S 1156 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF'CUPF:RTINO RUILDwc-EA.ECIA[CAL P `^rr No.
BUILDING DIVISION APPLICATION/PERMIT.
PLUMB ID-MblOBnN'IFIC J 1156
I-BUILDING PR(IJRCT IDM.N'I'IFICAR'IUN
ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT(
o e Bl
!'HOONF: NTRACTOR'SDAME: LIC NO'.
O!!' p/ LIZ NIC CONTROhp
ARCH TECT/ NUMBER: LIC N11 (DRE' O O e ,.v, r ❑
MRO
CONTACT. //gyp -P NE BUILDING PERMIT INFO
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T 7 $-9375 [:] Consultant Fees Paid by Applicant(Initial) � ELECT PLUMB MECH
9iS G o bNL -tLL
LICEN. CONTRACTOR'S DECLANATION QTY. ELECTRIC PfiRMIT FEE
I hereby alarm that 1 am licensed ander provisam,of chapter 9 mmmidng j :. JOB DESCRIPTION
WON with Section7000)nfDivision7ofineBmineu and Professions Cale.undo Vic
RESIDENTIAL:
WOO PERMIT ISSUANCE
f-wF in full force and effect. ❑SFDWh El KITCHEN REMODEL
�UU Lierse Class _ Lic'k APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIz.PIPE
FF Z W Dom GMtucna
to
66 Dan—
DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
F
Z:)
m 1 understand my plans shall be used as .hire records PANELS MODIFICATION
Z O y 7j- UP 9'0 20O AMPS
p'�..0 El INTERIOR ❑S CHIMNEY RPOOL
AIR
Llceosed l'rofessinnnl 201-ItXN)AMPS IMPROVEMENT SWIMMING POOLS
SYf,-..d)
OWNER-BUILDERDE he Com ION OVER I"AMPS ❑BATH REMODEIIREPAIR []DEMOLITION
SS 1' 6 1 hereby off roe IM1a 1 am exempt from me Comrennr's License Law far the
ipa,c 4 U Billowing moon.(Section 7071.5,Busina9.s mal Prefesnioo Code:Any city or county GNS ELECTRICAL ❑OTHIiR
W a 0 Na which requires a Permit to construct,alter,improve,demolish ter repair any structure
O.] priortoitsiewance,also requires mcapplicant frlwahlonaiu.file a signed smmmenl SPE'AI.CIRCUIT/MISC.
6� that he is licensed pursuant to the provisions of the Comtnmmr's License Low(Chapter 9
p$p0 (commencing with Seaton 7000)of Division Sof the Business and PofesaionsCnde)or TEM PVFR OR POLE? ST COMMERCIAL:
CL Lf, that be is c.acmpl therefrom and the Jami,for the alleged exemptlan.Any violoila of EW BLDG/ADDITION ❑DEMOLITION
YXI
Second 10113 by any applicant lot a pconbsubjmts the applicant o a civil penalty of POWER D VICES BNANT ❑FOOD SERVICE
not me man five hundred dollars($500). IMPROVEMENT
q QO 01,as owner ofthe pmpnny,or my employers with wages as their sale compsmmdiar SWIMMING( OL ELECTRIC
OTHER
willdothework.indthestrucmbab,sit imm�dedorallered mrsale(Sc,7045,lboutss
a 3 vad professions Cale:The Collectors License Law does not apply nm on owner of OU'RC'1'S-SWI HIiS-19XTU ES
Property who Mansur improves(hereon,and who does such work himself ur though
his own employees,provided thin such improvements um not intended or offered for NEW RESIDENTIAL r ECfR SQ FT.
sale.If,howasenlhe huilditigorlmprovemem issnld within oneyeurofemsdrlorthe �SQ.Ff.FLOOR AREA S/SQ.Irl'.
owner-builder,will have the burden of proving that he did nm build nr improve for per-
pose of sale J.
