S 0301 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECIRIC(1. PERMIT,NB.
BUILDING DIVISION APPLICATIONQ'ERMIT PLUMBING-ME:CHANIC.AL O O 3 01
r IIUILDING 1'ROJF.CT,IDEN'FIFICA'IION: ' �7 .L
BUILDING ADDRESS! - SANIFARYNO. API'LICAIIBNSOliMITAI,DA'll!
NH. 'l
OWNER'S NAME PHONIi: CONTRACTOkIS NAME: � ,t«QH LIC NO: Q
C! .S OJ S u. O� S (f/ NIC CONTROLM
ARCHIMC57HNGINEEIE C LIC NO: ADDRESS: 3,4_Al JOS sit ❑
/4.22 S E 9
CONTACT': ,PHONE: '' "BUILDING PERMITINFO
UV 3 ❑ Consultant Fees Paid by Applicant(Initial) BI. C ELECT PLUMB MECH
-LICENSE D CONTRACTORS DECLARATION ARATION r ,1 I
Ihcran firm that I" n:ed d of (sumo QTY }� a tELECT RIC IERMITf Mf . sij.� II7 I. +i-
ya p g , 'j JOB DESCRIPTION
DOZ with suction]aro)ofD'vn:u nJufthe Bu eandpm[ess onsCmie and my Ete est rc RESIDENTIAL
I W 0 PERMIT ISSUANCE
QUI;, in full fortt and eReet /f G' ❑SFDWL ❑KI'I C116N REMODI3I.
it License Clams •r/J�Lic.M AYI'LIANCIS—RI:SIOIiNTIAL ❑ADDITION ❑PLUMIIING RF.-PIPE
h L Date �� / � ' Commnnr
ARCHITECT'SDFCLARA'1'FON ❑NIULTI-UNIT ❑ST'ROC"LURAL
p.,pm PANES ..
I unAerxtund my plan.nhull M1e used ns puM1lic rccnNs _ - CHIMM0UNEY
RE N
�z�C UP T021NtAMPS El INTERIOR ❑CHIMNIiY REPAIR
F�L,F-U Licenced l'mfe"ioosl 201-1XXIAMPS PROV'. NT 0SWIMlsHNGPOOIS
OWNER-BUILDER DECIARATION
py13R 1600 AMPS Tit REMODF.URIiPA1R ❑DIiMQI.I'1'IDN
1 heathy ff
vmr Ill..1 um exempt fnnm the Contmcmds Licensc Law Rn the
LU following rcaum,(Section 7011.5.Business and Profcssimm Code:Airy city or county SIGNS FI.ECTRICAI,
U a W F whidt requires a,snob m uomtruet,alter,improve,demnlirli,m aTuu any..rueuue
prima hslsuuue,also requires theopplicnmt fmsuch permino file no,rid sudemem SPECIAL CIRC UII]MISC.
tbut he is licensed punoanuomr,arvidissof me Comamors License].aw(Chapter 0
=G'pX (cammermat,with Section 7000)of DivisionJof the nosiness and Professions Code)or TEM It METER OR IK)LPINS'I. COMMERCIAL:
6 y o y that be is exempt therefrom and the basis for the alleged evemption.Any violation of ❑N13W BLDGIADDI'1'ION ❑DEMOLTI'ION
U�y Section 7031.5 by any applicant for a permit.subjects The applicant it)a civil Penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
>y, not more drat live hundred dollars($50f- - IMPROVEMF.N'I'
M [71,asowdr,ul 0e properly,ormy employees with wages av thdrsnle emalsnxaIlu i, SWIMMING POO(.I3LI!'
C willdoth...rkandthesnunum is immaraded nrnReted for tale(Ner.7M ,Busincxs ❑GTFIEIi -
U m and Professions Code:The Contractor's License Law doe's not apply m an owner of OUTLI3'I'S—SWITCHIi.S—Il TU
63 - properly who M1uilds or impmves the...and who Arcs such work Thai or dtmugb
his own employees,provided that such impowe dents are not intended or oRemd for NEW REJIDENTHAL E
sale.If,however,the building or improvement is.old within one year of completion,the - SQ.17,1'L(lD REA $ISQ.17.
h ld will have T burden provingItlath did not build rimprove l P INN��
pus f )
TOTAL
❑1 runwar,of the p l ny forn eveltoivel,contracting with licensed contact t 1�
consuract the project(See 7014 Business and professions Code)The Contract r 1 - - r - - A�L �O.
