against ELECTRIC PEE
Iiabilou"'jud,mmtu.costsaal cxpcnm,wli,hmay i^a^y way accrue ngainxl swd City ACIER OR ADD TO MECH.
PLUMBING.FEE
or APPLICANT
thegaining of thispermit.
APPLICANT UNIIF.RSTANDS AND WILL COMPLY WITH ALL NOK-POINT AIR HANDLING UNIT(TO I(LIKIOCFM)
MECHANICAL FEE'
/ 7o vSOGRCE RIiGULAI IfN� LAIR HANDLING UNI'1'(OVER OJXPO CI'M) CONSTRUCI'ION'1AX
i` t , `nIZI/Y(
Slgmalurc of iaoCommena sine
EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FBI?
IIASARIIOUS MATERIAL S DISCLOSURE
Will the applicant or fumte bi exattfamsmre or handle havardoas mmerial THEAPING ONI'I'(TO 100.00)B'I Of 12 ,
as defined by the Cu sea inn M:mieipal Code,Chapter 0.12.and the Health uad Safety
Collo.Section2553260! HEAPING ONI'I'(OVIIR I doom It TO)
E3 Yes nNo VENTI LATION FAN(MNGLL RESIDE HMD Dom Rmcipop
�le Will in,a,henalor future huilding occupam use emalould or devices which BOILER-CON[-OIIP OR IOnfliIII A I'O)
mit harallou,air umntbyminams as defined Ibe Bay Arca Air Quality Management TOTAL: /
District'I BOILFR-COMP(OVER III0.000 BTU)
El Yes E]No
I have mad IM hvalloa Irmmrinls reunder Chu 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
gaircmcros un purr
fomia Health&Safely Code,Sedans 25505,25533 and 25534-1 uudir,li I lot,11 the NEW IIESIDI?N'1'EAt,MECI1. SQ.PL
building does not current v -atcnam.Ihatitismymspmsibiloym notify the occupant
o regnirememswhimrun. be mea Otinr l0 ixnrana o[a Certificate^ QcI an<yw1Tr� .
U n s l.,cut D: c ^ TOTAL: /' <)C)<)C)S(p r ISSUED Bei/V
OFFICE