S 1812 (2) APP"CANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF:RTINO IHHLDINC-V.LBCI'RICAI, PExCa i r NO.
BUILDING DIVISION APPLICATION/PERMIT DINGPLUPROJECT IDRN nFI I. Q 1812
BUILDING PROJECT IDNN'I'IF'ICA'E'ION
BUILDING
A`DDDDRR}gS ( SANITARY NO. APPLICATION SUBMITTAL DA'I'S
O 'g NAME; W J'sll0CN1i CO�Rq.��C�I'�O�R�'S ME L
S 3 ] / 4� Q LI/Q gKNE 3.0}Cpj ./q(� NIC ROLA
.'AHCHITLCI'/ENGINIIIiR: UC NO: I)pES' � �(�F—V ❑
CONTACT: PHONE: p d BUILDING PERMIT INFO
A711-
jj—�_ -.L 3 3� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUn MIKE
I /V�" Cl ❑ ❑
LICIiNSEDCONI'RACIOIt'SDECI.ARATION QTY IELECTRICPERMIT FEE
I musty ah nu that I am licensed under provlsinns Of Chapter 9 mrsoman dog JOB DESCRIPTION
Da'Z wlm Satioa TB(Xuofl)1KC
Busineas and Pmfessmns Cale.and my licensers RESIDENTIAL,
PERMIT ISSUANCE
11--w� in full farce and effe . TDA ❑SFUWL ❑KITCHEN REMODEL
IUU License Class Lic.p APPLIANCH!i-RESIUIiNTIAL []ADDITION ❑FLOMBINGRE-PIPF
j.Z(y putt Commcnnr
lin Qa [I MULTI-UNIT El STRUCTURAL
C'S DECLARATION
~HZ I undersmaimyplans,hall heusednxpuhlic records PANF.IS MODIFICATION
UPT02E0AM1'S
OZ�—n ❑IN'I'I!RIOR ❑CHIMNEY REPAIR
1=�F"W Licensed Professional 201.100IAMPS IMPROVEMENT SWIMMING POOLS
qX OWNER BUILDER DECLARATION OVER IM)AMPS
❑BATH REMODEDREPAIR ❑DEMOLITION
C w Q I hereby affirm that 1 am exempt from the Contractor's License Law tin the
i1yx5t1 U following reasoti.(Section TIUI S,Buswevs and Profexsin is Code:Any city or .emmoY SIGNS El.f Ol f{ER
W as C y which requires a permit to mnamm,alter,improve,demolish or repair any•mature
� prior its issuance,also requires the applicant for such pard,to Flcu signed tenement SPECIAL IT/MIS .
that he is licaneedpumnnit To the pnlkioraofhe Contractors Liacnaa Law(Chapere)
aQ (commencing with Seclion7"),(if Division 3ol'the Huxincaswid l'rolbssiotir Ctale)or 'I'IiMP.M ' s OR 1101.1!INSLl COMMERCIAL' �^
a a o C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLI'f10N
X— Section byany applicant hna pemtitsubjawfue.pplicanuna civil lntmlry of POWER ICF.
W y
not marc than Five hundred dollars($SBaj. ❑TENANT ❑Ir00D SERVICE
z6 1,as nwnerof the m n,nrm In ccs with wx cs as their sale cam tion. SWIM GPOOL ELliCHXC 01HER IMPROVEMENT
FO d po Y Y emD Y n rn'nwa ❑OI'l1ER
will Jo Ne work,and the he C'mc is oat,,mare arta w du s not a(Sec.o af.Business
W 3 m and any Inns Calc The Commcm...License Law s Ira not apply s ,1 owner of OUTL T 'WRCHF_S-FIXTURES
R'
,.,any who halls,or inided th thereon,and who nts Iran-,as himself or through
his own employeese provided thus such improvements we not intended or olPerN for NIiW kF.SID; SQ i'1'.
sale.If.however he building or impmvemcm is uslJ within one year of compktinn.the SQ.FT.FLOOR AREA BISQ.FT.
ponen-builder will have the burden of proving that he did not build or Improve fur pur-
w of,ale.).
1,as owner of the property,am exclusively contracting with licensed contrition a 'f[l'IAL:
cirri the project(Sec.9844,Business and Frofeasinnr, _.e:)'Ihe commit—s-
ariseLawdoes nmapply m anowner of propany who buildsar lnrpmves thereon.and QTY. I'LUMBING PERMIT FEE
who amhanx orsuch projects with a contmaum')liccoscd to rsuunt to the Conmmmn'x
License Law, PERMIT ISSUANCE
❑lam exennpt under Sec. .B&PC for his wn
Owner - Dam ALTER-DRAIN&VENT-WAIHR(EA) LUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby ahrm under penalty of perjury one of the following declarations.
