S 1640 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
BUILDING-ELEMRICAL ;P PryIT NO,
CITYOR0 PLUMBING
1640
LDINGUIVISION 1
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DAT II
t03llp cvZ sizA DTZ
NER'S NAME: ��,jfg�.a[[L�.��A�E i-11,NE p CONT'RACTOR'S NAME LIC NO:
�.Q� 7gu{/ MAix•' •7T' -01/ CA4&SR� l6i pl./ Ir• ` icz"t— NIC CONfROLM
�RCHITECI'/ENGINEEW LIC NO'. 7 ADDRESS: J}�TY J O ❑
C.�4H111�O IQLIo 9l(�fo
CONTACT: PHONE: BUILDING PERMITINFO
V —I' o Iy.OG ELECT PLUMB MECH
Si�E ✓ IgA �� (/(ill/ ❑ Consultant Fees Paid ``ly/ ILECT++
'GVG
LICENSED CONTRAMOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Jaz witin
Section 01B. Uivisinn 3ofba Businesslud Professor,Code.and my license is RESIDENTIAL:
{QO2 wt I'IikMIT ISSUANCE
F fall force and effect. ❑$FOWL ❑KITCHEN REMODEL�UU License Class - Elco APPLIANC17S-RESIDENTIAL )DITION ❑PLUMBING RIi-PIPE
P z pl Laos Cn.lncor
v160. MULTI-UNIT OSTRUCFURAL
ARCHITECCS DECLARATION
PANELS MODIFICATION
N Z I understand my plans fiall be as as public torrid,ZOZ4rO UP TO 200AMPS [3 INTERIOR ❑CHIMNEY REPAIR '
�4t:W Licensed Pmfessi...I 201-1000AMPS IMPROV17MEW C-]SWIMMING POOLS
OWNIik-BUILDER DECLARATION
6' I hereby aft ren Ihm 1 am exempt from the Contractor's License Law for the OVER IIILYIAMPS ❑BATII RF,MODIiIJREPAIR DEMOLITION
x0.06U following most .(Section 9031.5,Business and Professions Code.Any city nr cmmly SIGNS ELECTRICAL. ❑OI'HIiR
al�O y which requires a Permit to construct,alter,improve,demolish,or repair any structure
F. prior to its issuance,also requires the.applica.l for such pemliDr file a signed statement SPECI AL CIRCUIT/MISC.
y} oat he is licensed pms.ant o the Provisionsofthe CIH-1or's license Law(Chapter 9
IC (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)it TEMP.MIiTEROR POLEINST.
Il q M that he is exempt loan on,and the basis for the alleged exemption.Any vinlmion of EW BI.DGIADDITION ❑DEMOLITION
W..m Socumn 9031 S by any opplicoa fill,,pemnt eobject,the applicanua n civil penally of PoWpik DEVICES TENANT
Ell
SERVICE
am marc than five hundred dollars(E5W). OVEMF.NT
CZO ❑ Las owncroftheproperty,ormy employees with wages astheir sole compensation. SWIMMING POOL ELECTRIC
2 will do the what the stmcmrersnot imendednroffered lireme(Sec.91144,Il.xineas ❑OTHIiR
se and Professions Code:The Contractors License Laos docs not apply to an swner of OIITI.ETS-SWITCHES-FIX TURES
propeny who builds or improves thereon,and no reds such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FE SQ.IT.FLOOR AREA $/SQ.FT.
sale,If,however.the building or impoverrent is sold within one year of cmmplcti na,the
swingbolder will have are burden of proving that he did ml build or improve for par- NE /N
Edge of sone.). O !r• `
1,as owner of the propeny,am exclusively convecting with licensed contractors to
construct the project(Sec.3051,Business and Professions Cafe:)The Contractor's Li- I r�
nse law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who eonrmets for such poJeets with u conmeding)licensed pursmanno the Gsmmam's
License law. PERMIT ISSUANCE
❑I am exempt m lar Sec. .B&P C far this mason
ALTER-DRAIN&VI?NT-WATER(EA) VALUATION
Owner llac �^
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
� I I hereby affirm under penally of perjury one of the fallowing declarations: i
Fl I haveand will maintain a Certificate ofConsem in self ingm fm Workers Cooper- DRAINS-I ROOF,AREA,COND. STORIESIt TYPE CONSTRUCT ION
satin.,as Provided fm by Scandal 3700 i f the lalasr Code,for the performance of the
work for which this permit is issued FIXTURE - :RTRAP
[]I have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe Libor Cole,for the performance,ofthe work for which this permit is issued. GAS-E .:YS -Il .401) S OCC.GROUP APN
My War Cu ns 'unl sumnce comer and PalicynumMr urL�� _ .r GAS-EA.SYSTEMf
o.rw r� PnlicY Nn.:A�7 --(.�s]�,13!
