S 1565 (2) APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO C I BUILDING-ELERICAL PH IT NO,
BUILDING DIVISION APPLICATION/PERMI'1' 1'1.1161BING Mh:CDANICAI' 1565
I11111.DIN(;PROJECT'IDEN'r119CATION
Ii ILDINO ADDRESS.. SAN1'1'A1<Y NO. AYI'hICAI'I(1N SUIIMI'ITAh DAT
G I c I 5 f "I 61AV6 R-D • Z�
OWNER'S NAME: I ...TONE: r� N'I' ACI OR'S NAME LIC NO:
TNI VP NI ZI&2Z NAc III coN'rKQLa
ARCHI'I'EC'VENGINEERLIC NO A SS'. . ❑ � l�
IE fete G ISL84s ✓ `/
CONTACT: Plans, I l T BUILDING PERSITI'INFO
l ��It �� 6O 1 7s 91 T-1 ❑ Consultant Fees Paid by Applicant(Initial) It1.UG 11.F: PLUMB NIECH
/ I LICENSED CONTRACTOR'S ISRMI'I'ISSUANCIi
Licence In-CLARAl10N Q'IY IiLIsCTkIC PERMIT I'EE
CZ 1 hereby affirm that I am licensed under prnoi.ion.of Chapter 9(cJOB DESCRIPTION
1'
OaZ with Section 70,X))ofD.......Sof me Inqueeeand Profcv.ion.Cale,snit my llam.eis RESIDENTIAL:
W O
Fps.-. in full fhrccandif !- QSFDWL ❑KITCHEN REMODEL
aUU Lica J APPLIANCES-RESIDENTIAL, _ DITION ❑PLUMBING RE-PIPE
FZ Poc Cnnwanr %P,/Ty��
,RCHITECI'S DECLARATION PANELSM1ILJULT[-UNIT QN
STRUCRAL
�+
Z w Z I undercunJ my plamshall he coed m public nvnN. MODIFICATIONUP TO 21N1 AMPS
O Z O C INTERIOR Q CHIMNEY REPAIR
f=�F'u1 Licensed Professional 2011-IINX)AMPS IMPROVEMENT E]SWIMMING POOLS
,p 27, OWNER-BUILDER DECLARATION
z OVER 1000AMPS ❑BATH kIiMODE1JRli1'Nk QUIiMO1.IT10N
C C Q I hereby affirm that 11. exempt fntm tb, i,sioraars Liceroc Law,for ma
pKj 3 F following reason.(Seaton 9(131.5. t,alter.
and improve.
de o li h.or:Any din or rcure SIGNS RLF.CTRICAI, Q OTHER
y which requires issuance.permit requires
e carcase alcor,improves demolish, fi repair any tateme e
f'u'06 that he itssI rioedalsomgo a re the applicant for mchperminoicensle ae aw(stmpter9 $I'F.CIAh CIRCUIT/MING.
that menti gw it pursuant come of pit iota of the Conwness License Law Code)
(cal he is iscromameffran doh Dasisfr the Aland exsopeom.fAny,nCrdc)or l'EMP.METER OR POLIS INST. p
a a e 5 ohm he i.exempt thercfmm snit the basis for the alleged exemption.Any violation of ❑NEW BI f)G/A DI'tlhJNJ DDE-MOLIT10N
W m F Section 7031.5 by any applicant fora Permit subjects the applicant m a civil penalty of T'ON'ER DEVICES
I,z QTIiNA: ❑FOOU SERVICE
SSCcot marc man five hundred aullvw($$W]. IMPH _ l'
❑ Las owner of the Pmpeny or my employees him wa,es as 0eir cote cumpansmion, SWIMMING POOL ELECTRIC 29
F will Jo the work,and the slrucmre is not intended mothered for sale Sys.01114,Business El OTHER
!�7
e, m and Professions Calc The Counselor's License,Law does not apply to an owner of OUTLITS-SWITCHES-FIXTURES CIT
Tampere,who builds or improves thereon,and who docs such work himself or through II
his own employee.,proviJN Thal such improvements err,nut intended or offered for NEW RESIDENTIAL ELFC R SQ FE Vell
sale.IL however the building or improvement is sold within one yearofecmpletion.the _ SQ.FT.FLOOR AR $/SQ.FT
poer-builhave the burden of proving that he did not build or improve for pur- O
se aGmle.).der wi11 T . ,. q LA
Q Pas ox net of the pmpeny,am exclusively contracting with licensed contractors to rp
curse a the project Soc.o1N4.Business and property
whbut ds ori The Contractors Li- T
curse Lawdoesmrsuch primas with
awner ofpmpeny wbobuildubsimpms ac theCommf.anJ QTY. PLUMBING PERMIT FEE
xeha comrans for mcM1 proj¢u with a contractors)licensed pursunm m the Comrumr s 4=06 2-513ji
License Law, PERMIT ISSUANCE
Q I am exempt under Sec. ,R k P C for This.,,in
Owner Uac ALTER-DRAIN k V. IJi(WI /_�ya1.UA'DON
N'ORKF,RT COMPF.NSA'1'ION UECLARA'1'ION BACK FLOW P F.DEVIC. 'mak• a(
ca —
Ihereby affirm under Penalty of pseJury one of The following declaration V � OW
Q l have and will maintain a Certificate of Consenttoselhinsurefur Workcls Compem DRAINS-Iq.00 .k E OND.
