S 2551 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
F
RTINO BUILDING-ELP%TRICAI, PERMIT NO.
ISION APPLICATIONIPERMIT PLUMawO-NIN.I tcwl, S 2551
BUILDING PROJECTIDENTIFICATION: SANITARY NO. APPLICATION SUBMI FEAL DATE.
PHO3-2�-4 I'fiONli: (yCONT OR'ti NAME:1� [� LIC ND',\ � 7-Z7 a N {'M�far r I C� I NIC CONTROL p
RCHEITC1ENGINEER: LIC NO. ADDRESS: \; ❑
S1 So V4
C/O�NTACT: J PHONE: V y h1 Y Q .� $� BUILDING PERMIT INFO
45,42, II ./ + 11 1^'+ El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Pill,4ras+q IN L�44 d Yea ❑ ❑ Ll/- ❑
LICENSED CON ACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Inas 1 am licensed ander provisions of Chapter 9(commencing JOB DESCRIPTION
aw d'Z with Section 760(ool Division 3 ofthe Hurines..and Professions Codc.an ylicenseis
X00 `8 PERMIT ISSUANCE RESIDENTIAL:
F1- In full Intermit el�eN!
El STOWE [I KITCHEN REMODEL
�UZV License Clue. �/�� Us.N S O\
L Date APPLIANCIiS-NESIDIiNI'IN, []ADDITION ❑PLUMBING NIiPPE
hQ
A CHITIiCTontrunoe'S DECLARATION PANIi15 ❑MULThUNIT ❑STRUCTURAh
Z O y Z I milemm�d mY plans shall be med as public records MODIFICATION
OZ^� UPT021g1AMPS [1 INTERIOR El CHIMNEY REPAIR
Fa.~RI Licensed professional 201-1000AMPS IMPROVEMENT
mz-jj OWNERWALTERDECLARATION ❑SWIMMING POOLS
yp,C W 6 1 hemby uflirm?net 1 ant exempt from the Comwcmr's License Law,for the OVER I000 AMPS ❑BATH REMODEUREPA1R El DEMOLITION
.X a 6 FU+ following mason.(Section 7131.5.Business an,Prolesslons Gude:Any city or county SIGNS I?LI?LYRICAL ❑( TER
LLLL1l 4. which elpoms n To or to conslmn,alter,improve,demnldxM1,nr mpwr any snowme
O prn,r to its i>suuncc,also rcgrires the applicam for such permit In lilcasigned smlen¢m SPF,CIAI.CI IS
�y tbaheislicenuJpunuanlaothepmviiionsofaM1CConvactnr'sLianseL.aw(Chnp¢r9 /��_
X00 (commencing with Section 7")ofDivision 3 ofine Business and Professions GMe)or TEMP.M OR PoLEINSr COMMERCIAL:
a 6 e C mal rte is uemrt merefmm and me basis for the allege)exemption.Any vinlmion of ❑NIiW BLDG/ADDITION ❑DEMOLITION
a,�!! LL• Section 7031.5 by any applicant for a perma subjects me applicant to a civil penally of POWER D V CES
I+1^w ..n [I TENANT [I FOOD SERVICE
[F.. tmom mne Five thundfedd,lor yclo(S5001. \\`` IMPROVEMENT
CO 1,
as owner al lbs pmpetty,nnny cn+pinyces with wages as their tole rompensmlon, SWIMMIN OOL ELLELTIIICIlk
YY will dothewons Code: he Cont is pots Livens Law does
sol apply
t0an Rosiness ❑OTHHR
and Professions GMs:The Cnnlwmnr'x License Law dm..nal apply m an owner(i( OUTLETS-S ITCHES-FI%'TURES
property woo buil,.pr improves such
.ad who rias mch tinhimself ar Through
his own employeese provided That such mens I% nId w thin not intendedofm pleered for NEW RP_SID I LHCr ,!
sale.ILhower will have
he bur improvement itat h did none tbuildoimprovetfor 'hepur, SQ.FT.FLOOR AREA LSQ.FT.
owner-ealder will have the burden of proving that he did not buil)or improve for pun
El
of sale.).
