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"BUILDINflADDRUS
RTINO BUILDING-ELECTRICAL 1 PERMIT NO.N.S O ,r �S
ISION APPLICATION/PF.RMIT PLUMBING-MIiCHANICAI. SOOO1 ?`(` 11 L
BUILDING PROJECT IDENTIFICATION
SANITARY NO. API'LICM ION SUBMITTAL DATE
. I nIT-�A0 1' 93 CONTRACTOR'S NAME: LIC NO: NlC CONTROLp
. R: LICNO. ADDRESS: ❑
CONTACT: PHONE: HUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
LICENSED CONTRACTOR'S DECLARATION QTY_ ELECTRIC PERMIT FEE JOB DESCRIPTION
I berchy affirm that 1 am he...cd under provisions.f Chapter 9(commencing
0�7. with Section 700(pol Division 3ufthe Businecvand Professions Crdgand my license is RESIDENTIAL
LLT O O PERMIT ISSUANCE
F��.. in full force and elle ❑SFDWL EI KITCHEN REMODEL.
QU�j Licrn+ 's+�Lic.p APPLIANCES-RESIDE TIAL ❑AUDITION ❑PLUh181NG Rte-PIPE
F-Zm Date Commaar
vi<1
F O y ANCHITELTS DIiC-A TIN ❑ ULT-UNIT ❑STRUCTURAL
PANELS MODIFICATION
m_0 1 unJcntunJ my plans shall he used os public records� Oz�nO UP T02W AMPS C3 INTERIOR ❑CHIh1NF,Y REPAIR
F+�nl" Liccn.cd Professional 201.10MAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 10(10 AMPS ❑BATH REMODEUREPAIR 0DEMOLITION
C W 6 1 hereby all,.that 1 am exempt from the Cotmm
rcrs License I,aw for the _
igSOyU followingnuson.(Serum.]031.5,Mussiness and Pmfussinns Coda Any city.1 county SIGNS ELECTRICAL EJ
m LLO vFi which requires a permit to cm earuot alley,improve,demolish,or repair any structure R
priorto itsissuance,alsm mquims lhert,licam for such pe union Mannered neemert SPECIALCIRCUILMISC. TJ
That he is licensed puromal,,meprnvisionsof the Cnntmctnr's License Law(Chapter 4 COMM
+��G�O (commencing witb Section 7(XIO)oR)ivision Jofthe Bminess end Pr�fessionsCWO nr TEMP.MITER OR POLE INST.
6 LL pa that he is uempt henchman ad he hasis for me alleged exemption.Any violation of ❑NEW BLDGIADUITION ❑DEMOLITION
XON Section by any Vplican'for a Permit subjects the application u)a civil penally mf POWER DEVICES ❑TENANT ❑FOODSERVICE
not more than five hundred dollars(5501) IMPROVEMENT
CXr ❑ Les cwnerof'hepropenyormy employees with wage,R,theirsde compensation, SWIMMING POOL ELECTRIC
w2 will Jo the work,and the someone is not intended or offered forsale(Sea.]614.Business ❑O'fHGR
F
Y0) and Professions Cole:The Contactors License Law does not apply es an owner it OUTLETS—SWITCHES—FIXTURE
0"3.. property who builds or improves sten i and who does such work himself or landfill
his town emplmyees,pmlding Hasten improvements ate m intended carof,or cleared for NEW RCSIDEMTIAL ELELTR SQ FT.
Vote.If,buildcr will the hapt mu i,athe did nthoyearnfcprovetion,lac $(I FL' LOORAREA USQ,FT.
owner-builder will have Tho MnMen of proving that he did not build or impmvc for Cur-
pose mf talc.).
