S 0653 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUU.DIN(; MECI[A ICACA rIBtMIT Na.
BUILDING DIVISION APPLICATIONIPERMIT TING PROJECT IDENTIFICATION
S 0653
BUILDING PROJECT IDf:N'I'IFICATIDN
SANI'1'ARV NO. APPLICATION SI1BMIf"1'AI.DA'I'I
BUILDING A(Ov�I]kE5$: 3 c
OWNER'S NA F: P ONE: .gyp CO R CTOR'S NAM^ l LIC NO: N/C I C(1M`I)LM
nx
`� V IZ ❑
ARCIII FEC/F: GLNEL : LIG NO: AADU ti%S i � •y �
CON'T'ACT: PHONE: SLJJ-,v\IV\ HIJ ILDING PERMIT INFO
✓�� ❑ Consultant Fees Paid by Applicant(Initial) HLDG ELECT PLUMB MECH
LICENSEDCONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I batch,affirm Thal 1 am licensed under provisions of CTapler 9(commencing
OaZ with Section 90Ba)ofDivision 3ofthe Business and l'mfessions Codq.ndmy li.ase is RPSIDFNTIAI'
LL100 A PERMIT ISSUANCIi
FFA+ folIforce and eIT t �` �1yyas��� ❑SFDWI. ❑KITCHIiN RF.MODF,I.
�V I" Licene lass —Zv Lic.« `v
Q U APPLIANCES—RESIDENTIAL � ❑ADDI'TION ❑PLUMBING RIiPIPF.
'Don Date Cnnwemr ❑MUCIhUNII' ❑MODIFICATIO
ARCIII'IECTS DIiCLAHATIO
F,Dm PANELS MODIFICATION
OZ=Z lundentund my clans shall rte used as Public rte s Up TO NXI AMPS
❑INT1iRIOR El CHIMNEY REPAIR
Fi a Lwarred Professional 20I-1000AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION
J OVER IfxMh AMPS ❑µATN REh10DIiU1tIiPNR ❑DEMOLITION
C Q I hereby.Rion that 1 1. exempt from the Canton,Cos License Law for the _
iWyxy C Y V pawing rwenn.(Section 7NL?,Bnviness and Pndunsloro Cnde:Any city nr county SIGNS I?LIiCTRICN, ❑t]THlilt
W'3 lL ywhich require,a permh u+mnswcl,alcor,improve,demolish,or repair any stmcture c — G
f'LL'0g pdorm its issuance,also requires thcapplicant fmr teh pcman to fheasigned sgncna., z SPECIALCIRCUFVMISC. 2✓ .�
!�y Thal he is licensed pursuant mthe provisions nl No Cnnuucusrs Llcensa Luw(Ch:mter9
a�0 (commencing with Seainn 9(N1U).f Uivision3oObe Business and Pr..Ivs,4mr Code)or TEMEME'STRORPOLEINST. COMMERCIAL
a a c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
�M
Section 7031.5 by any applicant for a permit subjects the applicununa civil penally of POWER OF ICES ❑TENANT 0OOD SHRVICIS
1-^Qof more thin five hundred dollars($500). IMPROVEMENT
Las owner ofthe propeny.nnny employees with wages ns thcirwlc mmpensmion, SWIMMING POOI,ELECTRIC
S=0 ❑OTFII:It
ua. will do the work,and the structure is notamnded or offered for%ale(Sec.7th ,Busincsx
and P..l'cssinna Code:The Cootnmmrla License Law does net apply it an owner of OUTLET S—SWITCHES—FIX'T'URES
property who builds or improves thereon,and who doses such work himself or through
his own employees,prnvided that such impmvemena are not Warned or offered for NEW RESIDENTIAL.ELECT SQ En
sale.IL however,the building or improvement i, old wthin one pamof amrpletion,rhe SQ.FT.FLOOR AREA VSQ.I'p
vwrrr-hudder will have the burden of proving that he did not build or improve for pur-
pose
ur-
sae..
P a SpOl - TOTAL /
t ❑1,its owner of the property,,H exdusivdy Protruding widr:sensed w.momars m 1
construct the project(Sea 91414,Business and property,
whxi bui d%or i The cv prwitur emon,Li-
,h Law does conapply man itharofracuu(y won haddsorimproves Corenn,arta QTY. PLUMBING F M FEF,
who wnwea❑a.ruch prnjaf+with u eonuuanr(s)licensed pnduam m the Gmnnemre
License I... PERMIT ISSUANCE
❑ I.m exempt under See. ,B&P C for This nes..
