B 0645 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUP6R'IIN0 BUILDING-ELECTRICAL, � TRMH No �n ��
BUILDING DIVISION APPLICATIONIPERMIT 19,UMBING-MECILANIC.M. �VVv'1 �4Zg5' CC7�v7TI
BUILDINCPROJE TIDENTIF'IC'ATION
BUILDINGADDRE,SS: SANHARYNO. AYI'LICATIONSUBMITTALDAI'I',
'S NAME: ,/ I'110NE: CON I RACTOR'S NAME: LIC NU: �p
OWNER
Adillit! Nom, M2 S, A*2LF �S7- / S/tJB e o we coryTRDLX
ARCHH ECTIVNGINEER: LIC NO: ADDRESS f/d4 �Or �"+��- Q• ❑
F70(m)
PHONE: �T BUILDING PERMIT INFO
❑ Consultant Foes Paid by Applicant(Initial) BLDG ELECT PwsUI MECH
❑ t2/ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
y arerm m n I am Bcenttd under pr...Wam mf enapmr 9 bamor endng JOB DESCRIPTION
QRZ101 of Doshm 3mnbc Bu.inces road 11 fccaiouc Code,;I y1ocnwi3�._ RESIDENTIAL:WO p. 1'ERNIII ISSUANCE ,Fn:
O ❑STD\VL ❑KI'I CIIEN RIiAtODlil.QUULic.X APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RIi-1011
Z WConwmor
hn6a ❑MULTI-UNIT ❑STRUCTURAL
F=y
If UF.CLARATION PANELS
Z O-Z A�Plh.11 used ax public records h10DIFICAI'ION
OZ4- UPTO1.00AMPS ❑INTERIOR El CHIMNEY REPAIR
1=tnFly
Licensed Proiv,,wmul 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
C'W OWNER-IIUILD12R DECLARATION OVER food AMPS [I BATH RI MODEIIREPAIR jUIO TION
5 6 I hereby nfrinn that 1 am exmapl tram the Cnnmucwrs License law far theCA
k 3 L U fellow ung re,caul(Section 9031.5,Business and Prefessions Code Any city or county SIGNS ELECTRICAL El 01'l1IiR _
W,LL N which requires a permit to construct,dor,improve,demolish.or repair any swcmle I
!�
~+^O� prior to its issuance,alto requires the applicant for such permit to rile a signed statement SPECIAL CIRCUI'TIMISC. �-
E y that he is hm'epar
rant pant,,troc
he provisions al Conlmrs License Law(Chapter 9 ara a,5141
'C, (commencing with Section 9000)of Division 3 ofthe Business and Professions Code)or TEMP.MIT ER OR POLE INST. COMMERCIAL,
d ke C he,he is exempt Inerefmm and the hoses far the alleged cxcmpnno Any violation of [I NEW BLDG/ADDITION ❑DEM01.I1 10N
N Section 7031.5 by any applicant far a perndl subjects the uppllcenl m u civil penitlty of POWER DEVICES ❑TENANT E]FOOD SERVICE
FE< not more than live hundred dollvs 0850 I. IMPROVEMENT
[1 I.as oxneroftle property,or my employees will,wage.casmeir sole compcnsminn, SWIMMING POOL ELECT RIC ❑OTIIF.R
xC will do me work.and the structure snot emended, nosed l or calc(Sce.9044,ltusiness
L 3 m and I'mfessluns Gdie 11he Cristo is License law does not apply to an owner of OUTLETS—SWI TCHF_S—FIXTURES s
property who build,,or improves thereon.and who does Inch work himself or through
his own employees,provided that such in pooenwats arc noI i retired m olfcmTIAI,ELE"Sd Tor NEW RESIDCNSQ
sale.If.however,the building or improvement ismld within one year of completionthe SQ.Fr.FLOOR AREA VSQ.IT.
