S 2013 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Plifl'NO.
tBU11,DING DIVISION APPIACATION/PERMIT _ PLUMBING-MECHANICAL � 2013
BUILDING PROJECT IDENTIFICATION
BUILDING SANITARY NO. APPLICATION SUBMITTAL.[)ATI
M :
OWNER'S NAME: PHONE: CONIRACIOR'SNAME. LICNO,
M1 —GtIN $f S d9 NIC coNROLa
FIRCHITECTIENGINEER: LIC NO: ADDRESS: ❑
O
CONTACT. PHONE: BUILDING PERMIT INFO
J D- SI N y0V ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECH
V 2 ❑ ❑ ❑
LUvENSED CON TRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby alum Nm I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
ly00 with Secainn]fKNp out Divisinn3nl"rhe Bnsinevv and l'rofensinnn Cndo,anA my livenx is t PERMIT ISSUANCE 5"I .r1 RESIDENTIAI,-
I-- in full force and eBe V ❑SFDWL ❑KITCHEN REMODEL
�UV Licenxe�a�m-4��- Uc.N APPLIANCES-RESIDENTIAL OADDITION ❑PLUMBING RE-PIPE
F Z U Uam -.oaf--r-/ Contra"
vista ❑MUI.TI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION MODIFICATION
p„D ti PANELS
Z N Z 1 understand my plans shall txc used as pantie records 0 200 AMPS
❑
pZ-� UPTINTERIOR ❑CHIMNEY REPAIR
.`�.f"
F j Licensed Professional I 201-IOOOAMPS IMPROVEMENT SWIMMING POOLS
...4I OWNER-BUILDER DECLARATION OVER IWp AMPS C1BATH REMODEDREPAIR El DEMOLITION
6 I hereby affirm Nn from the am exempt frothe Contractor's License Law For the
3 LLF following reason.(Sermon]U3 L5.Business anJ Professions CWr Any city or Gummy ' SIGNS ELECTRICAL s Q [_1 OTHER
which requires a permit tot container,alit,improve,demolish,or repair any structure
,F-�� prior wits issuances also rcyuires the applicant Rrt such permit mfileasigned t:ncment SPECIAL CIRCUI'1'IMISC.
yy that he is licensed pursuant to But,provisions of the Cnmntcmrs License Law(Chapter Y
^a0 (commencing with Socrear700)of Division 3()fine Rosiness and Professions Gro)(it TEMP-MUTER OR POLE INST. COMMERCIAL:
d p,M fE @m M is exempt therefrom vW the Wsis for the alleged exemption.Any violation d ❑NEW BLDG/ADDITION ❑DEMOLITION
Secai(ni703I5 by any applicant for a Wmit subjects the applicant to a civil penalty of POWER DEVICES []TENANT
ma.,,,.ban five hundred dollars($50% FOODSERVICE
C IMPROVE
E] 1,ososabrofthe property,or my employees with wages aslben sole compensation, SWIMMING POOL ELECTRIC
Fy+ ', will do the work,and the stemare is not intended orotfered four sale(See"AA4,Businue ❑OTHER
Commencesn.
a 3 and Pmfessiuns CWr:The Commences LimeLaw does not apply to an owner of OUTLEI:S-SWITCHES-FIXTURES
proisany who builds or improves terven,and who does such work himself or through
his own employees.provided that such improvements am not amended our offered for NEW RESIDENTIAL ELEM R SQ En
sale.IL however,the building or improvement is sold within one ymr. complene.,the �OIQQIIon
awnerbuilder will have the burden of proving that he did not build or improve lar par- 7!7
pose ofsale.).1,as owner of the property,um exclusively contracting with licensed coninicaorsTATA
construct project(Sea 70W,Business and Professions Cade:)']be Coneacrors Li-
moseLuwdoesnmapplytoanowner of property who builds or improves intention,and QTY. PLUMBING PERMIT FEE
who conuans for such projers with a conuactons)licensed Pursuant to the Contractor's
License Law. PERMIT ISSUANCE
I am exempt under Sm. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
kitDate
(�
kitWORKER'SCOMPENSAT10N DECLARATION BACK FLOW PROfECE DEVICE 2 So
1 hereby affirm under peadlay mf perjury one of that following declarations:
Cl I have and will inaintain a Cerificare of Consenno self-insure l m Worker's Cominco DRAINS-FLOOR,ROOK AREA.CONU. STORKS TYPE CONSTRUCfl01
scion,as provided for by Section 3700 of the Labor Code,for the perfornamcc of the
work for which this permit in issued. FIXTUR HS-flak TRAP
I have and will maintain Winker's Compensation Insurance,its required by Section
3700 of the Labar Code.for the perfnnname of the work liar which this permit is issued. GAS-EA.SYSTEM-I INC.4OTTLEI'S OCC.GROUP APN
My Work %Cam nnsatmonlom cono manto my udEll"x/'h��//w- GAS-IiA.SYSTEM OVF.R4(EA)
Carrier: (. AI lilicy No.:
CGRTIFIIgCC OF • PION FROM WORKERS GRHASFANDUSTRL WASTE INTERCEPTOR COMPENSATIONINSURANCF: BUILDING DIVISION FEES
(This section need not hcrnmpined ifihe permit is lin one hundred dollars 1$1(HE GREASETRAP
1'LANCIIECK FEL
no less)
I certify that in the performance ofthe work for which this permit is issued.I shall SEWER-SANITARY-STORM PA.21X11,1'.