DETER—DRAIN&VENT—WATER(EA) VALUATION
Owner Date /)
WORKderp COMPENSATION DIFCefollo following
BACK FLOW PRRDiCr.DEVICE �J O� {•/
1•� vamd uBirm tinder sCraallyaf.1 Coneneot owlt-in,,ume ngdcelar.lin.s: /
(have and will maintain uCerrificate of Conseil In selGinatm for Worker's Compen- DRAINS—FLOOR,ROOF,AREA.COND. Xrodf TYPE CIINSTRUC'flOt
Ilion,as provided for by Section 37M of the Latuo Code,for the perfamamor of the
work for,InklOhis permit is issued. FIXTURES—NER'I'kAP -
❑1 have and will maintain Workers Compensation Insurance,as required by Suction
3700ofthe L.Nu Ctde,for the perfnrrnan4e�e��nfthe work for which fakpemrit is issued. GAS—EA.SYSTIiMd INC.4 OUTLETS OCC.GROUP APN
My W..lon',Comlwtsatitalics imeggier and Policy number am: �����f,�t
Carrier ����0011«X� YY .,,.L�l Iicy Nn.:-� a�-4�1 GAS—EA.SYSTEM.OVIiR4UzA)
CIiRTIFTC ATB OF EXEfIPT10N FROM WORKERS' GREASI%INDUSTRL WASTE INTL'RCEPTOR
COMPENSATION INSURANCE GR DIVISION FEES
(T his section meal not he cauplcacd iOhe permit is for one hnndred dollar%Vital) GRHASE'FRAP Q
.r leash PLAN JI ECK P..
Ic,rify that in the performance oflhe work for which this permit is issued,Ishall SEWER—SANITARY—SIORM EA.21X)IT.
not employ any pars..in any manna so as m hot.
rearm object the Workers'Compee- IiNERGY ITT,
� Z satin.laws of C.IH.mia.Dae WATER HEATER W/VENT/IiI.F,CI'Rk�(�O
2 Applicant ?S7
NOTICE TO APPLICANT:If,after making This Cenificme of Bxemption,you.should WATER SYSTEM/TREATING
a
(41NOTICE
subject m the Wmker•s Cnmpenition provisions of the Labor Cade,you must SOILS FINE
lit forthwith comply with such provlaioosm this pennilshall be Aeanalrmnked. WATER SERVICE
0
Uz CONSTRUCTIONuction LENDING AGENCY NEW RESIDENTIAL PLMµ. S Receipt at
UO I herewhich thi chat them is ssued(S(Sm.3097,
for the perfonnmcc of p
F' Under,Na which this permit is issued(Sec.tU9],Civ.CJ s.
Q U l.cndcr'x Name 'D)'I'AL:
r 4L1 [,a&,'s Address TOTAL:
y 1 certify that I have read this application and stare that the above iof narati.n is BUILDING FEE
.F. h cmreet.I name ,,eamply with all ally andcnunry....inncasnad slap laws rclmlng m .QTY, MECHANICAL PERMIT ,FEF.
U z building consimetion.and hereby authorize representatives ofthl.s city m enter uptm the SEISMIC 1:17E
soave-memioned property for inspection Saman,es' PERMIT ISSUANCEELECTRIC FEE
(We)agree m savr.indemnify and keep hamdess the Cily of Cupertino against /
liahiliries.judgments,costs and expanses which may in any way.wmeali (said City ALTER OR ADD TO MECII.
in nsequencc of the gaming of this pemrit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINTAIR HANDLING[NET(To MAN)CUM)
aAIN HANDLING UNIT(OVBµIU,( CONSTk11LTION TAX
Signa fApplican10,0ionlmemr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
o HAZARDOUS MATERIALS DISCLOSURE
Will the nppliwm nr far..building oceupnaldontor handle hmanous material HEATING UNIT(TO I(RUM)BTU)
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532o)9 HEATING UNIT(OVER 100.000 HIS
r7 Ya, ON. VEMI LAI ION FA N INGLE RES IDI PAID D e accept«3 --
Will the applicant or future building occupant use equipment or devices which
T(ITAI
emit hawrdous air communities as defined by the Nay Area Air Quality Management BOILER—COMP CHIP OR 1(10,0(X1 IT I`U)
District? Os
❑Yes ❑Nn BOILER—COMP(OVER I(XI,(IBO BTU)
AIR COND PHONE u
I lanes mud @elCode.Se materials505..irane an under Chnpmr G99d that Cali- '/l ISSUANCE DATE
Inmia Health&Safety Code.virions.1fam ?Sll and 25534.1 understand that if the NEW kESIDF.MIAI.MEC11. SQ.FT
building Joos nm eurrtndy M1ave a cont P rh t it is my mep.nsmiRly to omit,the occupant
ofN ¢ wi ttbe and priormi»u'nC nfaC• 'lcal I'( cu y
owns eathnneed.gem nae TOTAL:y9.gp IssuED Bv.J`9�' /-�Ai79 t-UCGI
OFFICE