S 1102 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY PF Ir NG.
CITY OF CUPERTINO ,BUILDING.ABLR"I ANIAI. 11 0 2
APPLICATION/PERMIT
PIAMBING-MBCIIANIGAI.
BUILDING DIVISION tlU11.DING PRfIJ F:CT IDI:NTIFICATIUN
SANITARY NO. APPLICA'T'ION SDBMIJ'I'AL OA'IE
BUILDING ADDRESS:
/0 2Lp SoLYTH e A pa LA Lv-D 12 -.3 Q
OWNER'S NAME: PHONE: ONTRAC OR'S NAME: LIC NO: NIC CONTROL It
A r . Aq 4r�> 3R(, 29 lm w Sim r� Ceml ❑
'ARCHITVCTIENGINEER: LIC No ADDRRESS'�1r� 1A'IG-LA✓gD V' TW�
CONTACT: PHONE: 10,5(E
`-FIBUILDING PERMIT INFO
❑ Cansultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
MEIANle Scr rS10 S 3- 7& 3 tK
LICENSED CONTRACT'OR'S DECLARATION QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter 9(cnmmcncing RESIDENTIAL;0CZ with Scetinn TODOW Division Sof the Business and Professions and mylicenu is PH MIT ISSUANCE ��
F 0 0 in full leave and effect 314 7 R y ❑SFDWL ❑KITCHEN REMODEL
aUU License Classy ��+ Llc'K APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
bnG Date Commclor ❑MULTI-UNIT CSTRUGTURAL
Z~00
E un - ARCHITECTS DECLARATION PANELS MODIFICATION
1 understand my pians shall W used as public records UP TO 2M AMPS
�'C [IC INTERIOR CHIMNEY REPAIR
0 ZPOOL
F4Lw Licensed Professional 201-1000AMPS IMPROVEMENT CSWIMMING POOLS
V ? OWNER-BUILDER DECLARATION OVER 1001 AMPS ❑BATH REMODEUREPAIR O DEMOLITION
�y I hereby affirm that 1 am exempt Erman,CImeartar's License Law for the }w ❑OTHER
Pj O y U following taloa(Santo 91131.5,Business and Profcssinns Calc:Any city or county SIGNS ELEM RICAL lJ
Fy. which regoires a permit to constract. he,improve,demolish,nr repair any structure
F v-04 priorm its issuance,also requires the applicant far such permit to file a signed statement SPECIAL CIRCUITIMISC.
"y that he is licensed pumuannudh<Prrvisinm of the Cnnvador's License Law(Chap¢r9 COMMERCIAL'
p0 (commencing with Section like)of Divisina 3 clan,Bminesuund Profession,Coda)or JEMPMHTERORPOI.EINST.
60. p� that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NE LDC/ADDITION ❑DEMOLITION
W M N Section 9Ot L5 by any applicant for a parotid sobjats the applicant In.civil Penalty of POWER DEVICES NT ❑FOOD SERVICE
not marc than five hundred dollars($500). IMPROVFMEM'
TSG ❑ SWIMMING POOL ELECTRIC ❑OI,us owner of the pmpcny,or myempinyeeswidh wages asthcirsnlcannpensnhnn, THER
will drum walk.and the structure is not intended nuanced far wle(St 7(W.Businessate OIITLEI'S-SWITCHP_S-FI%TURFS is
F and Professions Core:The Cuntracmrs License Law does not apply to an owner of
Iia pnapeny who build..,or improves thereon,and who does such work himself or through
his own employee,,provided that such improvements are not Intruder or offered for NEW RESIDBNTIAf.1iLECTR SQ FT.
