S 3357 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-MECH NICD PE LT NO,
BUILDING DIVISION APPLICATION/PERMIT PING PROGCTIDENIFIC
tlU11,U1NG PROJECT IDHNTIFICATION 3357
BUILDING ADORES$: SANITARY NO. API'LICA'1'ION SUBMITTAL DAf
2 ^/Y.
UWN}''R'S NAME: 1' UNE:
CO T AC'TOR'S NAM': LICNO:
NIC CON ROLA
LIC ND ADO
ARCHITECT/ENGINEER: RES :_ ❑
osz-
CONTACT: PHONE: BUILDING PBRMIT INFO
Z ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT P1 PME❑CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE
I hereby affirm that 1 sum licensed under prevision,of chapter 9(Ciamorneing JOB DESCRIPTION
OZ Z wiih Sectinn7aNgofDivisinn3of eHasl,,exsa.d Profes.mn:Cede andmyflecnae ix RESIDENTIAL:
m O '
5WF PERMITISSUANCE:in full force and eR 3 ��/ Q6L, ❑SI'DWL ❑KITCHEN REMODEL
aZ41 U�] ULicense;/, Lic.p pppL1ANCEB-RFSIDEM'IAI. ❑ADDITION '�I'1.GMBING R6PIPIi
b- nte Conwno
r8aa' ARCHITT:CPS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F„7 lin PANELS MODIFICATION
Z p in Z I understand my plans shall be used as public records
OZ�O UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Q`1"'41 Licensed Professional 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
W,4
K OVER Too AMPS [I BATH REMODF.{ EPAIR ❑DEMOLITION
1 hereby i ffvm that I opt exempt front the Commtai is License Law far the 1
X36 U following retain.(Sean,,.7031.5.Business and 11..R,siens Code:Any city or r mmy SIGNS ELECTRICAL ❑OTHER
W a y which requires a permit m con omel.after,improve,demolish,or repair any simc urc
pom he
sceload pursuant
to the previsions ofthe Conaermes Linens Law shadcnt SPECIAL CIRCUIT/MISC.
f } (trot he escingwidpursumn 70th)pmvisionsnf the C,Businnsand Paso Ww(Chupter0
trot he
ixemithherefrom and
ofbasisfr the
Business and Ani, 1.in par TIiMP.MLTF.R OR POLIi INST. COMMERCIAL'
ty y m fK thin io is exempt therefrom and the basis far Ne allege)exemption Any violation of ❑NL'W BLDG/ADDITION ❑DEMOLITION
>4!1 on Sation]B315hy any nppliwn(far a pem(i(suhjensthe applicant toacivil pcnahy of POWER UEVICf:S ❑TENANT ❑FOOD SERVICE
F_z_p+' not mare than five hundred dollars(S.500). - IMPROVEMENT
QUI,as owner of the progeny,mmymnpinye)s wifhwagesasthcirsale compensation, SWIMMING POOLELF.CI'RIC
= will dothend structure is the structuis not whandeder offered I...Ie(Se).70TL Business OTHER
W 3� and Professions CWe:'De Cmdocuu's Licemc Law does not apply In an owner of OUTLHTS-SWITCHES-FIXTURES
wlZ
ho build,or improvesthereon,and who does such work himsel!.,through
progeny
his awn employees,provided that such improvement,ce not intended or ollcred far NEW RESIDENTIAL[1.EL:R SQ I'm
sale.IL however,the building or impmvemem is sold within ane year ofcomplction,the le SQ.FT.FLOOR AREA {/SQ.FT.
owner-milder will have the burden of praying Ihm he did not build or improve for pur-
pdve'if sale.).
I,as owner of the propene am exclusively contracting with licensed contractors to TOTAL:
instruct the project(Sec.70W,Business and Pmfessions CWm)The Commaor's Li-
cense Law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for tech projects with u amtmcmrts)licensed Pursuaou0 the Commc70rs
License law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&PC for this reason
Owner Dale ALTER AIN&VENT-WA'1'ER(M) VALUATION
WORKER'S COMPENSATION DECLARATION RAC I. PROTE F.