awner,builder will have the burden of proving that he did not build or improve for pur-
pnscofsale.). IDIAL: LG/1 �
E] L as owner(it the property am excwavely contracting with licensed course to
construct the project(See.914,nosiness and Professions Code:)The Communes Li-
ncLaw doe,urn apply waa ovacrot pro,wo,who buildsor improves thereon,a ad QTY. PLUMBING PERMIT FEE
who contracts(,,,curb projena w'nh v comuuena(s)licenced puoaaon m the Contractor's
License law. PERMIT ISSUANCE
1 ant exempt ander See. .H k P C for this reason
ATTER—DRAIN&VENT—WNI ER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION HACK FLOW PROMCK DEVICii
I hereby anu m under peralty of parjury one of the fol lowing dMaratioac:
Fl I huveand will mefignea Cerifieaeof Comers mself-insure for Workers Compen- DRAINS—FLOOR,ROOF.AREA,GOND. STORIES TYPE CONSTRUCT ION
cation,as provided for by Section 37M of the laMn Coda for the performance of the
work fm which Inn pa aril is Toned. PIX1 URES—PER RAP
I have and rill maintain Worker's Compensation Insurance,as required by Section
39(0 of the Labor Code,for the performance of the work for which this permit is issued, GAS—EA.SYSTEM-]INC.4 OUTLETS OCC.GROUT' AI'N
My W..setsC ner,mtlan Insurance currierand Policy moull am:
Carrier: Policy No.: GAS—EA.SYS'1'IiM-OVER 4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE,11i ST RL WAS IT IN'I CRCEI'IDR
COMPENSATION INSURANCE BUILDING DIVNION FEES
(This section need nmbe connplched iflhe pe nal is hnone hundred ddlvs(SIM) GREASE TRAP
or less) PLANCHECK FEE
I ccnifychat iifle perforneuav nflboworl hr,hichthk perndl isissued,l shall SEWER—SANITARY—SI'ORM I:A.2W Irl'.
ENERGY FEE
noI employ any pmaon i.......oner ry us I b)cey the Wnrkus'Compen-
O Z satins laws of Cah1�l a3C 7�/4� WATER HEATER WNEM'/CLECTR
Applicant / ��� GRADING PIAT
z NUIICE TO k b ll[�R'T'Etl'nifma y should WATER SYSTENVfRE HNG
04 t become wbject m the Worker's Comperoarsm Prrn s ons of the labor Crde,You must SOILS IEE
.�j .�-t bu ins comply with such pmvi...mon,this permit shall be deemcA«vokcd. WATER SERVICE
WW
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLhiB. SQ.FT PAID Date Rowiph X
V� Ihcrcny lt0itm thvt lherc esu construction lnuling agency fur the perfonnvna of '
F he work far which this permit is icvaNd(So,.3097,Cir.CJ
Lenders Nance TOTAL:
VLando,Address )OTAI"
wI ccnify non I have read This uppllcnlon an _roots Ihm the above infatuation is BUILDING ITEFkG correct l agree to comply with all city and county medical and sham laws relating to QTY MECH ANICAL PE R M IT FEE
V Z building constriction,and hereby authorize representatives of thin city m enter ulam the SEISMIC p-H
uhovcmcrioncd property loom nspcc'o purposes. PERMIT ISSUANCE
(we)agree Io save,indemnify and keep harmless the City of Cupertino againstELECTRIC FEE
Iiabilihics.judginems,costs and expenses which may in any way accrue against said City AITF.R OR ADD TO MSCI I.
PLUMBING FEE
t
ncyncnce of the granting of This pooh.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0."CFM)
MECHANICAL PEE.
SOURCE R[GULATI S.
�� V p�;,�/��f{� AIR HANDLING UNIT fOVCR 100a)CPM) CONS'1'RUC'I'ION TAX
of
Signature Applivenh(Commcnn r y+m P/ EXHAUST GOOD(W/DUCI} HOUSING MI I'IGATION FEF,
HAZARDOUS MAI ERIALS DISCLOSURE
Will the applicant or future building owcupam store or handle hwnrdous material HEATING UNI'1'00100,00)BTU)
as defined by the Captain.Municipal Cola Chapter 9.12,and hhc Health and Safety
Code,Section 25592(a)'I IIEA'IING UNIT(OVER I(X)Mk)11'H))
L3Yes ❑Nn PAID —
VENTILA'TIONIPN(SINGLEHESIDI Doc Recciptp
Will IM1c applicant ar(Inure building necupmn use aptipmenl or devices A
emit hw.urdom air contaminants m dcbnW by the Huy Arw Air Quullly MnnugCR—COMP f3HP IBR I(HLI1I)"'U) TO tOestrin^ ER—COMP(OVER IM MIT BTU)NnONDI'IAUNERI have real the hwardoms nwrerials rtyuirtmcnts under Chaperfi95 oflM ISSUANCIi DAThhone,,Health h Sa(ay Gde.Seehinn.c 255(15,25533 sand 25531.1 undammnd thatRIISIDEM'IAL MIiCH. SV.f4.buildingJoesnlcu hue mm�unl,thw it is my raLwnribiiitym notifymcowsaft - ormissuanceofaCenificalc nt0 etanT
Owner or atuhorized agent Du TOTAL: ISSUED BY: s
OFFICE