S1829 -APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEtH NO. 1829
BUII,DING DIVISION APPLICATIONT..ERNIIT PLUMING-MECHANICAL
BUILDING PROJECT 1DEN'1'IFICA'1'[ON
BUILDING ADDRESS: SANITARY NO. APPLICII']ON SUBMI'I-I'AL DATE
f70 ed g v •v VX, 7 23 e—L�'
t5W 'ERS NAME: ^O -PHONE: C'ONTRACfOR:S NAME: LIC NO:
.J /t/ NIC CONTROLq
ARCIII'I HC7UEFGINI3R:Z LIC NO: ADDRESS: ❑
-;if 2
CONTACT: 7 PHONE: BUILDING PERMITINFO
o sr � r� Ya8 �ls�G Y�7L ❑ Consullanl Fece Paid by Applicant(Initial) BLDG 'I 'Cr PLUMB MIz H
❑ ❑ ❑
1101 YSFD CONTRACTORS DECLARATION Q'IY ELECTRIC PERMIT FEE
In by affirm that licensed d provisions of Chapter9(commening _ TOB DESCRIPTION
O0Z ES t ]WO fD 3 theBas dP fssin :Cd Inylic RESIDENTIAL:
1 W. wt PERMIT ISSUANCE NW.,. .full Gtuntd clRc r�mss ❑SFUWh E]KITCHEN REMODEL
aUU Date I_ic.p gpPL1ANCES-Rt51DF.N'1'IAh ❑ADDITION [I PLUMBING R�PIPE
tn se p. Date Contractor
Orn ARCHITECTS DECLARAT[ON - PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZOI z I understand nh hall be ed,ns u biw orsord, - MODIFICATION
y- Ypanssusp
OZ,.,a UP T021NIAMPS ❑IN'I'F,RIOR ❑CHIMNEY RIiI'Alk .
H�.B'.u] l."onsul Professional 201-10A)AMPS IMPROVEMENT I]SWIMMING POOLS
OWNER-BUILDER UECLARA'I RUS OVER IU00AMPS OBATH RESIODEUR t DEMOLITION
a:ow25 Q I hereby affmt that 1 am exempt from the Counselor's License Law for the
yxj 3 LL F following reason.(Section]031.5,Business and Professions Gale:Any city or county SIGNS ELECTRICAL ❑OTHER
ZP le
0 which pe t t carve, It p L
e demolish.M1 p 1 structure
�d mic I I--are,also mcuio,Ih 'Ill' hl h,nodin,fl b Lttencat SPECIAL CIRCUIT/MISC.
A 'butt licensed p : It Ih p ':to fth C t t L e 1' (Chapter9
aca� (commute hgwidaSection 7000)ofDivision 3 o be Busifv,,.nd Professions Cole)or TEMP.h1 I:HER OR MOLE INST. COMMERCIA:
a a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
y
Section 7031.5byaa,applicant far.permit subjects the applicant to a civil penalty of POWER DEVICES C1 TENANT ❑I`ODD SERVICE
t than Five hundred J II :1$5D0
^Zr uoIMPROVIiMIiN'1'
< 1 fthep ty Y tar y 1h 6 forIl : 1 't n. SWIMMIN(I POOL LLI'CI RIC
ESQ
will th kandto a t tint Jd [t e, (Sec.,,an Business- ❑OTHER r pv�T
Cr-o
W�m and I n fe:: . Cale: Il C tmemr's License,Law docs not appy at an cattier of OUTLETS-SWITCHF_1-I9XTURES J� Q
6 3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements art not intended or effemd for NEW RESIUENTIAI.ELIiC!'R SQ FT
,fidsILbowcvcgthchuilding onntpromnmm issold within n.cYmrof anmplmion.me SQ.ler.hL(Ill AkEq EISO.FT.
erbtdlder will have the burden of Pan ing that he dad not build or ingnove Isar p l
poscofsale.). v
01.as weer of the property,am exclusively contracting with licensed instructors to TOTAL ^/
onsaum the project(Sec.'/U1-L Business and Professions Cole:)The Contractor's Li-
-m Law doers not apply to an owner of progeny who builds or improves thereon,and Q'I'Y, PLUMBING MIT FEE
WhOCOoloRCIS lsaraaOl pntjeets with ncommlocol)1111-1 callool Bathe Colnmelary
License Law, PERMIT ISSUANCE
1 ant esempt under Sec. .B&P C torr this reason
Owner Date
ALTER-DRAIN&VLYI-WATER(6\) VALUATION
a�
WORKER I COMPENSATION
y,a DICT ARAIION BACK FLOW PROTECT.IIEVICF. OOO
t� -/ . by B t der pctalUnlpel y fe II rd s'.
