S 0395 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CIT4ADDRMS:
RTINO BUILDING.FILECTRICAL PERMIT NO.
BUISION APPLICATIONIPERMIT DING RING-h1ECHANIFIC S 0395
BUILDING PROIRLT IDHNTIFICATION
BUIL / / SANITARY NO. APPLICATION SUBMITTAL DATE
/o5¢ lU
OWNlPHONE CONTRACTOR( A/�}�A�%! N/C COMAOL#
ARCRER: LIC NO: ADDRfjS&/CON `/�/ Psr�ur:. YO V,' // ff�J^ BUILDING PERMIT INFO
z'SVQ/ C� ❑ Consultant Fees Paid by Applicant(Initial) BLDG 17 ECT PLUMB IEC
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPFION
1 hereby aBinn and 1 oto licensed under pravldons of Chapter 9(commencing
Qgz with Section7fW)ofDivision 3afthe Businessand lhofessitn.v nCo/dc,and mylicenseis PERMIT ISSUANCE, RESIDENTIAL:
WOO in full fore0anlc 4��u� ❑SFDWI. C1 KITCHEN REMODEL
U License Clear Lic.p APPLIANCES-RESIDENTIAL. []ADDITION [I PLUMBING RE-PIPE
f..6 to para Comm f/'
FA ARCHITECTS DECLARA ON PANELS ❑MULTI-UNIT [I STRUCTURAL
MODIFICATION
Z p 4 landscaped my plans shell be ural as public records
oz—aUP TO 200 AMPS ❑INTERIOR CHIMNEY REPAIR
❑Licensed Professional 201-I(00AMPS IMPROVEMENT ❑SWIMMING POOIS
R fJ OWNER-RUILDER DECLARATION OVER IME AMPSQ BATH REMODEUREPAIR 0DEMOLITION
�reyJJy al I hereby affirm that 1 am exempt from the Convector's License Law for the OTHER
pe 4 U following reason.(Section 9031 5,Business and Professions Cade:Any city or musry SIGNS ELECTRICAL. /f-1
LL 3 LL which requires a permit to mnsomi.alter,improve,demolish,or repair any sanctum
,F„.u+� prior to its issuance,also requires are applicant for such Permit to rile a signed statement SPECIAL CIRCUIT/MISC.
sSSSS5 yWyWy that he is licensed pursuant the provisions or the Contractors License Low(Chaprer9 COMMERCIAL:
pG�� (commencing with Scnion]B00)of Division3ofthe Bminns and Professions Code)a, TEMP.METER OR POLE INST.
d ey that he is exempt therefrom and the hesis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�N Section]011,,by any applicant far a permitsoncrux the applicant macivil penahy of POWER DEVICES ❑TIi"ANT ❑FOOD SERVICE
F, not more tM1ao five hundred dollars(SSgp, IMPROVEMP.NT
p � ❑L as owner of the property,a my employees with wages as their sale compensation, SWIMMINGPf101.ELECTRIC ❑OTHER
•• GGG will do the work,and the swclum is not intended mattered for aale(Sec.714,1,Business
tad Professions Chde:The Contractors License Law aceot s napply to an owner d OUTLETS-SWITCHES-FIXTURES
io
pmpeny who builds or improves thereon,and who does such work himself or through NEW RESIDENTIAL ELECTR SQ FT.
his own employees,provided that such improvements are not intended or offered for TFEE _�p FLOOR AREA 9SQ.IT.
