S 1253 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUR LDING-IMECI'RICAL PFSITND, 1253
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL l`1
BUILDING PROJECTIDEN IFiCATION
BUILIIINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAPI!
olbu- to ,2 s*X9 75 2 L"19�
OWNI!R'S t0MTh q� {f0_' [ kACI' 1'S NAMii: LICNO'.
�{/La•�Vt„ {/a N/C CONIR(ILN
• ARCI IITECLENGINEI!IR - LIC NO: AI )RES I ��l ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BAG ELECT .0 MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEC
PS
I hereby affimt that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
BIZ with Sectio 7X10)of Division 3ofine Husincssand Prntastier,Cate.and my license i. RESIDENTIAL:
E,WO in full force and effect — PERMIT ISSUANCE ❑SFDWL ElKITCI IHN REMODEL
�Uru Loren Lic.0 APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
I-Zi D.1 Contmmor
ARCHITECT'S DECLARATIO PANELS
❑man-UNIT []STRUCTURAL
ZONZ 1undersaW my Plansshall beurdapublic recods OMODIFICATION
Z�Q UPTO2XIAMPS ❑INTERIOR ❑CHIMNEY R17PA
IR
r4E'W Licensed Istroosional 201-10MAMPS IMPROVEMENT SWIMMING POOLS
XF; OWNI!R-BUILDER ULCLAkAI'ION OVER 1000 AMPS El BATH REMODEL/REPAIR F1 DEMOLITION
low44''Q 1 herchy m imi that 1 am exempt from the Contractor's License Law for the
XX( U following reason.(Sorrier]031 5,Business and 1'mm,,in is Carlo Any chy or cnumy SIGNS IU.ECI'RICA], ❑OTHER
W 3 W H which requires a permit m construct.alter,improve,demolish,nr repair any structure
OQ prior to its issuance,also requires the applirnm fursuch permino fileusigned sulemeot SPECIAL CIRCUIT/MISC.
'list he is licensed pursuant to the provisions man Contractor's License law(Chapter
W pa'p0 (commencing with Senion]OIX)of Division 3.fdm business vnJ Professions Cade)or TEMP hfEDiR OR POLE INST COMMERCIAL'
a c z 0nu he is exempt therefrom and the has..for the oB
eged exemption.Any violation.1 [I NEW RLDGIADDITION ❑DEMOLITION
m
Section 7031.5 by any applicant for a permit subjects the applicant at a civil family of POWER DEVICES ❑TE.NANT ❑1'001)SERVICE
uw more'lum five hundred dollars(&5(10).
F Z Y IMPROVI:MY:NT
SQ ❑ Lo.owner nf the pmpeny.or
remyemPbyees oithwred for sale(Sec.
compensation, SWIMMING POOL ELECTRIC
FO will do the work,and the structure is not inrcndeAmuOcred Em sole(Scu.]1114,Rosiness ❑Out IBR
w unit Professions Coke:The Contractor's License Law docs not apply to an ismer of OUTLEr S-SWITCHES-FIXTURE.
pa upeny who builds or impmvas thereon,and who dues such work hmnsel l'or through
his own employees,provided that such Improvements am not intended or offered for NEW RESIDEerrIAL ELECT R SQ
sNe.11h.wcvcr,rbc building orimprnvcmem is solA within nuc year of cnopletin r the SQ.FE FLOOR AREA $/SQ.PI'o
owner builder will have the burden of proving that he did not huilJ nr improve for pur-
p:s,of sale.).
1,as owner of the pm Nit,am exclusively contracting with licensed mnuacntrs to 'I'(ITAI.:
rnnctmm the pT.jem(Site.]OW,Business and Prifessiin.c Code:)The Cintmmnrs
cense Law dos not apply to anownet of property who builds or improves thereon,and QTY. PLUM RING PERMIT FEE
who amtmns for such pmjems with a contmcncrtO licensed punoant to the Commences
I.icenxe Law. PERhtI'1'ISSUANCE 4 s
C]1 ant exempt under Sec. .Ii&P C for this reason G�
Owner Dam ALTER-DRAIN&VI!N'f-WA'I ER MA) .t;VAIAATffigf
WORKI!R:S COM 111?NSATION DECLARATION BACK FLOW PROTECT.DEVICE </Iy(CI
I hereby aftimt under penalty of Perjury one of Ne following declan tions: L/
❑ I hnveand will mointuimn Ceti&um of Consennn selbimare frWorkeLv Gmtpem DRAINS-FLOOR,ltO()IIARI:A,COND' 3'IORIES TYPE CONSTRUCTION
sati.q as provided far by Section 3700 of the Iabtn Coke,for the perfmmunce at the
k for which this on,is issuedFIX'1TRES-PER TRAP
have and will in orcin Worker's Compensation Insurance,as required by Section
]W ofrhe[.:to.,Code fir the performance of the work for which this pennh is issued. GAS-PA.SYS TEM.I INC.4 OUTI.EI'S OCC.GROUP APN
My Wares sons., n Iso re artier and Policy numberms: N.