❑ Lasowner of the property, land conlrmling with 01hee,adoc I.,-
come
TA
onivucl he project(Sec.](144,1{uxinex.0:uW Prufesiiona GMca''he Cnnlrumor's Li-
se Law dues not apply to an owner of property who builds or improve%thereon,und QTY. DMBjM ?FEE
who scrawls forsueh projects with a commends)licensed punarm to the Contractor's
License Law. I SUA • So
So"`
Sec. ,B&PCformisreason Uftakl
Owner Dom
& -
FI AIJER- WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION K1+1. 1'R. T.DEVICE '
1 - I hereby union under penally ol'perjury one of the inllnwing,alnmainnx:
I have and will maintain a CertiEctne of Consent to self-insure for Worker.Cool DRAT AOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 3700 of the Inbar Code,for the Performance or abe
work for which Iris pemit is issued. ES-PER TRAP
❑I have and will maintain Workels Compenstr on Insurance,as required by Section
37M ofine LOMn Cale,for the performance ofine work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUT' APN
My Worker's Compelnution Insurance carrier and Policy number arc:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(CA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIUINDUSTRL WASTE INTERCEPTOR
Mus section racial not be completed if me penin is forme hundred dollars(SINB BUILDING DIVISION FEES
or less.) GREASE.TRAP PLANCHECK FEE
I cenify dol in the perfofmancenfthe work for whichlhis pend,is issued,]shall SEWER-SANITARY-STORM FA.300 FP.
mtempayany in any manner wax to become subject Wurke+s'Compton- ENERGY FEE
,� satin Laws of .pale
Applicant +S+y WATER HEATER WIVENTIELIiC TR 0 GRADING FEE
I, NOTICE TO AI'I'LICANT:If,after moil,This Ce mune.?HicmPaior,you should
WATER SVSTIiMlfREATING
a ; become mnjeet y me Workels ism,or his provisions oto of the Inbar Code,you mull SOILS EFF:
Lfd fonbwim comply with such pmvisions or anis permit shall hJeemM revoked. WATER SERVICE
UO CONSTRUCcIONLENDING AGENCY NEW RESIUENTIALPLMB. SQ,FT. PAI
D
I hereby u0iml that mere isuconstruction lending agency for performance of Dam V Receiplp
LA F+ the work for which this permit is Issued?Sec.3097,Civ.C.)
O U larders NameTOTAL:
Icadu.Addm,, T 4
y1 comfy that I have read anis application and slate that the above infortnmion is BUILDING FEE
(n corral.I agree to comply with all city and county ordinances and slate laws reining to QTY. MECHANICAL PERMIT FEE
V.Z building conduction,and hereby imsmim reprosentativesofinis city loemerupon the SEISMIC FEE
above-mentioned property for ampiw inn porpous' PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino stili nil ELL'CI'RIC FEE
Iiabilhas,judgmenes,costs and expenses which may in any way uccme against said City ALTER OR ADUTO MUCH. PLUMBING FEE �A
in niequence of the gooding of this ponnit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL ME
SO CE REGULATIONSI� (�
!J Ute._-.\I 3—�w1 q 9 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sign.mre ofA,,IirmWCm CC mrr -C.]� �l�• Dale EXHAUST HWD(WMUCD HOUSING MITIGATION FEE
HAPARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant somorivndle hazardous namrial HEATING UNIT(10 100,000 BTU)
a.Defined by Ile CuNainn Municipal GMs,Coupler 9,11,and the Health and Safety -
Care,Section 25592(.)? HEATING UNIT'(OVER 1000011 BTW
❑Yes $Ash- VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will am applicant contaminants a building bythe Bay so Area
Air Qualitosom or y
Management
BOILER-COMP DHPOR I00.00011TU)
nit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL
mric/1
7YeY iwl � BOILER-COME(OVER IW,IIfI(11{TU)
I have feud the hazardous material requirements under Chapter 6.95 of the Cull- AIR CONDITIONER ISSUANCE DATE
funis Hoalm&Safety Code,Section.25505,25533 and 25534.1 undersand mat if the NEW RESIDENTIAL MECH, SQ.FP.
building does n,fNmntly haves to 1.than is my responsibility,n+notify me occupied J` 4
oflhe rtyuim a hsh must G:me avis'. anfn Cenificac of Oce
Owner m awhorieeJ agml Doleanc TOTAL: ISSUED BY: O
OFFICE
F