,15
c La d t pplyt fp perty h h "Idsorntpfnvcsmcreo d QTY .' 'PLUMBING PERMIT I t T ' EEE- r`
whol such projects with acnlaa nOl licensed pursuant the Commeuns - V `' �`1Ny
License law. PE RM I I'ISSUANCE, VUC�
E] m1&I am exnpt under Sec. . 1'C Ice this rcanm •�y �Jf
�
Owner Date - ALTER—GRAIN&VI3NT—WAT
ER(EA) VA
WORKER'S COMPENSATION DECLARATION HACK MOW PROTECT.DEVICE
/ Ihereby affirm under Penalty ofpu'ryry one of the following decimations:
❑ I have and will maintain a Cenificme or Consent to self insure for Workers Comped- DRAINS—FLOOR.R(A)F,AREA,COND. STB TYPECONSTRUCDON
salon,us provided Ina by S.Tion 3](X1 of the Lat Code,ratio,pm
erroramcc of IT,
- -
work for which this permit Ix issued. FIX'I11RFS-13ER*TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
370Boflhe Lamr,Code,for permrmadoculthe work farwhich this permit is issued GAS—EA.SYSTEM-I INC.40UTLET:S DEC.GROUT' APN
My Work C mpph� tion In' mac r and Policy nyyempe 1m
Camer.�Y/}I F_ 7-'!Je/.O a Policy No.: V gs�9B GAS—EA.SYSTEM OVER 4 DIA) .
_ CERTIFICM 1301;EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRI.WAS I'It INTERCHVIOR
BUILDING DIVISION II!1!S _
11Tis action need notMcompleteJ irthc permit is 6nmc hunAreJ Jnllars(EI(XB GRI3ASC TRAP
or less) PLANCHECK PE13
I certify that came ishfommnceofThe work forwheliddspermit is issued,l slwll SEWER—SANITARY—STORM EA.21X117.
nm employ any person in any manner so as m hecrane subject To the Workers' m
Copcm ENERGY FEE
,c u.()at.()at. WAl IiR HEATER WIV I!M'IIiLECTR
A,,I
z A Imind Lo - CItADING PEE
3'D)APPLICq
ti NT:If,after making this Ccnificme of Exemption,you ahnuW WAl'IIR SYSTENVIREA'1'INC,
a ' become subject m the Worker's Conc,doomn provisions of the 1-aMv Code,yma mutt SUITS FEE
UJ forthwith comply with such provisions or this permit shallM deemed revoked. WATER SERVICE
= Z CONSTRUCTIONLENDINGleading
agent NEW RESIUENTIAI.PLMB. SQ.I?. ('AID
Ihcmhy affirm AtuT there isuconswetimt Rndiug ngencY for the perfnmtnnw of Dwe kmeipT
G O the work far which this permit is issued(Sec.11107,Civ.C.) -"
F Lender.Name
LU Landed Address 'TOTAL:
1 ri fy th tib doh. pplicatinn and zeros thanhc M cif t .. „• . .�A BUILIIING FEE
h correct I agree t comply with all city d county and hance d state to
QTYo: MECHANICAL PERMIT f 'I _t 1. EI E
VZ building construction,and hereby authorize representatives of the city to enter upon(he SEISMIC FEE
uhnvo-nrevianW properly for Inspection purpncas. PERMIT'ISSUANCH
(We)agree m sax,indemnify and keep h untless the City of Cupertino against ELLC TRIC FE
liabilities.judgments,costsand expenses which may in any way acemeagainsTsaid City ALTERORADDTOMECfI.
in consequence of the granting of this permit. - PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO TO."CFM)
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNI'I(OVER 10,000 CFM) CONS I'RUCTION TAX
Sigdamre fA,li,mg0Cmaba,hmr Dam EXHAUST HOOD(W/Gucr) HOUSING MITIGATION FEE
HAZARDOUS MATF.RIAI S DISCLOSURE
Willme...licamorfumm building occupant store mhandle hazardous material HEATING UNIT(TO 101,00 BTU)
an defined by the Cupertino Municipal Chale,Chapter 9.12,and the Health and Solely
Code,Section 25532(5)7 HBAONG UNIT(OVER 100,000 BTU)
❑YIN ' 0 N - VEN]I PAID —
HOILER—CO PQHPOG LERESI T Dam Receipt#
Wndousl the applicamorfm%aure building accupbythe ayAuse eas Air Qmot Maduswhich BOILER—CDMP(JHP DR 10(1,000 BTU(
omit hasaNnus air cnnmminants as defined by the Bay Area Air Quality Managatcm TOTAL:
Droner? BOILER—COMP(BVER 10b.000BTH)
[I Yes 0 N
I have rcadihe machausntaTcrlals dommumus under Chapter 6.95 of the Cali- AIR CONDI'f10NH1t ISSUANCE DATE;
furors Hcahh er Safety Code,Sections 255(15.255]3 wd 25534.I undersand That it the NEW RESIDENTIAL NIECH SQ.FT.
building dives not currently have a alma,dust it is my respmaibility to notify the ust upam
of the rats m acs which mux Moret nor m is..a.of a Certificate of Occupancy,
Owner or unted agent Dem TOTAL: ISSUED HY:
OFFICE