ImtvcandwillnwinminaCeniticatenf Consenttoxclf-inst'Nfor Worker's Compen- DRAINS-FLOOR,RODEARFA,COND. STORIES TYPE CONS'IRUCHON
action,as provided for by Section 3700 of the Labor Cale,for the perform:mce of the
work for which this pernit is issued FIXT URLS-VER TRAP
have and will ntainmin Worker's Compcnsaion Insurance,os required by Section GAS-EA.SYSTEM-I INC.3 OUT[.EPS
:Par of the Labor Code,for me laidabumce of the work for which this penal is issued. OCG GROUP APN
My Worker.Componsmiorylnxunonacaricrand Pnlleyn m e a OAG_I;A.SYSI'P.MOVERn(Pd) -
Carier: A/�+ dLaR 7 Policy No.:
T C.'RTIFICATE OF EXEMPT ION PROM WORKIiks' GkBASIJINDUSTRI.WASTE IN'03RCEPT(IR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('liticsecdonnced tint becompleted'dfheperoul is formic hunichaldmllars($IM) GR IASRTRAP
or less) PLANCHECK FEE
L«nifythat intheperformanceofrhe work fm whichthia permit is tamed,[shall S13WER-SANITARY-STORM EA.208 FE
not employ any peamt in any comma at,alto hamw W
am aulical the orkers'Counpen- ENERGY FEE
Z satin laws of C.ffanm Dam WA'I'17R HEATLR W/VENT/!LECfIt
O Applicant GRADING FEE Pill
lrebeNOTICE TO APPLICANT.If,after making this Certificateinl of ILannptia d you n'Intaild
nmol WATER SYSTIiM/IRCATING
E
Mcnme nuh'cm to mu Wodct's con enmtinn I'hu Lnbnr coda,rot must sous 11?B
p lir miit hall QAA
[31 fnMwith comply with such provisions onhis permit shall bedamnl rewked WATER SIiRVICF.
Q. Q
Z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ,FT PATO
Nec<ipt
U - Du p
i herehy aliinn that mem ix a mnsbucIran lending agency for 0e perfunntirne mf
L) 0 the work for which this permit is issoeJ(Sec.3897,Cis.CJ fnaA-ti r 1
0 Lenders Name ,Q o [ 'l1yfAL:
LU17 Lender's Address Na V 1 BUILD[N lil'
0. 1 Owil'y that I have road this vpplicaion and state that One shove infer,afion ix
F (/) carred.l agree to comply with all city and.mall ordinances and nae laws relating as QTY. MECHANICAL PERMIT FP.E
[� Z building cnnswctimn,etidhereby aahmm mpresentativesathis city mentpa
or unthc SEISMIC FEB
above-nwntioned pngeny for Inslwcri:m purposes. PERMIT ISSUANCE!
(We)agree to se,indcnmify and keep hanulcvs the City of Cupertino against EhIi6TRIC FE
save,
liubilities.judgmems.costs and expenses which may in any way a came against said City ALTER Olt ADD TO M ECH.
in nwimence of the printing of this permit. PLUMBING 113E
APPLICANT UNDERSTANDS AND WILL COMPIN W11 If ALL NON-POIM AI R HANDLING UN IT(TO 10,000 CFM)
MECIIANICAI.PEE
SOURCE 1213GUTA'1'IONS. '
AI it HANDLING UNIT(OVER 10.000 CFM) CONS'MUCi'ION TAX
SignvfnreofApplicantlContracmr Date EXHAUST I RICO Dv/UUQI) HOUSING Mill RIATION FEE
I IAZARDOUS MAITRIALS DISCLOSURE
Winewripplicamo(future huilding«cuprraworeonhandle hazallons material HEATING UNIT(TO 100.0I0 BT U)
as detimal M1y the Cupertino Municipal Cole,Chapter 9.12,and the Heahh and Safety
Coda Scaien 25532(0)'1 I]BATING UNI'P(OVEIt WjfflBTU)
❑Yes Fl No b,• m an, VENPILAI'[ON FAN(SINGLE ki?SID) PAID Doc RaciptM Will the appllcaor limtm builAing to use enuipmenl or devices which
emit hmurJous air conmmimm�s ns Jd1neJ by dm Ituy Amu Aid Quality Manngenwnt BOILL+R-COMP LHP OR 108,10 BTU) TRY
DisuiaP
❑Yes ❑No BOILER-COMP(OVER 100,003 BTU)
I have read the hamNons materiels rcquircmens under Chapter 695 ofthe CO. Alit CONIII'1'IONP.H ISSUANCE DATE
fornia health&Safety Cale,Sections 25585,25533 mall 25534,I understand that lithe NEW RESIDENTIAL MECO SQ.FT.
building does urn ammmy have a tamum,tha it croy res{amshility to notify the nccupnnt // `���
ofhomynlre era,vil mu.vt ut p,ion vxc a,'ifa Ceoilicmeaflhvrymq.. J
Own 4fFad e TOTAL ISSUEDBY:
OFFICE