❑ 1,as Brener of the pmpety,an,csdusivuly Praha,...with licensed contractors i-
onstrvcl the project(See.9044.Business and Professions CaleO'I'h.Contractor's Li- t" A 1 D
camrs,law does not apply to an ow,net of prol'cny who builds or improves thereon,and QTY' PLUMBING PE IT
who contracts for such projects with a commands)licensed pursuant o the Contractors
License Law. ,r PERMIT ISSUANCE JA�20
1 am exempt under Sec. .B&P C for mis mason a
ft
AUER-DRAIN&VENT-WATER( ) VALUAtiM
Owner Date WORKER:SCOMPENSATIONDECLARATION 1 .O. Ii ry(jt: �UrCJ'InryU
I hereby anion under penalty of perjury one of the following dccla tions:
El VEAINS-O(IOR,ROOP,A STORIES TYPECONSTRUCTIOL
sation,as provided far by Section 37W of the labor Gale,for the performance of the ��
work for which this permit is is.aed. - R/WAt
O
❑1 have and will maintain Warker's Compensation insurance,as required by Section n^�,
7700ofthe labm
orCeds,far the perfoanceofthe wok for which this permit is issued. - A.. '0ha T, OCC.GROUP APN
My Workers Compensation Inumet,caniervnd Policy V-9 52 F CO p
ureter: Policy Nn.:
lft
CERTIFICATE OP EXEMI"I'ION FROM WORKlzRS'
ccpdpENSADON INSURANCE ST .' •PTOR 'O"`e BUILDING DIVISION FEES
(This section need not be completed If the permit is forma hundred dollars($100))
e ®d Btu PLANCHECK FEE
toy any mat mine performance of the work bronchi this,man is is+ueJ.l shall g
not employ any person in any manner so as to became wbjm m the Workers Compete oftd •I' a ENERGY IFF.
Oz salmon Laws of Cadifinnum Data WATER HEAfE WN' ' IiCTR S GRADING FF,F.
z Applicant
NOTICE TO APPLICANT:IL after making this Certilicule of Exemption,you should HA
h y become subjects.the Workers Compensai..pmvinionz of the labra Code,you ansa OILS PER
WH fonhwinhcomply with such provisions or this permit shall hedemned mveked SERV li
Q
CONSTRUCTION LENDING AGENCY NEW REI ' PAI
`7 z I hembyaffinmbeuhe.isaconmmmion lending agency fortheperfrour of Date Reecipnif
U the work for which this permit is issued(See 7097,Civ.C.) • -
W I-+ Lender's Name TOTAL:
U Lenders Address L:
1'�r" Gk7 I certify that 1 have read this application and state that the aMm -nfamumion is - BUILDING -li
fry canes.I agree menmply with all city and county ordinances and state laws relating nu QTY. MECHANICAL PERMIT FEE
U z building construction,and hereby uuthoriae renesemalvesofthis city asenter upon the SEISMIC FEL
above-mentioned propeny for inspection p nitows' PERMIT ISSUANCE
(We)agree to save,indemnify and keep hapless the City of Cupertino against in FEE
liabilities,judgment..M
may in tiny way acme against said City AI-TERORADDTOMECIL
asequence of Ot PLUMHING FF.R
APPLICACOMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IU.000 CFM)SOU .- EGULAT Q Q MECIIANICnl.11?E
r/ � /Q AIR HANDLINGUND(OVER 10.000CPH CONSTRUCTION'isx
Signawre afAppli n ntrannr Date P,XIIAUST HOOD(W/DUCT) HOUSING MITIGATION FIih
HA RDO Al ER ALS DISChOSURE
,I cruor titin uildingoccupent emre nr handle hoenloussmaenal II EATING UNI'1'(TO 1 CA000 RTU)
as defined by the Capetian Municipal Cock,Chalacr 9.12,and the Heabh trod Safety
Code,Section 25532my? H17ATING UNIT(OVER 100.000 If Of
❑Yes ON. PAID
V17NTILATION PAN(SINGLE RESID) Dam Receipta
Will me applicant infurore building by the B sew a Air uQu of devices which BOILER (SHL'OR 100.0 0 BTU)
mil hvallous air contaminants as define)by me Bay Arta Air Quality Management TOTAL:
D sefict?
❑Yes _ ❑No BOILER-C(7MPlOVER 100,000 BTU) _
I base read me ha omm us am eri raiui¢mcnna under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomite Health&Safety Code,Sections 25505,255)7 and 255]4.I understand!that time NEW RESIDENTIAL MECIL SQ.EL
Haddad,do.,am cnncntry haven Leman Inn II is my rvrrymsibility o notify she acceptol
of me 1,mremems which nun he met prior et issuance of a Cenilieme of Oceupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE