S 0152 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO nuu.nmc-el.ncralcgl, PLRMIr N°. 015 2
BUILDINGDIVISION APPIACATIONMERMIT i'LU\IEING-AIk:C11ANICAI.
HUIhDING PROJEcr IDNNrIFiCAT1ON
BUILDINGADDRESS: $ANII'A 11Y NO. AI'I'LICATION SUBMITTAL DAII
I OWNER'S NAME: — PHONE: CONTRAC OR'S NAME: LIC NO:
NIC CONIROLA
_•ARCHI'IEC'FIENGINHF.R: LI NO: A)DRREESS ❑
• ' 1
CO�NTAe�CT�.�yt�Xs�sa PHONE BUILDING PIiRMIT INFO
irV�Wr.0 Fs -+�\N+Cl ❑ Consultant Fees Paid 6y Applicant ELECT PLUMB ECII
aA w 9 -oj�y` ❑
LICENSED CONTRACTOR'S DECLARATION QTY 131.ECTRICPFRMIT FEE
1 hereby affirm that 1 am Iicensd under pmvisian.s of Chapter 9(commencing JOB DESCRIPTION
ad with Section 7000)IuDivi.sion 3 ofthe Business and Professions Code,and my license is RESIDENTIAL'
PERMIT ISSUANCE
F00 in fuBfmaeondeaen. ❑sFDWL ❑KITCHEN REMODEL
si O(FU{i�'1 License Class Licp APPLIANCES-RESIDENTIM. CADDITION El PLUMBING RE-PIPE .
Date Cmnlowan
VVII 44 i0.L ARCHITECTS DECLARATION PANELS ❑MUCI'1-UNI'F ❑STRUCI URAL
ZQ an I undedmnd my plans.shall aused as public records MODIFICATION
OZ—O UP TO 2D)AMPS ❑INTIiR[OR F1 CHIMNEY REPAIR
Fs,RJ W Licensed Professional NII-1"AMPS IMPROVEMENT E]SWIMMINCPOOLS
GYM ya OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑8 HRIiM(IDEfIREI'AIR ❑DEMOI.1'1'[ON
,R.S'y�a I neren affirm that 1 am axon n In a the Cantramare I.icensa Law for the
LiyS O q U following ee...If(Section 7031.5,B nummis and Profasionx Code Any ehy ter tuunly SIGNS ELECIRI 1. HER
t+�a W y which rr,mw,a permit in construct,aneq improve,demolish,or repair any sla core
C) prior to its issuance,also requires the applicant for such pemtino file a signedxmtemem SPECIAL 'tl IIS
�} that he is licensed pnsuanno the provisions of the Contractors License Law(Chapter 9
C (commencing with Section Y(XXI)of Division 3 ophe Businew and Professions Cover r TEMP.ML POLE INS r. L
P, m e' thin he is axampt therefrom and the music for the allegW morruion Any violation of E, I D 1[J (]DEMOLITION
^m
Section 9131.5 by any applicun[for a permit arbiters dwapplicunt to n civil penally of POWER DEVICES �(p�pV/e FOOD S17RVICE
ZGnot more than five handed dmllurs(5500). IMP j'vi1{fNT
❑1,as owner of the property,or my employees with wages os thcirsole compensainn, SWIMMINGPOULIiLECTRIC VV
will do the work,and the auuctum is not intended or offered forme,(sec."1044.Business OTHER
and Prnfexaions cote The Commcnsr's License Law drove forapply to an rune,of Olfl'LETs-SWI les-FIX oars
property who huilds or intpmrvcs theme I,rad who does mah work himself or lhum h
his own employees,pnrvidcd that such Intpmvcmcntx are nor intended or n11'em 1 for NEW RESIUEN'1'IN.F:LECI'a SQ FII
sale.IL however,the building of improvement is sold within one ycarof cmmplmi In,the SQ,FE MOOR AREA SISQ.FT.
ownef-builder will have the burden of proving that he did not build or improve for pur-
poor of sale.).