not employ any person in any manner xo as to become subject m the Workers'ContENEROZ GY DLI: 2 / O
Z soman Laws of Cali forma.Dam WATER I]LATE R WIVENDELECHt
7� O Applicant GRADING PGE
G M NGGCE'IO APPLICANT:IL after making this Ccmificate of Exemption,you should WATER SYSTEMOREATING SOILS FEE
(~ herrme subjer a,the Worker',Compensation previsions of ane 1-abar Calc,you moxa
Wti forthwith comply with such provision or this permit shall be deemed revoked. WATER SERVICE
0
a
CONSTRUCTION LENDING AGENCY NEW RESIUT:hT1Al.PLMB. SQ,FT. PAID �Z
VQ Thereby atfi.reds there ismsnnswrion lending agoney lnnheper(nn.nee of Da Remi M
the work for which this prmit is issued(Sm.30)],Civ.C.) T 1: r
ULnnders Nome
Lenders Address TOTAL: �g
1 certify that 1 have read this application and tato that the above information is BUILDING IT; ( o'
V0.) correct.1 agree to comply with an city and county ordinances and state Iawl reining or QTY. MECHANICAL PERMIT FEE O
U z building coosauetlon.and hereby authorlx representatives ofthis city to enter upon the SEISMIC FEE
aisle-rue n rd p,o,c.y for i npemion pmp()sn. PERMIT ISSUANCE
(We)agree m suit,indemnify and keep harmless the City of Cupertino again ELECTRIC FEE
Embilities,judgmems costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH.
PLUMBING PF.E
in nneof the granting this Permit.
APPLICANTCANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON"(TO IO,IXgI CFMI MECHANICAL FEE
SOUIiC'I 'GULATIf i -
%l+�X AIR HANDLING UNIT(OVER 111,000 CFM) CONS'IRUCION TAX
Signau •ofAp amor/Commebr Date EXHAUST HOOD IWIDUCO HOUSING MITIGATION FEE
HAZARDOUS MXCERIALS DISCLOSURE
Willi appiicarel or more huildingomupatn store or handle herallous material I ILNI ING UNIT('10 100,000 BTU?
as defined by the Cupertino Municipal Crede,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER I(q.00q BTU)
❑Yes [I No VENTILATION FAN(SINGLE RESID) PAID -
Dae Receipt If
Will the applicant or future Wilding occupant use equipment or devices which BOILER-COMP(3HP OR IIg),(Xp BTU)
mit hvardous air contaminants as defined by the Bay Area Air Quality Munagemem TOTAL.
Hornet? BOILER-COMP(OVER 100,003 BTU)
❑Yes ❑Nu
I have read the harudaus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE.DAT
forma Health&Safety Code,Sedan 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.FT. 9 Qy
Is]it ng it men it have afired,thafit ismymsrymsibilaytonotify(be occupant U r 2 1
of in mine., t aas
ma prior m issuance nfa Cenif n of Oc
O roru rnzedugcni i Data
TOTAL: ISSUED BY:
C_
OFFICE
PANEL STRUCTURAL ENGINEERS, San Jose,Calibmia 1: WH
® E 7 °_95002
;r DES .-. . CHK
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Revised 3"-24-
616K
"-2-SIGN FOOT(NCC
Fo_R
_eGSH.ItA _J:APANE5.E_CU.15-1AE____ ._-- --_:----.__--
10700 5 . DE ANZA 3LVD.
CUPERTI-Ko', CA
5co : 5t r u c-tv.ra t ca.1e-ulaMOV)ss.t9rt
.....— ___---
- Coc1c : 1994 08C
Wivid : 19 Fsf
-- , Concrete: -I"c1 .2,50.0._ ps.f - - ----- -- ---
R21v%fcmiv%j Steel Grade_ 40 or GO.
StructL)veJ Ste�A : ASTM. ABCs en, eIA for �5t-4n4avd .ipi�e �plvvnns:
ly sFinA1. :6c__WSTf _ A5001
IN ACCORDANCE WITH THE CITY OF
CUPERTINO CODES AND ORDINANCES
DATE -
—7 p
ESS 0,R, - - -
SIGNED_.(__ __ _ UST -
—
beikept on the an�.j, - � T
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rawful to male s or aiteraGunS - - — NC -. `
on same with u 1n pe mscion fr.0M _ - _
the building ucp, EN.
Cupe Lino. ....
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The stamping of no .Peri iptloBB
SHALL.NOT be ^n , a r b be-fflC-'- -------
approval of Lha _ .. ._.. . _._._ .
fo
- nt-p--{r v_.Citv?S' �� � Law.._._._.�_. _ _ . .-------- •-•--
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PATEL STRUCTURAL ENGINEERS, San Jose, Calitomia 2---OF- ,.z
® anaEcr oae O 98002
D" CHK
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passive Soil P✓ess. — 200_psf
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