I batch,off n under pRally al perjury ane of the follnving dcclumtinns:
I Rwmmd will maintain a Certificate ofConscnt msell'-insure for Worker's Cnmpcn- 1* LOO RM,C ). STORIES TYPECONSTRUCION
smion,an provided for by Section 37M of the Labor Cede,for the performance of the
work fur which this samol is issued. FI 'S -THAT AD
1 bave.nd will maintain Worker's Compensation homa.a,as radioed by Section
3]0pof(he labor Cod,for the pc,forryuneriuthe work for whicbthis permit is issued. C -RA,SYSTF -1 C. T OCC,GROUT' APN
My WoAtee Compensation Ill...ance,mrier and Policy number are:
Cartier: Policy No.: A EA.SYSTEM-(lVER4(FAI
CERTIFICATE OF EXEMPTION FROM WORKERS' G D SI'RL WASTF:INTERCIi
COMPENSATION INSURANCE BUILDING DIVISION FHUS_
(This section need not be completed ifthe permit is for onehundred dollan($100) GRMSETRAP
m Ica,) PfANCHECK PER
lociifylbatmth normanc..ftheworkforwhicb this permit is issued,Is hall SHWER-SANITARY-STORM F.A.2(p
not enmley a no /gist o/cine sed+ t m the Workers'Cnmpcn- ENERGY FEE
z sntim�Luw of e a 6 iY'tS Wq'I'FIt IT HATER WIVRNT?LECfR
Apel' I l GRADING FEB.
z N(TT 0 APPI.0 ':IL.flier making this Ccnifine of Exemption,you should WAVER SYSTEMfBEATING SOILS FEF.
msubjed to the orkcr's Compensation provisions of the Ln6a Cede,you mus
fonhwitb comply with such profs' ns nr,hia permit shall be deemed revoked. ' WATBR SERVICE
Q
4' CONSTRUCTION TINGING AGENCY NEW BESIDES UAL PCMB. SQ,FT PAID
U O l hereby affnthauhe.is a nsmform
coarat lending agency far the perance of Dote Re¢�ptp
the work far which this permit is isued(Sec.3097,Co.C.) TOTAL:
0 Lender's Name 0 1 D
WL,nda's Address
0. I certify amt I have read this application and state that the above infnrowtion is BUILDING FEE
Ln correct.l agree it)comply with all city and Coity ordinances and state laws relating In QTY MECHANICAL PERMIT FEE SEISMIC FEE
U Z building construction,and hereby adthorize representatives ofthis city mcn(er upon the
alove.mrntioned property for inspection purposes. PERMIT ISSUANCE
ELECTRICFEF
(We))gree 70 save.indemnifyarm
and keep hloss the City of C.Nnin.against
liabilities,judgments,costs and edemas which mayin y way accme against said City ALTER OR ADD TO MECH. PLUMBING FEE 1 2�
onseyuenc fthegrzI.sZ,of(hispermil.
in con A iNDER. DS ANU\ ILL. WITH ALL NON-POINT AIR HANDLING UNIT(To 10.0B0CPM) MECHANICALP'cE
S IRC' TUI
/ AIR HANDLING UNIT(OVF.R 10.000 CFM) CONSTRUCGON TAX
Signamrcid Ap cam(Contmc70r Thar EXHAUST HOOD(W/DUC) HOUSING MITIGATION IEE
HAYARDOUS MATERIAIS DISCLOSURE
Width,,applicant nr mons uildias....atsmresn handle hazardous material HEATING UNIT TO INI.000 BTU)
.s derided by the Cupertino Municipal Code,Chadic,9.12,and the Health and Safety
Code.Section 25532a)P HEATING UNIT(OVER 100.000 BOO,
❑Yes �Nn VEM'ILAT ION FAN(SINGLE RFSI D) PAID
Data Rucipl p
Will the applicant OR future building necitia l us,equipment nr device.which BOILER-COMP(311P OR 101.0 0 BTU)
emit humrdims air co.tamina.la n,de11nW by the If.,Are.Air Quality Management T
District?❑Yes QS No BOILER-COMP(OVER 103,000BETU) O
AIR CONDITIONER ISSUANCE DATE
1 have rend(hc hdwrdws mme0als 09�
der Chapter rata of Dat if
�J
fmnin Health&S' ty Cnde,S.T., 255534.1 utdemaW thin if the NEW RPS IUENTIAL MECI1. SQ, / -f
buildi sex rrct tmnanh aibiltry to ify the ,idea L
al OR ext, m m. mm r' ofcaner rauthriz. agent Datc TOTAL ISSUED BY:
OFFICE