SQ.IT.FLOOR AREA
owner- elder will hbuilmngmke.of
isslidhe
non ildoric. parva for the
owner-Wilder will have the burden of pmviag that he Jid not Wild or improve for pur-
poseofsale.). T
C 1,ns owner of the progeny,am exclusively cnmmeting with licensed crtdructarx to
onsuuct the project(Sec.7044,Business and Professions C.eU The Cantmnor'e Li- FEE
cense Law does not apply m o
un wner of Property who builds or improves thereon,and QTY, PLUMBING PERMIT
who contracts for such projects with a coninalm(s)licensed pursuant to the Co itawl, 's
License law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reaam
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner [).in
WORKER'S COMPENSATION D[CLARATION BACK PLOW PR(TTEC'f.DEVICE
1 hereby af&m under penalty of perjury one of the fallowing derleadmm:
C I have and will maintain aCenificote of Consent to self-insure for Workers Compel- DRAINS-FLOOR,ROOEARPA,COND. STORIES TYPE.CONSTRUCfI01
station,as provided for by Section 3901 of the Labor Calc,lir the performance of the
work far which this permit i,issued. FIXTURES-PE
❑I have end will maintain Workers Compensation Insumnea as required by Section OCC.GROUP
37004 the Labor Core,fm the perfmmunce ofthe work for which this Permit is issued GAS-RA.SYSTEM-1 INC..,anD EfS APN
My WarkersC pensetin In..,umne y er and Policy nwnbcrare: GAS-HA.SYSTEM-OVER 4(I7A)
Cartier. OcaM�niicy No.:
CO
CI?RTIFICOF EXEMPTION FROM WORKERS' GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('rhosection mallard ha completed ifdae)cruit,is Porono hmudraldollam($Ilk) CREASIVI'RAP PLANCHECK FEE
or less.)
toy say that int he pby..on,I,,the work Brwhich this the W rktas Ourfarll SEWER-SANITARY-STORM EA.201 FC ENERGY FEE
not employ any)ammo in any manner sa m m bes:ome subject m the Wnrkcrs Crmpen-
Z sntinn Laws of California.Dole WATER I If?ATER WIVHNTIELIiCTR GRADING FEE
ZApplicant
rNi NOl'ICE TO APPLICANT.If,after nuking this Cenificaro of Exemption,you should WATER SYSTEM/LREATING SOILS FEE
H became subject m the W.,ka,I Cumpensmian provi,illm of the Labor Code,you mu.a
Qforthwith comply with such pmvisionlluddspenrialill hedeemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL. SQ.SQ.FT. PAID
Dam Receipt p
C].JZ I herebydfirm that hem is a connmction lending agency for the parfonnance of
LL EEE•C••• the work for which this Permit is issued(Sec.3097,Civ.Cr TOTAL.:
0 Lenders Name TOTAL:
Lenders Address BUILDING FEE
L05 1.r
.rally that I have mad this application and same m.,]he abuse imfmmatiom is
V6J conal.Ias=m comply with all city and county ordinances and stale laws relating In QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V Z building construction,and herebyautherm representatives ofthis city mernerupan the
those-mentioned property for inspection purposes PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may In any way uceme against said City ALTER OR ADD TO MECH. I'LUMIIING PEE
in consequence of the granting of Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IIANDLING UNIT(7010.003 CFM) MECHANICALFEE
SOURCE REGl1LATIONS
^// a / /JI- ^ �^L-zj�� AIR HANDLING UNIT(OVI?R IQIXNI CPM) CONSTRUCTION'1'AX
Signatare.(ApplicanUCmararacam/ra'✓`�, Dare E(HAUSTHOOD(WIDUC I HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicandorfumrehuilm-9scruputsmte or handle W.mm,s material HEATING UNIT('1'O IL0,11O BTU)
as defined by the Cupertino Municipid Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 101,010 BTU)
Code,Section 25532(a)'f
I]Ycs El No VEN TILATION PAN(SINGLE RESID) PAID
Dam RcaipdM
Will the applicant or furore Wilding accupont use equipment or devices which BOILER-COMP(3HP OR Ilk."BTU)
emit hazardous air cenmmina ds as defined by the Bay Area Air Quality Management TOTAL:
I
District? BOILER-COMP(OVER IBa,000 BTU)
C)Yes El No
AIR CONDITIONER ISSUANCE DATE
1 have real the M1 odras materials requirements under Chapter understand
of the Cali-
2-
building
uiforma Health&Safety Code,Sections,Ban i 25533 and 25534.I undcmmnd that if the NEW RESIDEN'T'IAL MECH. SQ.FR /
huilJingdcea not currently have atenant.Natoismy ioee of,bilityme ofyflaw
prary. d
of the n•♦♦• meats w m t be tm -m m issmnce of/�Cenificme of tXcupvncy. —_
TOTAL: ISSUED By,
Owner or untrimmed agent Dme
OFFICE