C]1.as owner of the prmpeny,am exclusively contracting with licensed contaann to TOTAL:
construct the project(Sec.70,14,Business and Professions Csde:)'I he Contractors Li-
censeLaw doesNor apply to on,owner ofpmpcny who builds or improves therwn.and QTY. PLUMBING PERMIT FEE
whoeontmctsf Tsuch projects with n contractors)licensed pursuant tithe Contractor's
License Law. I PERMIT ISSUANCE
1 am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VP.NT-WA'1'F.R(EN VALUATION
Owner nam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under Certify of perjury one of the fnllowior daclmalimnsWorker's Ca -
❑Ihzve andwillmountain sCertificate ofCamaraLothar Come,
for Worker'sce at the DRAINS-FLOOR.ROOF.AREA.CORD, STORIES TYPE CONSTRUCTION
,tune,as Fmvidhi for or Senior 3]00 of Tae Lothar Code,for the performance ml the
wnrk forwhich this permit it esker FIXTURES TRAP
I have and will maintain Worker's Compensation Issuance,as required by Stttion
3 X)nf the Unfair Cnda,name,pool......fIM1e wnrk for which this Fermi'it iswed. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' APN
My VAUce,Cumpe tion I n r and PnlicYx.DDyy
Cuniee�aNITU �Ygpcame Policy1,122 r IQI Io.50`4 GAS
-EA.SYSTLh1-OVERJ(LA7
CERTUTCATE OF EXEMPTION MOM WORKERS' 11
GREASPIINDUS'fRL WASTE INTERCIiPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not becmmpleted ifNepermit is fmrmnehundfed d011ars(SIM) GREASE.TRAP
or Ices.) PLANCf1ECK PEE
I certify that in the performance,of the work fou which this pentyl is issued.l shall SFiWER-SANITARY-STORM G.IlX)FT.
not employ any Canon in any manner so as to become subject to the Workers'Comped- ENERGY FEE
Z
su'imn Laws of California.Dae WATER HEATER WNENTIELECI'R
zApplicant t GR GIT?f:
re, NOTICE To)APPLICANT:IL after making this Cendionle of Exemption,You should WATER SYSTF.M/IREAI'ING S S .E _
abecome subject to the Workers Compensation provisions of the Labor CuJy you must ( 1 {
{✓a fcnhwith comply with such provisions or this permit shall the deemed revmked. WATER SERVICE I
QPi
CONSTRUCTION LENDING AGENCY NEW RCSIDENTIAL PCMB. SQ.FT' Recei
VQ Ihereby elfin.thauherena conaation lendingvgenty for the pafonrance of
VU
he wnrk for which this lemlit is lowed Sec.3197,Civ.C.) . Li
O Leiner',Name TOTAL:
LU)1 Lcro Address
I certify that L have read this applicaion and slam Iherthe above infm
nrainn is U NG IT'
i.. V) correc,l agree to comply with all city and county ndinances and nae laws relating to QTY MECHANICAL PERMIT FEE 56
(,) building amswctinn,and hereby vu'harim repremoativcs of this city on enmf man the _
above-meminned property fainspectio.puryoses. PERMIT ISSUANCE �� ELECTRIC
WO agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADDTO MECH. PLUMII 'FEE
in consequence of the granting of this Nmat.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECIIA, ]CAL FEE
SOUFIk'E JyGULAT10N5. /oISR
198 ALR HANDLING UNIT(OVER 10.00007) CONSTRICTION TAX
Sl-�II 014AAp_ppllic—aoViCtornatemr I Oure EXHAUST BULL(WiDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futurcbuildingwcupunl 11-11 nr handle havNnus ant,modMOM*
NIT(101W,IXIII BTU)
as defined by he CaNninn Municipal Code,Chapter 9.12,and the Heahh and Safety
Cade,Semina 2553260? NIT(OVER 100.0X1 BTU)
❑Yes El No' ION IAN(SINGLERESID) PAID
Dam Receipt M
Will the applicant or future building accupam use equipment or devires whichOMP(3HP OR IMOM BTU)
emil hazunlous vi,oulaminana ns confined by the Bay Area Air Quality Mmugenain 'I'O'1'AL:UisWa? OMP(OVER 104(X10 BTU)Yes ❑NoreadhomrdmusroamridsrequirementsuITIONER ISSUANCE DATEfomiu Health&Safety Cedc.Sadirons 25505,25533 and 25534.1 understand that if theENTIAL MECH. SQ, T. 1 �/ r/
building docs not currently have a tenant,Nat it is my responsibility to Ratify 0m occnpunt ` ti VVV
-fth<rtquiremcnts which moa be met priormissuwre tufa Cenificae offRcupatrcy. -{I� s1
Owner of adorned agent Date TOTAL ? ISSUED BY: -G fCfCl,
OFFICE