B 0612 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUDDING-ELECTRICAL R PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF,CIIANIC'AL S000 g06
BUILDING PROJECT'IDIINI'IF'ICATION
HUILDINGADDRESS. SANITARY NO. APPLICATION SUBMI'FEAL DATE
294 7 P-4 ( � G�
OWNER"NAME: P ZONE: CONTRACTOR'S NAME LIC NO:
` � (ZA � NIC CONrROLN
RCHITECT2NGINEER: ,JICi LIC NO: ADDRESS: ❑
CONTACT: PHONE: d BUILDING PERMIT INFOJ�� R� -Aol ;i 4d/,A31f ❑ Consultant Fees Paid by Applicant(Initial) BLDG EITC'P PLUMB MUCH
JN c.cj�^ El ❑ EDLICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alum that I am licensed under precision,of Chapter 9("murmuringJOB DESCRI ION
ooz with Section70of of Division 3 ofthe Business and Profession,Code,and my license as RESIDENTIAL:
W
won full force and elicct.i PERMIT ISSUANCE
F W - ❑SI'DWI. ❑KITCHEN REMODEL�U[J License Cluny Cont APPLIANCES-RESIDENTIAL. ❑ADDITION [D PLUMBING fill-PIPE
0 Zj a Date T'S DECLARATION
F 4 y ARCHITECT'S IIILCLARATION PANELS ❑MUCI'1-UNIT ❑STRUCSTRUT AT16
zgnz I understand my plans shall be used as public records MODIFICATION
UP TO 200 AMPS OZ—� ❑IMROVE ❑SWIMMING MOT
9AIR
4F rJ Licensed Prefessinnai 201-I(RIOgM1lS IMPROVEMENT CI SWIMMING I'OOIS
OWNER-BUILDER DECLARATION OVER Brad AMPS El BATII REMODEUREPAIR ❑DEMOIA TION
I heresy affirm that i am exempt from the Contractor's License Law for the
Li�SOyU which
ntorson, eons,n]03LS, r.roles and improve,
da.ium Code.Anyelty or fracture SIGNS EhIiC'rRICAI. ❑CrfIIER
int a 0I"' which rcyui..v permit to consumer.the,alter,impmvq demolish, fi repair any swctnrc
O that boslcensed purr ant to ms the provisions al lathe such penninoicense Law(comment SPECIAL CIRCUIT/MISC.
fly
(commencing
scansed pursuant to Division ofthe nusicoses nessnicenx Laonx Cedror9
ad 00
(commencing with gation]II0U7 of DivisionJnfthe Business and lhofevinnsCode)or TEMP.MCI'IiR OR POLE INST. COMMERCIAL:
ayx e¢ that he is exempt dominant and me baric for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^m
Section 7031.5 by any applicant for a Ext-musubjects me applicant to a civil Penalty of POWER DEVICES ❑TIENANT ❑FOOD SERVICE
on
not mora than Five hundred dollars($50h. IMPROVEMENT
[] Lasnwnerofme,pngreny,army employee,with wages us Nair vole comperi..n. SWIMMING POOL ELECT RICILZ
will do the work,unA the swemm is not intended or offered far sale(Sec.]040.Business ❑OTHER
and Professions Code:The Contractor's License Law docs not apply to an owner or OUTLETS-SWITCHES-FIXTURES
propeny who builds or improves themon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELF.CTR SQ IT.
ele.If.however,the building or improvement is sold within one year ofcompletionJM FT.FL $)SQ.14.