CLkI"IC 'fE OP P.XIiMITI(IN NoFROM—W IKL'RS' ({RIiA51%INDUS'I'NI.WAS i14OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe Permit is for one hundred dollars($IW) GRIzASH TRAY
It,less.) :PA
HECK FIiIi ��
I emify that in the fix,momanceofthe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 Fr.
not employ any person in uny manner so as 10 banana subject to the W akeri Camper- Y I.:
Z
gains laws of California.Data WATER HEATER W/VENTIMECTR NG '
'�O O Applicant
y NOTICE TO APPLICANT:If,after making this Certificate of lixemprion,you should WATER SYSTEMaRE.ATING
become subsea m the Worker's Comfougaion now...onx of the Labor Code,you mol Tai
�• fonbwith comply with .on pookiommThis permit shall Federated revoked. WATER SERVICE Qy�y
S! Q
6
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT, 9OS•l�O
`7� Ihembyaffinn that the. commuction lcndingugency for the performance of Dam ReceiptN
Q the work for which this permit is omeal(Sri.3197,Cie C.) TOTAL:
O V pander's Name f0 A
Lender's Address NG FEE ��
y I certify that 1 have notal this application and state that the above infmmution is
N correct.l agree to comply with all city and county ordinances and state laws mining m QTY. MECHANICAL PERMIT FEF: C FEE O
L)Z building construction.and hereby addition,representatives of obis city o enter union the
uMvc-meminned propeny,for inspection Purposes. PERMIT ISSUANCE [LECfRIC PEE
(We,agme o stove,indemnify and keep harmless the City of Cupertino against
brobilitiesjudgmenv.costs and expenses which may in any way vccme agodiougid Cal, ALTER ORADDTO MFCIL PLUMBING FEE
in consequence of the gaming of this permit
APPLICANT UNOF.pSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 10.001 Cl'M1 MECHANICALFEE
4ddflarb,
6NS �/ 98 AIR HANDLING UNITtOVER 10,000CFM) CONSTRUCIIONC� � 'Date EXHAUST GOOD(W/DUCT) 110MATERIALS DISCLOSURE
plicanux fuwre building occupant store or handle hazardous material HP.AHNGUNITOOH10,0p0FITU)
upertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.0010 OTU)
Code.Section 25532(d?
❑Yen ❑Nn PAID _-;,cu+�„9 J,vi k FFt.Lll1 BOILER
ONPAN(SINGL00,000 II) Dare RecerplM
WIII the applicantan furore building by the Bay
me equipment of Devices which BOILER-COMP LSHP OR IIMI,IMX1 BTU)
emit haallous air umwminanu as defined by the Boy Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes F-1 No
I hnvc real the M1azarJous mamrials requirements under Chapter(.95 df the Coli- AIR CONDITIONER ISSUANCE DATE
famia Health&Safety Cole,Sections 25505,25533 and 2.5534,1 understand that if the NEW RESIDENTIAL MECH. SQ.PC
buildingdoes not currently have a adds.and it is my responsibility to r tifythe dormant
of the mearm ems which must be met prier to issuance of a CenBed of tXcuryncy.
Owner or thm Dm
orized loved T�A ISSUED BY
au
OFFICE
ADDITIONAL, PERMIT FEES
A
BUI LDI NO PROJECT I DENTI FICATION VALUATION
MR NING
ABORT./0314 C44SrCt4. ua,
OWNERS
TIE FEE SUMMARY -
C-004240 E¢EEN+M I .„NNE 144 oto 3
CONTRACTOR A BUILDING
NAME �/
64rS LL ✓Eruc xo ES4"1.�Z2” PLAN CHECK
CONTRACTOR'S Lb FEE
AOOREss �L•.9��2�
U[�•9'MIII'b. _PNorvE SEISMIC FEE J
DTV. ELECTRIC PERMIT FEE
S• UTLETS-SWITCHES-RECEP .314 ELECTRIC •S�
LIGHTING FIXTURES PLUMBING
APPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS O
SIGNS TRANS. TOTAL
SPECIAL CIRCUIT
PERMIT VALIDATIONEMP.METER OR POLE INS. t
bd
MOTORS SEE FEE SCH.
O SERVICE CHANGE
Z 2
F N TOTAL
ISSUANCE DATE
W > CITY. PLUMBING PERMIT FEE BLDG ELECT. PEG. MECH.
D. O ❑ KJ -1D ❑
D. 2 ALTER-DRAIN&VENT-WATER IEA.)
U O BACK F LOW PROTECT.DEVICE
LL I-
O IU DRAWS-FLOOR.ROOF,AREA,COND.
} h FIXTURES-PER TRAP
2 GAS-EA.SVSTEM-I INCA OUTLETS
(, GAS-EA.SYSTEM-OVER4(EA.) .
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.200ft/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAL
CITY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH. 7�
APPLIANCE �(� -
AIR HANDLING UNIT ITO lOJIDOQF.M.)
AIR HANDLING UNIT(OVER 10=r-F.M)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.I
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOILER-CORE(3 H.P.Or 100,000 B.T.U.)
BOILER COMP lo-,IOO,DDD BTU)SEE FEE SCN.
TOTAL