S 0933 APPLICANTTO FILL IN INFOfIMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO
BUILDING-ELECI'RICA], Pe IT NO
BUILDING DIVISION APPLICATION/PERMIT PING PROJELRING. IDEN'1 IFIC u 0933
BUILDING 1'ROIF.LT IDtNrIFICATION
GILDING ADDRF 5: SANITARY NO. APPLICATION SUBMI'ITAL DATE
PHONE: A R'S NAME: LIC NO
O NE ME: ,_VC V!/ ' NIC CON]ROLM
Ul
I QLAQ t4 M.6
/J r
ARC I' . 2 LIC NO: )DRPS caE 9,y'b E3G - Rd
CONTACT. G• HONE
BUILDING PERMIT INFO
Jo 1 G p�l7 400L E:1Consultant Fear;Paid by Applicant(Initial) BLDG LEC .PLUMB, MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby nRrm that I um licensed under provisions of Chapin 9(commencing
OAC with Seetion]IIO11)afDivisionJofthe Business end Pml'cssinnx Crede,andmylicenmin RESIDENTIAL,
PERMIT ISSUANCE
�I — in full force and ellen. ❑SFDWL El KITCHEN REMODEL
aUU License Class Lic.g APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
rFis Q4 Date— mr
Coanm ❑MULTI-UNIT ❑STRUCTURAL
I-Dm ARCHITECTS DECLARATION PANELS MODIFICATION
ZZ j2 7 I umdersmad my pluns shall Is,used au public recants
O UPTO 200 AMPS
pp El INTERIOR [I CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT I]SWIMMING POOLS
JJ OWNER.BUILDC•R DECLARATION ❑BATH REMODEVREPAIR 0DEMOLITION
OVER Troll AMPS
n'LLQ I naso affirm that I 1 exempt froman the Cessions a License Law for the ❑OTHER
d V Counting reason(Section]03 13.Business and improve,
de add Cale:Any city of county SIGNS ELECTRICAL
3 LL t' which requires a permit rx bimIconstruct.aper,improve,demoli111 fi repair any snucturc
F'��� prionnims issuance,also requires she applicant lar ouch permitm fileasigned smtemenr SPECIAL CIRCUIT/M1SC.
;!{} that he is licensed pursammthe pmvisiom of the Conmecmrs License Law lChvpmr9
COMMERCIAL
COQ (commencing with Smith7Udu)of Divfsinn3ofthe Banineumal P..fesawn,Code)m TEMP.METER OR POLE INST.
ITION
Tea y that he is exempt therefrom and the hasi,for the alleged exemption.Any violation nr [I NEW BLDG/ADDITION ❑FOOD ERVI
uX1 L� Section]OJLS by ony vppliam fora permit xubjects the applicannoecivil penahy of POWIiR DEVICES ❑FOODSERVICE
m not mom than five hundred dollars($500). IMP OVEMENT
�=6 Las owner of the normemployees with woe es as their sole compensation, SWIMMING POOL ELECTRIC
Q ❑ Pmµ y Y B µ" ❑OTHER
L.
will dmftwork,andthe a Cont is notintended,mothered
Lawdosactamic(Sec.]047,Business
W 3 and Pmfnho la Cade:The Contractor's License Lew docs oat apply m nn owner of OUTI-ETS-SWITCHES-PIXTURPS
progeny who builds or improver therein,and who taco tote er of through
his own employees,provided that such improvementsnts ve not intended
d o or offered for NEW RESIDENTIAL ELECfR SQ
sale.IL bower will h building bur en of gement is at hedwithin one build
or i provetfo".the SU FIC FLOOR AREA b/SQ.FT.
