00040128 APPLICANTTO FILL IN INFORMATION WITHIN RED,LINES-USE BALL POINT PEN ONLY R O O 4 b( a p
CITY OF CUPERTINO BUILDING-ELECTRICAL 1 PI:RA1I NO
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL
t BUILDING PROJECT IDENTIFICATION II -
BUILDING ADDRESS SANITARYNO APPIJCATIONSUBMIITALDATE
iR7,in A\ oaKo0u I,A�aE
�) OWNER'S NAME HON CON CIFOR'S NA E IJC NO: N/C CONTROL#
,dM ' �o 39o31S
RC ITjiCT/ENGNEER.t IC O- ADDRESS ❑
OSS G(�r! ANA
'ONTACT �0 Woes (^asp N RY PHONE" [ �- BUILDING PERMIT INFO
1�1 JIZ ❑.Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�i ❑ ❑ ❑ ❑
LICENSED CON TRACT OR'S DECLARATION Q' ELECTRIC PERMIT , FEE
1 hereby affirm that I am licensed under pmvis om of Chapter 9l commencing ( JOB DESCRIPTION '
CCZ with Scotton]WOl of Drvts.nn3oflhe Bonmossoad Prnfesam Cade,andmybacrew° RESIDENTIAL:
1" n 1u111orce and effe g �j PERMIT ISSUANCE
�UF I"news Clas. Lose �50�- ` ❑SPUWI. [I KITCHEN REh/ODEI.
ZU y- n 0� Bps APPLIANCES-RESIDGN'i'[AI. El ADDITION ❑PLUMHING RR-PIPE
vi a q Date Contractor—��y.'p
ARCHITECT'S DECLARATION) � ❑h1ULT1-UNIT ❑STRUCTURAL
Z O m Z I undentend my plans snail be used as puhlmc renal+ PANELS MODIFICATION
py-� UPT0200AMP5 ❑INT'ERIOR CHIMNEYREPAIR
F4 wi Licensed Pmfes+umal 201-1"AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODL/RE AR ❑ EhI01JTION tison 04 I hereby a1Rnn,M1d I am eaampt ffom the Comeacvars Lmeme Law for the
00.0 following reason (Serum]031 5,Business and Pofessions Cafe.Any city nr county SIGNS PLECTRICAL ❑OTHER
mQy xh,,h req.I...a permit a,cnn+tfuct,alter,improve,demolish,or repair any stumble I FVII rQ_ JZVI
WO.J that henl¢en eJ pursu m90 the provumn of the COnlprxtore License Law lChxpler9 SPECIAL CIRCUI T/MISC.
�Q� (cnmeracro with Section7000hal Divmm,3 of the Business and Pfofessons Code,or TETUP METER OR POLE INST COMMERCIAL:
that hen exempt themirrom and the bests for the alleged exemption Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
W w Section]0315 by any applicant bar permn+ubjens the appltcamn,a civil penalty of POWER DEVICES OTENANT ❑FOOD SERVICE
_zy not more than five hundred dollars($500). IMPROVEMENT
[:1 1,as owner ofthe property,or my employees with wages as their solecompensamn. SWIMMING POOL ELECTRIC
'F'FC will do the worA,and the stmaum is no,intrndeJ ar offered Tarsals f$ec O(H4,Business ❑OTHER
4 and Professions Code *[he Convenor's lumens,Law Joe+not apply ,,on owner of OUTLETS-SWITCHES-FIXTURES
property who ha0dc h urps—e+,hefeon.onof who Ones such work himself,),thnmgli
his own employees,pmvNed the, a,h improvements are not Intended or offered for NEW RESIDENTIAL ELECTR S;;iiiirp so
sale If,howe+er,the budding or improvement is sold within one year r ofcompleuon,the SQ PI'FlUORAREA $/SQ FT
nwnef-builder will lime the burden of Forams that he did not build or impose for puf- eve .
pose of sale) /
- ❑I,a+nwne,of the properly,am enJu+rvely contracting with hcenad enmmnnrc m TOTAL
construct the prnlect(Sec.7044,Business and Professions Code)The Contractor's 1"t- ,notion Law does not apply to an natural property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE O
who.nmmn+farcuehpo)ectc with a cnatmcbro l reensed mmeammthe CmuCcmrs
Lateme Law. PERMIT ISSUANCE
C]I am exem de
ptanr Sec ,B&P C fmhn.,,,a
ALI ER-DItAIN&VENT-WATER(EAT VALUATION
Owner I ►� 7s t550a
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE 1�r.