Xon,as and will manta neCcrnEcate of t tLbor ode.for
Wtminato of ation-
DRAINS-FLOOR.R(l01 AREA,COND. STORIES' TYPE CONSTRUCTION
moon,as provided for by Ss issu d. of the tabor Ctulc,for the pednnnuncc of the
work fur which this)smut is issued. FIKTURIS-RiR TRAP.
and will oat,for he trios Compensationwork
bor Insurance, h required by Section' -
590(I rdthelatvhrCale for he pedomtuncoadthe PI lbr which thispunnit leissued. GAS-f?A.SYSTEM-I INC.gOUTLF,TS OCC GROUP AI'N
My WckcygImp >,Ae r:nyp<c: tJyellcy mm�bcrare: GAS-EA SYSTEM-(IVER i(EA)
SS�� ..aa/Yr ani'
Camvr. /� A� � P IN FROM
t �CERTIPICATB OF Ii NFION,�T)N FRANCEI WORKERS' GREASIANDUSTRL WASTE INTERCEPTOR
COMPENSATOt'o, .it
for BUILDING DIVISIONItil3
(lTis section need nm he cnmplend it the permit it forme hundred dollars($I W) GREASE'I'RAT'
or less) I'LANCHECK PI?I?
Ieeoify fleanl hepedonna.cmdnhe worklitrwhieh Ibis pea too is ismed,Ishnll SEWER-SANITARY-S ORM EA.200 FT.
not employ any pm.on m any moaner o.s to become aihject to the Wu.lofi,Compcn- ENERGY P138
oz cation laws of Califort Date WATER HEATER WNENTIELECTR
Z Q Applicant GRADING FEE
NOTICE'f0 APPLICANT:If,after making this Cenifcme of Fxemption,you shadd WATER SYSTEMn REA'I'ING SOILS FEE
� � heron,subject to the Workers Compennmion pmvili ,it he Labor Code,you must
Qforthwith.amply with such p ovinnss...thin permit.hall he deemed revoked WATER SERVICE P A /3-A,y
D. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUMP. SQITPAID `�
V O I hereby affirm thatthere is a construction lending agency for the pummiance of . . Date Re<eiptx
the work l'or which this pent A 1Sce.3W7.CIe CIJUL
U Lcnduks Nunn— 'IOFAL
} j Lender's Add..... '
TOTAL:
�I�•6. I mink that 1 have mad this application and state that the above truncation is _ t ,,. BUILDING HE
F' y correct.I agree to comply with all city and county ordinances and rate laws relating. QTY MECHANICAL PERMIT FEE
V Z building nutsauction,and hereby amhorize representatives of this city to enter upon the SEISMIC lT}E
A...ca tcminned posy for in....nor purposes. PERM1'f ISSUANCE.
(We)agmc to save,indemnify nal keep harmless the Cil,of Caperton.against ELECTRIC FEE 3 <
Iinhilities,luJgmert¢,aaarnnd expenses which may inany way crunmapainst said City ALTER OR ADD TO MECI.
PLUMBING pl[E
in asequence ofthe Ironton,1S this permit.
APPLICANT UND[RSTAN SAND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNTI'(TO IU.rpO CISlp
SOUNf GULATI(lN5 MIiCHANICAI.ItiE
�9asO� ��l AIR HANDLING UNI'1'(OVER IQIIIXI CPM) CIINSTRUCTIf1N'I'A%
Wgnalurc Vf ApplicnnVContmctorr Dude EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HALARDOUS NIA'1'ERIALS DISCLOSURE
Will theappfi,me or future building occulum,umeor handle hamrJnm material HEATING UNIT(TO 101.0100 B'TU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cut,Set., 25532(u)' HEATING UNIT(OVER 100.000 BTU)
❑Yes VEN'ri LAI TON FAN(SINGER RESID) PAID Dmc Receipt)
W ill the applicant carr future building occupant use equipment or devices which
vnrdous air contaminants as defined by the Bay Are.Air Quality Marmgement BOILT:R-CO>IY(3HI.OR IIM).(1W HTlll
emit ha
District! f 1
El Yes BOILER-COMP fOV BR It1V.g1U H'Tlll
Ih dtheh rd materials 9 t: J Chapter 6.)5 fthe Cali AIR CONDITIONER �C ISSUAN'C17 DATE
fordo II ❑h y C de Scott... SSUS 25533 J 2553, l rte and tha f the NEW RESIIlEM1T1A1.FIIiCIi. SQ.FT J v
bull gr' t me tlyh t at;,, S ,,m llttvt nosily thexcupant o
ofd C m 1°nsw�nsthe pa nJsarssual.�y{':✓ .t ol'(dkc, yA [/��1
Own aandeaced age. 7v Dave TOTAL: ISSDED BY: f a - O
OFFICE