tion,a.provided for by Section 37M of the Labor Code,for Ne performance of the STORIES TYPE CONSTRUC710
nark for which This peril is issued. IFIXTURES-PER TRAP CZ
Q 1 have and will maintain worker's Compensation Insurance,as required by Section
37M ofihe Labor Code,for the praffarmanmofthe work for which this permit is i...o1 GAS-FA.SYSTEM.]INC.4 OUTLhTS OCC.GROUP APN
My 'orkpls>:yte: mapE_tir��ie�sumny}camer gond,bm, �j''�)JN+ Z< 9 GAS-IEA SYSTFb1-OVIiR 4OiAI
77//111�f(l�/1p1 PI yNo.: y<//Al
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASI%INDUST RL WASTE INTERCEPD)H
IThb refinanced not be completed ant,permit is for onchumlred dollars t$I anBUILDING DIVISION FEES
in less.) GREASE'I RAP PLANC iG
Icerify that in no Performance of the work for which this permit is issued.Ishall SIiN'lik-SANITARY-S"TOHAt ISA.NN)IT.
not employ any person in anv manner so as to become wbject .,he Workers'Cumpen- ENERGY FEE
O Z ration Laws of California.Date WATER BEAI'IER W/VENT/ELF,CTR
Z Applicant GRADING PEE
y NOTICE TO APPLICANT:If,atter making This Cenons at of Exemption,Labor
you should WArER SYSTE.WI'BEAT ING
? become scoop m the Worker's Compensation provisions Uf the Labor Cale,you mull SOIfS PF[
� turmwM comply with such provisions or p,rmn shall he Ae�mcJ revoked. WA'fBR SERVICE
a �
� z CONSTRUCTION LENDING AGENCY. NEW kISSID1iN'TIAI,PLMR. SQ.EL PAID
U O thereby affirm that there is a comwction lending agency for the piommmance of U: Rveca,na
IT. Ea the work far which his permit is issued(See 3097.Civ.C.)
Q U Lendke,Name 'r(TI'AL:
Lenders Address T lAl
F0.Wi 1 cemfy mut 1 have read this applicnnim cad ,am dentine aAwe information is BUILDING E E
fA correct.Lugo to comply with all city and county ordinance%and shoe laws retain,to QTY MECHANICAL PERM IT FEE
Z building construction,and hereby authorize representatives of this City it,enter upon he SEISMIC FEE
aMve-mentioned property for Inspection purposes. PHkMI'f ISSl1ANCI?
(Wel agree m save,indemnity and keep harmless the City of Culenion against ELECTRIC FE/
Ilabilities,judgmetns,costs and expenses which may in any way uceme agaimlxairiCity ALTER OR ADDTO MECH.
consequent ming of this permit. I PLUMBING EF.
APP tICAVN�DJT, )WILL COMPLY WI"rH ALL NON-POINT AIR HANDLING IINI'1'f10111,INXI CIM) MIiCIIANI AL IFF,
AIR HANDLING CHI I'(OVER 10jift)CpM) CONS I'RU AX
RTgunuarlZe of AppleanVConmalian }* EXHALES FOOD(W/DUCT HOUSING MI'IIGA'TIO ';E
HAZARDOUS 11 'ERIALS DISCLOSURE
Will the applies.,nr fumm building nccupnm sono,or handle hazardous material 1117NI'ING UN1'r(10 1 P,)PE BTU)
its defined by the Cupertino Municipal Code,Chapter 9.12,ant]the Ileallh:cod Safety
Code,Section 25532(u);' HEN)ING UN1'r(OVER HNI,non B'IU)
Q Yes QNn
V17N'I'I LAI'ION I AN IS I NGLI!RIES I OI PAID
Will the applic:un or Imam brudag:mcupant be er,a pumnt nr devices which Uma Rerel I a
ton hanmJuunair nmhminnnts as JufinW by the[lay Area Air Quality Manugcntma BOILER-COMP(311POR INocto if Iu)
Disu e,I YUAL:
QYet E]No BOILER-COMP(OVER 100.000 B'1'U)
I have read the hazardous materials reyuimlChup
altt b 95 of the Cull" AIR CONDI'I'TONER ISSUANCE DATE
nnnIr under
forma Health h Safety Code,Socum,25505,25533 and 25534.1 undcranmd th:a it the NEW RESIDENT Al.MHCII. SQ.FII
building does not eurmtnly haveanese Thal it is toy I c.panQlidr,m.s yThe nn'us
or he myai nrems'fill,amt be ma in a maninecof a Caffi,,ne of O,,a, cy,
Owner err authorized agent Unte 10 hCSUHD I3 Y: Met
OFFICE