pass,of saldcr will have the burden of peoving that he did not build or improve for par-
you of sale.). TOTAL:
❑ 1,as owner of the property,vat exclusively Professions
with licensedheamammrs i-
cause a the es not (Sec.]Da,Business and property
who builds
Code:i TheContractors
than mr, nd
Li-
cause Law dos not apply to an owner of papery who builds or improves thereon,and QTY. GING PERMIT FEE
who contracts for such projects with a contmctons)licensed pursuant to the Contractors
License Law, PERMIT ISSUANCE
I am exempt under Sm. .B&P C for this reason
ALTER-DRAIN&VENT- .R(HA VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 4 r-
I hereby a1Rna under penalty of parlay one of the following ded atal-as:
. 1]Ihave and will mvinmina Carificamof C"Meal to self-insure far Worker's Conten- DRAINS-FLOOR.ROOK AREA,CONE' O STORIES TYPE CONSTRUCTION
s tion,as Provided for by Section 3700 of the Labor Cale,for the performance of the
walk for which this permit is island. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3]IM)ol'the LOMrCode.lnr the perlonnunro fbawnrk for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' AINMy Wnrl¢J' C. tab Ira ecarri and PalitY{ap ' GAS-EA.SYSTEM-OVER41 EA)
rrier
Ca „y—p.PQ Policy N(Ms
CE IFICATE Oh EXEM ION FROM WORKERSGRIiASFJ1NUUSTRh WASTE INTERCEPTOR
COMPENSATION INSURANCE I 1 DIVISION FEES
car last.) 1'LANCHECKt
(Thiasmmnneednm bacompleted it Ne permit is Corona hundred dollars(I GREASETRAP �r
'
I vanity that int he performmiceoOhe work for which this permit is issued.111-11 SEWER-SANITARY-STORM IIA.200 Fr.
nso
ot employ any person in any manner so as a u
become object the Wmker%Cnmpen- 13NF.RGY FF.E 0"tt,
z action Laws of Cedfomia.Duro WATER HEATER W/VENTELECTR GRADING FEE
z Applicant '
pJ NOTICE TO APPLICANT.If,after making this Cenificate of Exemption,you should WATER SYSTEMRRFATING SOILS HE
a ; become subject to the Workers Compensation previsions of the Lobar Code,you must
Lel ti
forthwith comply with such Provisions or this permit shallM deemed revoked. WATER SERVICE
QPAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. Date Receipt 9
1 hereby affirm that there is a construction lending agency for the performatrc,of
the work for which this permit is issued(See 3097,Co.C.) TOTAL:
QLenders Name
V TOTAL:
Lenders Address
0. .I cenify that I have read this application and state that the above information is
BUILUIN
LIE correct.I agree to comply with all city and county ordinances and slam laws relating In QTY. MECHANICAL.PERMIT FEE SEISM .FEE
U Z building construction,and hereby authorimrepresentatives ofthis city to enter uµomht
above-mentioned progeny for impatlon purposes. PERMIT ISSUANCE ELE RIC FEE
(We)agree m sme,indemnify and keep harmless the City of Cupertino against
liabilaies,jadgments,consand expenses which maymany wayaccrueagninatsaid City AL TEµOR ADD TO MECH. pLUMBIN FEE
incase to of the a ming of this permit.
All A f 1 STAN S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CPM) MECHANICAL. E
$O CE 1 ONS. /
7 AIR HANDLING UNIT(OVER 10.000 CFM) CON59'RUCTION TA
Si m r 'p man nuacmr Date EXHAUST HOOD(W/DUCT) HOUSINGMITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occult store or handle bazardnux material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safe,, HEATING UNIT(OVER 100.000 B'rU)
Cads,Section 25572(")] '
0Ye. ❑Na VENTILATION FAN(SINGLE IIESID) PAID Dam Rcceipmx
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HPOR 100,000 BTU)
emir hereabouts air commandments as definrl by the Bay A.Air Quality Management TOTA
District'! BOILER-CO MP(OVER 100.Of108T11)
❑Yes []No
I have real the hazam d" andanals requiremde
ents unr Chapter 6.95 oft he Cali- AIR CONDITIONER ISSUANCEDATE
forma Health&Safety Cradle,Sectias 25505,25573 and 25534.1 undersand tom if the NEW RESIDENTIAL MECH. SQ.IT.
building does not currently have a tenant,that it is my resparadolity to notify the occupant _
of the requirements which most be met prior to is nonce of a Cerpficale of Occupency.
Owner or authorized agent Data TOTAL' ISSUED BY:
OFFICE