S 0464 AYPLIUAN 1 TO FILL IN INFORMATION WITHIN REO LINES-USE BALL POINT PEN ONLY
CI TY OF CUPERTINO BUILDING-ELECTRICAL PE MIT NO.
BUILDING BE
VISION APPIACATION/PERMIT PLUMBING-MECHANICAL
0464
BUILDING PROJECT IDENT'IF'ICATION
LED IL1)fNQADDRFSS: -�// SANITARY IS APPLICATION SUBMITTAL DTAE
Gfovv(LINIH
A `t�k N//I/ 2,fZ- 99y CONTRACTORS l .t[� 673G -r l�
NIC CONTROLp
ARCHITECTMISGINEER: LIC NO: ADDRESS: f ❑
Z,(02-s— A-4-4/+a Al �
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EL CT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 em licensed under pme,oms of Chapter,9(commencing JOB 13SCRIPTION
PDMZ th Section TIX1ncfDiOmm3ofthe Bo61.,sand Pmfessimss Cde,andmylicemmis RESIDENTIAL:
OO wt PERMIT ISSUANCG
C W n full force and eRenC�/� / HV p,� ❑SPDWL ❑KI'I'CIIEN REMODIiL
aUU Licenxe Cn'/ I/ • - LIeK 10 Ol APPLIANCES-RGSIDENTIAI. ❑AUDITION [I PLUMBING RIi-PIPE
a t lid Dam Lic.1 or M�Ia47h-M�'
FOy ARCHITECTS DECLARATION G/(-(,( PANIi1S [I MULTI-UNIT ❑STRUCNRAL
z0!/17�. tun xlrfdm 1 Xah amdvx public records / ^ MODII§CATION
OZ - UP'I'(I2IXIAMPS ❑INTERIOR [I CHIMNEY REPAIR
F-FW Licarled7cammeral 2UI-IIXpAMPSMPROVEMENT ❑SWIMMING POOfS
OWNER-BUILDER DECLARATION OVER IIXp AMPSEl TH REMODF:UREPAIR ❑DEMOLITION
C W 6 1 hereby mff std that 1 am exempt from tM1e Contmcmr's Lictum Law for the
ip5,O y U following mason(Seddon]U LS,Buxim:m and Pndasninns Care:Any city or county SIGNS ELECTRICAL Tlil?R _
W a LL F' which requires v permit to dmxwd,altar,improve,demolish,or repair any structure _ F
0S priorm in issuarece,also rtquireavh,applicam for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
eft
"} that he is licensed pursuant m the provisions of the Contmctm's license Law(Chapter 9
00 (commencing will Section 700D)of Division 3 of the Business and Profusion,Code)or TEM I'.METER OR POLE INST. COMMERCIAL
d o eC that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION D DEMOLITION
+ may Iselin,TIED LS by any applicant fora permit subjecs lie applicant oucivil pevlly of POWER DEVICES ❑TENANT ❑FWD SERVICE
p, } our more fn rive hundred dollma S510B. IMPROVEMIiNT
6D1,as owner of the proam,,or my employees with wages as their sole compoosetion, SWIMM ING POOL HLEMB IC
wit Jo the work,and the structure is not intended or offered formic(Sec.7044,Business D OTHER
m and 14ofessions Cede:The Comrecmr's License taw does not apply m an owner of Of1T1.ITS-SWITCHES-FIXTURES
a 3.. propeny who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or ofcred for NEW RESIDENTIAL,ELECTR SQ FT
vale.If,however.the building or improvement is sold within one year of complcJon,the SQ.F..FLOOR AREA $ISQ.17K
cr-builder will have the burden of proving that he did not Wild or improve for put- RT B
ryas of sale)
D I,as owner of the property,am exclusively contracting with licensed eontmemrs to
consider the project(Sec.7041,Business and Professions Code:)The Counselor's mLi- SE
Li-
cause law does not apply to an owner of pal who builds or improves thercnn,and QTY. PLUMBING PERMIT FFE h
who contracts for such projects withacomdmtvmx)Licensed pursuantto the Cmademe, /x'fo /IFIeXJTI
License law. PERM]LISSUANCE c
Vf
D I um exempt under Sec. ,B&P C for this reason LV
Owner Date ALTER-DRAIN&VENT-WATER LFA) L ON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penally of Perjury one of the following declarations:
Ej I have and will maintain aCcrtificamol'Consent to.self-inwrc l'or Worker's Compen- DRAINS-FLOOR.ROOF.ARI7A,GOND. TORIES TY PE CONSTRUCTION
satins,as provided far by Section 3701 h
of the Lar Cole,for the Performance erforme of the
work for which this dron is issued. MIXTURES-PER TRAP
e and will maintain Workees Compeasatinn Insurance,as required by lection
.]01of be Labor Care,for the Performance ofthe work for whist', itis' OAS-HA.SYSTEM.I INC.4 OUTLETS OCC GROUP APN
My Worker's Com nsaunn Insure std Pali mnW
Cmrm� icy get, �' Q 0 GAS-FA.SYS'TF.M-OVER4(FAI
cnRTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASILINDUSTRL WASTE:INTERCSPIOR
BUILDING DIVISION FEES
(This section rceddmu bcamplmed IDho Lummt is frame hundred dmtars($IW) GREASETRAP
or tells)(T
FEE
I cenify that in the Performance ofthe work for which this permit is issued,(shall SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any manner so as m become subject h,the Workers'Compen- ENERGY FEE
Z ,Z cation Laws of Cslif.dan,Date WATER HEATER WIVENT/ELECI'R
Applicant t GRADING FEF.
r^ NURCE TO APPLICANT:If,after making this Certi&me of Exemgim,you should WATER SYSTEWMEATING SOILS IFF.
abecome subject m the Worker's Compensation previsions of the IaMu Code,you must
W forthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE
Pr Q
UO CONSTRUCTION LENDINGAG NCYagency
NEW'RESIDIMIALVIMU. SQ.pp PAID Date Recciplp
1 hereby acorn Ihanhere is s construction 30 lending agency for the perfomrance of
the work for which this permit is issued(Sec.1(197,Civ.C.)
�' ULcndr'x Name TOTAL:
U Lender's Address TOTAL:
111BUILDING FEE
0. I cenify that 1 have rtaJ this application and mute that the utxwe infonmotion is
Wcorrect.I agree to comply with all city and county ordinances and.state laws rebating to QTY. MECHANICAL PERMIT FEE
U ;7 7 building conswction,and hereby mull representatives of this city m enmrapon the SEISMIC PEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmlexs the City of Cupertino against I ELECTRIC FEE
Iiabilitla,judgmems,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
to ameequencc of Ile granting of this permit PLUMBING FEF.
APPLICANT UNDERSTANDS A ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 11.0110 CFM)
*OURCRLATIO MECHANICAL RIi
W� ? AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
' /Conwcmr 1�7 Date EXHAUS'1'HOOD(WIDUC'1')
HOUSING MITIGATION FEE
HAZARDO MRTERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hmadous material HEAT ING UNIT LTO 100,0X)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Seolitn 25532(a)? IIEATINO UNIT(OVER I W,BIXI BT(])
❑Yes ❑No VENTILA'T'ION FAN(SINGLE RESIDE PAID Dae accept If
Will the applicant or future building necupanl ns equipment or devices which
,.it tatnums air emonninum,as defined rea by the Bay AAir Quality Martagement BOILER-COMP OIL`OR IW,IXXI BTU)
l
Dik"i"? BOILER-COMP(OVER 101000 BTU) rz
DYes DNe \0 as rill
1 have read the Israel materials mquiremenis under Chapter 6.95 of the Cull- AIR CONDITIONER ISSUANCE DATE
India Hcalh&Safely Cssle,Sections 25.5115,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdoes not currently have a term,that it is my responsibility to notify the occupant
of the d E'irements which must be men'nom i.e.of a Cenificare.occupancy.
Owner or aumoriael ngenn Data TOTAL ISSUED BY:
OFFICE