owner-builder will have the burden of proving that he did not build or improve far our. D Q a
peso of
❑ Las owner once propeny.am sine si an([contracting with:)Iheal amtmerom i- 'TOTAL: D
Li-
cuconstrve
rect theproject(Sec.o an wnerofsnoperty wh i butuns Cade:)improves
Contractor's 1.1- -
c selawdaennrnapplymmaithaofpmpenYwheboiWsoriapprotheCoreon,and QTY. PLUMBING PERMIT PEE MAY 21199
who comma¢far such projects with a ennwemr(s)licensed pursnvm m the Contractor's
License law. PERMIT ISSUANCE
❑I am exFem\pt under See. A,B&P C for rce�on
cG S S�
ALTER-DRAIN&VENT-W'AIHIE(IIA) VALUATION
WORKF 'SCOMPENSATIONDF,CLARAHON BACK FLOW I'ItOI'ECT DEVICIi
1 cby affirm under Penalty of perjury one of the following declarations:
❑ I have and will maintain a Cenificam of Comeal to self-insum for Workers Compare- DRAINS-FLOOR,ROOF.AREA,CONDSTORIfS TYPE CONS'TRUCION
ration,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
370(lofthe Labor Code,for me peromennea ofthe walk for which this permit is isvucd, GAS-EA.SYSTEM-1 INC.4 OU9'LETS OCC.GROUP N'N
My Worker's Cempcnwlion Insurance earlier and Policy no imer are,
Carrier Policy No.: GAS-BA.SYSIEM-OVER 4(EA)
CERTIFICATE OF EXEM PEON FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE IM'INCEPTOR
HULLOING DIVISION FEES
(Pastorate.Tistte.need rm
not W completed if the peit is farone hundred dollars($1no GREASE'IRAP
nr la,,,) I'LANCB[CK FEE
I acuity that inOne performencenflhc work far which this per is issuW,1A.11 SEWER-SANITARY-STORM IiA.21X1 FP
net employ any person in any manner so as to Income suhjectIn the Workers'Conspen- ENERGY FEE
O Z ration Laws of CN;l'mnis.Data WATER HHAI'1iR WNENT/ELFC'IR
Q Applicant GRADING FEC
oii NOTICE TO APPLICANT:If.after making this Certificate of Rxempti...you should WATER SYS'I'ENITREATING
a ' become subject to the Worker's Compensation provisions of the Labra Curie,you most SOILS FEE
forthwith comply withruch provirmue,this permit shall bedecmeJ revoked. WATER SERVICE
6 Q
UO
CONSTRUCTION LHNDINGAGENCY NEW RESIDENTIAL ELSE. SQ.Fr, PAID Date Rnei
1 hereby affirm that there is a cams rC-10 lending agency for the perfommncc of
4o (~-t the work for which Onix permit is issuad(Sec.7099,Civ.C)
Lender's Nmnc
Lenda'n AJJmu TIV
O. I ccnify that I have read this application and state ohm the.bare information is BUILDIN LE
F (A caned.l agate to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT IEE
U Z building construction,and herehyaatrmia representatives ofihis city menferepon the SEISMIC IEE
above-mentionN propeny for inspection purposes. PERMIT ISSUANCE
(We)mor.n save,indemnity and keep harmless the City of Cupertino against PLECT UC I'
liabilities,IuJgmm�tn,cnstx and expenxhs which may in any way ucerun against said City ALTERORADDTOMECI I.
in consequence of the gn:ming ofihis proud. I'LUMNI �FBE
APPLICANT UNDERSTANDS AND WILL COMPLY WI III ALL NON-POIN'P AIR HANDLING UMT(IO 10,000CFM)
SOURCE RREGULATII . MECHANIC FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONS'I'RUCfIO TAX
Signam u r/Au xuu pplri`ca,unin/Commcnr a Data T EXHAUST HOOD(WNUCT) HOUSING MITIG TION Atli
HAZARDOUS MATERIALS DISCLOSURE
WillmenPpllcam or rumm bolding occupant store or handle lunardous materiel ifF—rlNG UNIT PFO IOB,IXX)It I'U)
as defined by tha Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety
Code,Sation 25532019 HEATING UNIT(OVER FRI,1MI urTO)
EJ Yes ❑No VENTILATION FAN(SINGLE RISID) PAID
❑ate Rceciptp
Will the applicant criminal building occupant use equipment or devices which
-nth ha addous air cumominwts a,Jdined by the Bay Area Air Quality Management BOILI3R-COMP OHP OR I0O.0001ITIE TOTAL:
.Js
E]
OYcx ❑No BOILFR-COMP(OVER RNI,I)NRTU)
1
AIR CONDITIONER
1 hath mal the hazardous fions 55 5,255memr under Chapter est of nth Cali ISSUANCE DATA\
firmia Heahh&Sat&ty Code,Sations25505,255JJ and SSW lunlemggppdk1 mat if the NEW RESIDENTIALMECf1. SQ.FT.
building does nenoZichn1 a tenant mat it is my res if ey
ofine rc hn be met prior rte (v m f}gT,,(�(!cy.
rggsyaCt or
.
(wOwn�er 44.1horv.ed agent Date TOTAL: ISSUED BY:
OFFICE