❑ 1,as owner of the propcny,am exclusively contracting with licensed contractors to
conduct the poise,(Sce.7W4,Business and Professions GxlaO The Cunb.mnr'v Li- -
case Law does not apply toanowner ofproperty who builds orimprovesiheram,and QTY. PLUMBING PERMIT t' FEE
who contracts forsueh pmjecm with a come s)licensed pursuant to the Contractors
License Life. PERMIT ISSUANCE
❑Iam ma, ea. .R&P C fonds.."
w at ALTER-DRAIN&VENT-WNI FR(EA VALUATION
Date
6RIKEFITO PI! A'I' DECLARATION BACK FLAW PROTECT.DEVICE
l hcreny firm ander pens ,jury one of the fnllnwing dwlamtinn..:
I hove ondw maimmna Cenifcamof Con.wnt toself-mane for Workers Compen- DRAINS-FLOOR.ROOF,AREA.COND, STORI,s TYPHCONSTRUCTIOP
cation,as provided for by Section 39W of the Lar Cafe,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will moiredo Worker's Course muation Insurance,us require)by Section
3703(it the Labor Code,far the performance of(M1c work for which this permit is issued. GAS-HA.SYS'1'l:M-1 INC.00LrTLETS (ICC( O APN
My Worker's Compensation Insurance curia and Policy number are:
Cartier. ]',,lie,No.: GAS-EA.SYSTEM OVER 41P.A)
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASMNDUSTRI,WASTE.INI'ERCF,PfOa
COMPENSATION INSURANCE ILUING DIVISION FEES
09hi,sactmn need not aeompletal lOhapermit lxforsmchundredallars($K0) GREASETRAI'
ants.) PLAN C lilt on
I certify that in the performance ofmc work forwhich this permit isinued,I.shall
ant told,nn on in on eeso ata become subject m the Workers Corwin- SEWP.R-SANITARY-STORM PA.2W FT. ENE ii
y pees y mann ) M
Z scion anus of Califomix.Date WATER HEATER W/VF.NT/f:LEC1A
12 A NOTICE
t CRADI FEE
/..I- NOTICE TO APPLICANT:IF,ober ranking this minim,of life LidurtCa,you should WATER SYS'1'llMffRP.ATINC SOIL FEIi
CZ
��' beams suomp y the Wath pr Compensation provisions of di Lnhar yoke you mus
fonhwilh comply with such provisions or this permit shall h Jcemd evoked. WA'1'F,R SERVICE
CONSTRUCTION LENDING AGENCY NEW R[SIDCNI'IAI.PLMB. SQ,PI'. F
V [[[.cz I hereby affnn that there is a construction leadingagency roe the perfo..ace of Dam Receiptp
... the work for which this Parini[is issued(See3097,Civ.CJ
W U Lender's Name IOTAI.
❑ TOTAL
LenJ 's Address
m : '
I certify that 1 have mea min.,heation and ante tom the dame m mnmimo is I
U )TNG Iaili
Le; correct.l a gree to comply with all city and county ordinances and sm¢laws reloingro QTY. MECHANICAL PERMIT FEE
C.) Z building construction,and hereby authorize representatives of this city to enter upon the ISM .IEE �F
w+ nave-mentioned property for iruccetian purposes.
1 Wc)agree to cave,indesnnif J keep hanniess me Cit f Cu nrtinn against
PERMIT ISSUANCP. HCTRI'FILE
g yam p yo
luddlitie.s,judgmenm.costs unit expenses which may in any way active against send City ALTER OR AUDI 10 MECH.
AMBING 'C13
in onsequence of the muting of'his Permit.
APPLICANT ON S NDS s COMPLY WITH ALL NON�POINT AIR HANDLING UNIT(TO 10.000CFM)
ECHANICA PEE
sou noC_ AIRIIANDLINGUNIT(OVF.RIIMNICFM) ONSI'RUCiI( TAX
entre mf ppliw WCour tot Dam IiXIIAUST 11001)OVIDUCT) HOUSING MIT]G TION PER
HAZARD 1ATERIAI S DISCLOSURE
it heapplierniffumrebulldingoecupantomforhandlcharsrdoilandeial HEATINGUNTI.fr'OIW,fXl011TU)
as defined by the Cupertino Municipal Cone.Chapter 9.12,and the Health and Safety
Code,Section 25532m)t HEATING UNIT(OVER 100,000 BTU)
❑Yev ON. V17N'I'ILAT10N CAN(SINGLE R I ISTD) PAID Dam NcaiptM
Will me applicant or future building occupant use equipment or devices which
oma doses air commitment,as define)by the Bay Area Air Quality Management BOILER-COMP(JHP OR 100,000 BIV) TOTAL:
_of
setp HOILER-COMP(OVER 100.000BTU)
❑Yes ❑No
I have rend me hammers materials repuircmenrs under Chapter or 0m Cali- AIR CONDITION I7R ISSUANCE DAPE
forma Hwhh&Safety Cale,Sections 25505,25533 and 25534.I understand mm if the NEW RESIDENTIAL MECH, SQ,Ff.
building Joe,,nor currently have o mount,that it is my corsooduhy ro notify the occupant
of the nquir mmo s voth must a met parr tat icmami,of a Cenificam of Oceepancy.
Owner ora do ict!agent Date I': ISSUED if
OFFICE