Cameo _Policy No.: �-p' GAS-EA.SYSTEM OVER 4(HA) ,
C RTIFICATEOFIX(EM11HON FROM WORKERS'
COMPENSATION INSURANCE GRHASE aNDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION IT!ES
(Th'usrctio ineernor becnmplemds the pemtit is foronehundreddollus(SAID)
,art..) GREASE'I'RAP PI.ANCHFCK FEE
I eerily that in the performanceofthe work tnrwhichrhis peon is issued,l shall SEWER-SANITARY-ST(IRM P.A.2W FT.
net employ any person m any manner so as to become subject m the Worker\'Cnmpeo- EN17RGY FEE
Z sarin laws of Odilinna,]),Is WATER IIHATER WIVENTLECIR
7�7 GRADING F
Applicant IiIi
G y NOTICE To N'PLICAN'P IC alis,r akin,this Ccoricn r of Exemption,you should WAI ER SYS"I EMOMEATING
F become sobject m the Workers C.mpea,linn Provisions oI the IaMn Cu le,you must SOBS FEE
Bmhw lit comply with such provisions...this permit had is,decimal rrv.k,d. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR SQ.FI'. PAID
U OD. ReeciptN
1herchyahis
that there isinswetionlending agency for the performance of
the work for which1,this permit is is,nel(Sec.31X7],Civ.C.)
0 F" Lender's Name TOTAL:
L) L<ndets Address TOTAL:
I certify that I have read this application and state that the above nomination is BUIIDIN
r
(A correct.l agree to comply with all city and county ordinances and stale laws relating to QTY. MF.CHANICALPHRMIT FEL?
LJ 7. building mwwcti.n,and hereby authorize mpresematives of city mentor opnn the SEISM).1�'
above-mentioned provenY for inspection Purp.ces. PERMIT ISSUANCE
(We)agree m save,indenmily anJ keep hnnnlees the Ciry of Cnpen.no against 1 ELECTRIC Fl!
Iiabilities,judgmenis.costs and expenses which may in any way berme against said City AUITRORADDTOMECIL
mnmryencc of the gmmlogn(this lcoit. PLl1MBING !L'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10,000 CFM)
APPLI
SOURCP ONS A / MECHANIC IME
L ' _ s S �./`7 1pd AIR HANDLING UNIT(OVER 10,11(X1 CFM) CONSTkl1C ON TAX
Signature of pplicantrContaenr JV�s—y- // )are Ca EXHAUST11001)(WIDUCI) HOUSINGMITIGA NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant it future building rccupant more or handle hicamous material IMATING UNIT(TO I W.000 B'I'U)
as de0ned by the Cupertino Municipal Code,Chapter 9.12 and the Hoalnh and Safety
Code,Section 25532(a)? HeNrINO UNIT(OVER IPilots)BTU)
p Yet, ❑No VENTILAITON I AN(SING LE RI7SID) PAI)] Data RceeiptN
Will the applicant(it future building recaps,use equipment m devices which
emit bounden,air comminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3111'OR 100,000131U)
TOTAL.:
D..tHe,! BOILER-COM P(OV ER 100,000 BOJ)
❑Yes ❑Ni
I Love rend fle hazunlnus onalt6als reFiiremems under,Chapter 6.95 tithe Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cede,Sections 25505,25533 and 25534.1 undersand that Hthe NEW RESIDENTIAL MECIL SQ.FT.
building dues nor enrrently raven er ra,that it is my respmsibiliry m nnrify rhv occup:mt
.f the requirements which roust be met he,m issuance of n Cambium of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE