00010121 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O I;;L_I
CITY DI CUPGDIVRTIN0 PBo 3NG-n .;I�i.NCAS PERMITNO,
BUILDING DIVISION APPLICATION/PERMIT I BUILDING•PROJECTIDENTIFICATION
BUILDINGADDRESS: SANITARY/NO. APPLICATION SURING FIAL DATE
�15 , 1 r,
OWNERS NAME: PHONIII CONTRACTOR'S NAD, CNO:
ZNIC CONTROL#
TF 'T/13N ,i tR: .` LICNO: �� pD11 rk a o ❑ G,
CONTACT: PHONE: /-11 _I ( BUILDING PERMIT INFO
HW' ��t mrd X12- 2221 ❑ Crnsullanl Fees Paid by Applicant(Initial) HLuc eLECT PLUMB M1?CH
�' ❑ ❑
LICENSED licenON sed rada,S oilsDECLARATION t
I ion 70 Dad that 1 am ftho W baser pn,visim,a of Glmptur 9(mmvmmmlug QTY s 1?LECTRIC PERMIT FEE JOB DESCRIPTION
yOy1 a'Z with Section]1I(111)ml Dlvision3nf tan Business and Pnsfessions Crile,and mylicensc is RESIDENTIAL
FSO nfull form an�'�j�)��f�� (J, PERMITISSUANCE
LUV Licens@ CI1s t•-`¢�}-5=����Lic.# ❑SfUWL ❑KITCHEN REMODEL
1Faa DmcComrinor APPLIANCES-RESIDIiNTIAL ❑ADDITION El PLUMBING RB-PIPE
ARCHITECTS DECLARATION
,. o, ❑MULTFUNIT ❑STRUCRIRAL
Z O-,Z. 1 understand my plans shall bemost es Public records PANELS
O Z G UP'1 U 200 AMT'S MODIFICA'T'ION
H{3 W Lensed Prnlc,,mial - El INTERIOR ❑CHIMNEY REPAIR
�WX-I OWNER-BUILDER DECLARATION 201-10010AMPS IMPROVEMENT E3 SWIMMING POOLS
6 I herebyeff,.that 1 am exempt from the Cmitmctor's License Law for the OVI:k IWp AMPS 1-1BATH REMODEURHI'AIR ElDEMOLITION
U following mason.(Section 7031.5.Business and Professions Cash,Any city SIGNS ELECI'NICAL or county ❑OTHER
3 tL F
F LL O y which requires a permit m conswd,else,improve,demolish,or repair any svuchma
< prior to it ismance,also requires Beapplicant for such pemuuo File a signed statement
W-� SPECIAL CIRCUIT/MISC.
}Q 2 that he is licensed punuem to the provisions of the Contractor's License law IChnpter9
(mrtunencing with Smtiun]qx0 mf Division 7 nOhe Business and Prnfassions C,
♦]O TIiMP.METER UR POLI:INST. COMMERCIAL:
dmat he is exempt mcrcfrmn and the basis for the alleged exemption Any vinlaY
��
Section 7031.5 by any applicant for a Permit subjects the app!icam macivil pen {CE$ El NEW BLDG/ADDITION ❑DIiM(ILITION
FZ} not more than five hundred d.11.,(S500). ❑TENANT ❑FOOD SERVICE
SaO ❑ Las owner ofthe progeny,or my employees with wages as their sole comm, inion, 1 C IMPROVEMENT
L. will do the work.en it he svuaurc isnot intended.,.ITcmd battle Sce.]044,Basin 11 HER C E �1
all 3 m and Professions Code:The Contractors License law mxs not apply m an owner OUI'LE ��("---r
property who builds or improves thereon,and who does such work himself cont,
his own employees,provided Ihm such impnwome ar are not marded nr olTet -W I L El.
sale.14 however.me building or inmprovemem is sold witlmin one year of co leIinn,t SQ.IT.FLOOR AREA $ISQ.FT.
owner-Wilder will have the burden of proving that he did not W iIJ or ire p - ,
pose of sale.). -
❑ 1,as owner of the pmpeny,am exclusively convecting with licmuc m
construct the project(Sec.9044,Business cad Professions Code:)The onw Iss IN
cense law ones not apply m an owner of property who builds or improves thereon, PMIT FEE
who contracts for such projects with v tummemr(s)licensed pu........he Commemdsalal
License I.aw. -
❑ m
Ivexemptunder .Sec. ,B&PCfaflu1mason PIJiMITIS AN
ACMR-DRAIN&VENT-WA
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICIi
I hereby affirm ander penalty of perjury one of the following declarations:
❑I have and will maintain a Cenifcam ofConsendto self-insure for Workers Cooper- DRAINS-FLOOR,ROOK AREA,COND.
smion as provided for by Section 37W of the Labor Cndc,for the performance of the STORIES TYPE CONS'INUC1'[ON
work for which this pant is issued. FIXTURES-PHR TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
J]Wof�,khga Labor Cale,for me perfommme ofine work far which this peman is issued. GAS-EA.SYSTEM-I INC.4 OUTL17S UCC.GROUP MIN
MY WraXfflprnmtlon Insurance nsunce carrier and Polic um n I? FA
policy No CAS- .SYS'1ER
'EM-UV4(EA) 22
\\CERTIFICATE OF EXEMPTION FROM WORKERS' to-JJ22
-I I
COMPENSATION INSURANCE, GREASEANDUSTRL WASTE INTERCEPTOR
Olhis section need not W w,mpleted If the permit is barium hundred dollars IS I W) Rl1ILDING DIVISION FEES
nr less) ' GREASE TRAP �� _ �P.ANCI Kg3I? -
1 certify mm in the perfnmunce ofthc work forwhiah this permit is issued,],hall
not pl person in any manner so ax In become M1jecno hn Wmkeri Com SEWER-SANTI'ARY-STORM EA. VTOTAL
� J1
'.`! pen" ERG P
C) r tin h 1rc r0 f/L7aI J��r, / =1VSIERHHXIURWNENTffil.F.C1RENT/F,I.HC'1'Rpp icon 1 L� �E1 APPLICANT. I, Def m5 g'd is Cegnuale o empeB tion,you should ATINGhecomesubject to the Worker's Compensation previsions ofthe lahorCode,you must forthwith comply with such provisions onhi.s permit shall he deemed revoked.CONSTRUCf10N LENDING AGENCY D
Z LMH.
L)C) I hereby affirm that is a constriction lending agency for the Performance of at, Baratta#
GA LP the work ror which this permit is issued(Sec.JIN],Civ.C.)
l^ Lender's Name U TOTAL:
W 1<ndcrI Address 1 ranee that 1 have read thirty and ounand star mat dd,hnve iwsrelation is LDING FEE
rh arzowl.l agree ns umngsly with all city and county mrelnunces and,,are laws relmingm QTY. MECHANICAL PERMIT. FEE
) Z building conswction,undhereby authorize representatives ofthis city menter upon me SEISMIC 17EE
above-mentioned progeny for inspection puryuses. PlikM1T ISSUANCE
(We)agree to save,indemnify and keep harmless te hCity of Cupertino against ELECTRIC FET?
liabilitiex,judgmenta,costs and expenses which may in any way accrue against said City g1;TER OR ADD TO MF.CfI.
in cue
onseqnce of the gaming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS ANILWILLC MPLY WE HAL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
"oApplicanUcanni
L TION}. /./- ,I�� MECHANICAL FF.E
G I AIH HANDLING UNI'1'(OVER If1,Ibit CPM) CONSTRUCTION TAX
licanUcanvactdr s Date EXHAUST HOOD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION MEiapplimam orfurore buildingmecupam area,handle hazardous material HELVEING ON I'FIT()101,000 BTU)
e Cupertino Municipal Cuda,Chapter 9.12,and the Health and Safety
532m)? HEATING UNIT(OVER I(o(o0 B1'U)
ElNo
VENTILATION PANS I NGLE RESI D) PAID
Will the applicam or future defined
occupant use equipment or Marta which
Date Receipt#
J mit haeardous air contaminants as Defined by the Pay Amer Air Quality Management BOILER-COMP pHP OR 1 W,OIXI BTU) a D
Uixvict?❑Yes No BOILER-COMP(OVER IW-000 HTU) TO'fA.:
I have mad the hazardous materials requirements under Chapter 6.95 of me Cali- AIRCONDITIONER ISSUANCE DATE.
broom Health&Safety Cotte,Sections 255115, 33 and 25534.1 undemtand that if m° NEW RPSIDI3N)'1AL MIiCI{. SQ.FL
,Wing donstot rentlyh trnan4 mat it nesperaibilit mm�oifytheaccupant 3�
ft wbic , erre ora cu J
Uwnetrammoria, agent � � y
Dure T01'AL: ISSUEDBY.
OFFICE