thereby affirm under penalty of hequry one of the fallowing declarations Co /rI_
I hoc and will"ImmmneCemficate tit Coment to mlfanwre Orr WOAer'c COmpen- DRAINS-FLOOR,ROOF,AREA,COND STORIES TYPE CONSTRUCTION
ation,as poeided for by Section 3IDf1 of Ihe Labor Cale,for the,perrormauto, the
work lur wh¢h Nis pemuus issue d. FIXTURES-PER TRAP I p\1
❑I have and will moron Worker's Compencaeou Romance,se fequved by Section
37W ofthe Labor Code,for the performance orthe work forlwwhich his permsyic i+med, GAS-EA SYSTEM-I INC,4 OUT OCC GROUP �I APN
came,,k Aqj om pen PPnlay Nn.y lA\\rI{1ZOI DOI h� GASH-EA:SYSTEM-OVP,RJIF.A)
CERTIPI ATEOFEXEMITION FROM WORKERS' O'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEES _
IThms.ecmin need not M1e completed lithe permit is loronc hundred dallnre($100) GREASE TRAP
nr les+l PLANCHECK PEE
'l umtify the Inn he performance oRhe work for which thin pe.not nis+'C,, ,sa SEWER-SANITARY-STORM EA 200 FT
not employ any pennn m any moons{r� to bemmS,,Wblest m Ihe WorAeri Compen- ENERGY FEE
,0 anion Ca m am z Q Applicant 2iM /r__O_a� -V C� WATER IEAi'ER WATNT/ELECIR
GRADING PER
mr y NOTICE TO APPLICANT If,after making his Certificate of Exemption,you should WATER SYSTEM/TREATING
abeuime whim to the Worker's Cnmpemation phonam+mine Labor Code,yea must SOILS PEE
FA7 forthwith comply with such pownum+or this permit,inin be deemedrecaked WATER SERVICE ,
Q
,Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLA1B SQ Ff PAID
V Q (hereby nfOrm that them msu construction lending agency for the performance of Date Sorrier#
40 the work for which this pefmu is I....it(Sec.3097,Cos.C)
H Lender's Nam= TOTAL:
U Lender's Address TOTAL
I Bendy,M1a,I have nvJ this application and state Fannie above mformauon ms BURRING FEE
F A woes,.I agree to comply with all city and county ordimanno,and state laws relating to QTY. MECHANICAL PERMIT' FEE
) ,ZZ, building construction,and hereby authunze reprea:madves ofthis city to enter upon the (SEISMIC FEE
above-memmred property tar mspecoim Impose,, PERMIT ISSUANCE
(Wc,again to save,Indemnify and keep harmless the CITY of Cupertino agaim, ELECTRIC FEE
liabilities,judgments,costs and expenses which may in tiny way accrue agamct said City ALTER OR ADD TO MECH PLUMBING FEE
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT ( AIR HANDLING UNIT(TO 18000CFM) hIF.CHANICAI.FEF.
SOURCEREGU,4ATIONS. ,✓/ /�{
�„ ✓/ / LAIR HANDLING UNIT(OVER 10,(1(0)CPM, CONSTRUCTION TA%
Signature o Applicant/Contart or Date (EXHAUST HOOD I W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future budding occupant store or handle hazardmomatcnal H EATING UNIT I TO I M,000 RTU)
as defined by the Caperton Municipal Code,Chapter 9 12,and the Health and Safety !
Cade,Section 25532(oln HEATING UNIT IOVER 110,000 HTU)
El Yes QI No
VENTILATION FAN(SINGLE RESIDI (PAID Datc Receipt#
�n WiII the apP onta or future building,ied occupant use ea All Qua or devnes whuh
tit
hazardous air contaminants as tletinetl by the Bay Area An Quality Managemem BOILER-COMP(3HP OR 1110,11110 BTU)
TOTAL
strict❑Yes O1 No (BOILER-COMP(OVER H10,00 BTU,
1 base Tried the hazardous nietomals regnmrementa uadef Chapter 6 95 of the Cal,- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Coda,Such as 25585,25531 and 25531 I undcntend Nm d the NEW RESIDENTIAL MECH SQ PT
budding does not currently have a tenant,that it is my responsibility no notify Ne oo.panl
,If theregu1rcyfeats which m,,,���ma//////sfflff3ppppppeeeeee rmissmamce oracarlUcatq�ol�C��l1pamyCn
Ownefnra hon�ennt Had I TOTAL: (ISSUED BY
OFFICE