sale.If,however,the building or improvement is sold within one yearem completion,the
obuilder will have the burden of proving that he did not Wild or improve for pur-
pnsseof auto). l'OTAL:
1,construct owner of the pmpeny,.Rosiness
exclusively Professions with j meed conwemea hs
mmLatheproject(Sec.o an Businessand Professions Cwlr j The Cnmmcmrs L.i
whocoawdts firs apply tots with
ommeri ave@s heddorimpro the
thereon,and QTY. PLUMBING PERMIT who amwcu forsuch projenv with o wmructm(s)licensed pursuant m the Convector's
LicenseLaw. ,B&PCfonhis reason PERMIT ISSUANCEI am exempt under Sm. ALTER-DRAIN A VENT-WATER 1EIOVALUATION
Owner A Date l.SdS•
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirin under Penalty of perjury one of the following dada stiuns:
I have and will maintain a Certificate rf Consent ha self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCfION
amine,as Provided for by Section 3]00 of the Lamm Code.Tor the performance of the
work for which this permit is ismul. FIX9'URB-PER TRAP
I have and will maintain Warkers Compensation Insurance,as required by Section
37X0 ofthe Labor Code.for the Performance ofthe work for which this permit is issued. GAS-EA.SYSTf?M-I INC. OIITLFfS 14 DCC.GROUP APN
My Wa n satiNfinman cAamim and Policy /q mss '
.: ✓g0y GAS-EA.SYSTEM-OVER4 LLA)
Cartier. Policy Nu:
CERTIFIC COMPENSATION
WORKERS' GRRASPIINDUSTRL WASTE INTERCEPTOR
COMPI3NSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed it dra permit isforime hundred dollar,(SIM) GREASE TRAP
PLANCHECK FEE
or le )
Loy myThetisthein performance as in ork for become subjectch to permit irkers' omperl GEWER-SANITARY-STORM EA.2(gI FT. ENERGY FEE
not employ any Prwn in any manner so as m become subject m the Worker.Compcn-
z satins Laws of Califomiz.Data WATER HEATER W/VENTCLEC1'R GRADING FEE
Q Applicant
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTE vt7REATING SOILS FEE
hmmom subjem m the Workers Compensation Provisions of the Lahr Code,you must
Ix rte+ forthwith comply with such provisions mans permit shall be deemed revoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB, SQ.ET. PAID
Date Remi
1thereby ichrtethas thereisu ed(Sm.30lending agency far the perfo.....f
W� the work for which this permit is issued(Sec.3U9],Civ.C.) AL:
Q Lender's Name TOTAL'
r LUt1 Lendars Address BUILDING FEE
y I certify that I have read this application and state that the above information Is
tiLI) correct legree mcomply with ell city unJPoumy ordinances and state laws relatingto QTY. MECHANICAL PER FEE gEISMICFEE
LJ Z building construction,and hereby amhmiu representatives of this city to enter upon the
above mentioned property for inspection purposes. PERMIT ISSUANCE' •SD E ECRIC FEE
(We)agree to save,indemnify and keep harmless the Cif,of Cupertino against
liabilities,judgments,costa and expenses which may in any way accrue against void City AL;MRORADDTOMECH, PLUMBING FF.E f �r rvr
in consequence of the granting of this Permit. v
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM) MECHANICAL FEE
SOURCE REGULATIONS.
' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sanmurc of ApplicanUConnother Date EXHAUST HOOD OVIDUCT) HOUSING MRIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE n
Willthe mplicanmr future building wcupantsmre or handle haaallous material T
HEATING UNIT(TO IM."BTU) .
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health end Safety
HEATING UNIT LOVER 100,000 BTU)
Coke.Section 25532(x)?
❑Y°s VENTILATION FAN(SM�A
PAID
Duo Rcc<Ipts
Will the applicant or future building occupant use equipment or devitts which BOILERTOTAL:LIRE C
I mit Im ardrus all contaminants as&read by the Bay Area Air Quality Management TOTAL: �.
David? //- BOILER-COMP
❑Yes
I have read the h ode.S a tionsanummul, 5.2553 en4 under Chapter 6.95 of the Cali-
AIR CONDD'IONERISSUANCE DATE
fomiaHwlth&Safny Cade.Scabene8505,onnyand 25534.Iunderstand thatment NEW RESIDENTIAL MECH. // •/zO 7
hull' gJ ga mcurrcmlyhaveatenant.Nat it is my responsihlhrymnot fy the rccupam1('�
of N �r/�w rich musl6e met Pim m issusnceM Cen- , f llpa Ty
/her/olauthotiudagent / UDoley— ISSUED BY:
OFFICE