S 4303 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PFRMIT PLUMBING-MECHANICAL S 4 3 0 3
HUILDINC.PROJECT IDE.NTIFICAI'ION
BUILDINGAUORFSS'�(�)
SANITARY NAPPLICATION SUBMITTAL
TAL DATE
�O�1S � C '�,8v0 , /k 9-
ONE COMAlJ - _ TT
NIC CONCROI,� 4
ARC I I I I'ECTAiNGIN EER LIC NO: ADDRESS'. ❑
113 Sr�►Qo
CON'1'AC'I': PHONE BUILDING PERMIT INW
/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I helehy affirm that 1 am lieemed under prossd0ns of charter 9(cmnmendng JOB DESCRIPTION
Z with Section 7")ofDivision Bothe Business and PmfesslUnxCWe,and my hPERMIT ISSUANCE ceme is RESIDENTIAL:
F,1O_ in full force and )p J
C H 9 3 ❑SFDWL C1 KITCHEN REMODEL
¢VV Llcenx' Lic.X APPLIANCES iFZon�L U :ea Cnntrace+r C ❑ADLA TION ❑PLUMBINGRE-PIPE
ARCIII'I'IiC'I'S UI,CLARAr10N ❑MUI:TI-UNIT ❑S'TRUC'TURAL
F H Z 1 understand mY Plans droll be thea as Public recut PANY.1,h MODIFICATION
CZ—M
O Z� UP TO 2IXIAMI'S
❑ ❑INTERIOR ❑CHIh1NEY REPAIR
FNF'LL: LittnxJ Pmfeaaional 201-1(X10 AFIPS IMPROVEMENT D SWIMMING POOLS
OWNER-HUILDER DECLARATION
1 hereby affirm that 1 nn exempt from the Comment's Lianx<Law for the OVER I000 Ah1PS CI BATH RF.MODF.VREPAIR (]DEMOLITION
W 3 LL U following reason.(Section 2W L5,Deeinexa and Professions CWe:Am'city or county SIGNS ELECTRICAL ❑OTHER
FNOLL LL h which empires a permit m aim the peer,improve,demmh,eperif t fi repair any xwmentstarm _
g -----------
poor to issuance,afro mquirtxthe applicant for such perminO BlcrsigneJ statement SPECIAL CIRCUIT/MIST.
ion that he is liccm,d Pursuant the provisions of the Contractor's License Law(Chapter 9
nC, (commencingaflo Section IlNX))mf Division 7o1 tire Busiuro.ed Pmfnxiom Code)or TEMP.ME'T'ER OR PULE INST. COMMERCIAL..
ci.ya y that he is exempt therefrom and the basis an the all,ed exce,peon.Any vlolmoon of ❑NEW BLEGIADDITION ❑DEMOLI9'ION
X 2Scuuoo 7031 5 by any applicant lw a per I,subjects the npplicanno o c'i,I pen:Jly of POWER DHVICIiti
uI"w ❑TENANT ❑FOOD SERVICE
F=Qnal more Than five hLodned dol Inn(SMEE).
i] I.as owner of the pm,L or my employees with wages as their sole conmpcosetion, SWIMMING POOL EL> TRIC IMPROVEMENT
E O will Jo the work.and the svunurc is not intended or ot'fered for sale(Sec.Told.Bminess ❑OTHER
F
W 3 m and xity who
Cade:The Contractors License Law does not apply m if owner of OUi'Lf!TS-SW('TCIIF.S- ES
property who builds or improvca thertun,and who docs such work himself or through
his awn employees,provided that such improvements art not intended or offered for NEN'RFsU)ENr AL R 'Q FE
sale.IL however,the building or improvement ix%old within one year of complctiagnlue OFSU IT.FLOOR AREA S/SQ.FT.
owner-builder will have the moden of proving that he did not build or impmve for pur-
pose of sale).
Fl I,m owner of the pmpeny,am exclusively conlmetin,with licensed comraam a m
instruct the project(Sce.9144,Huxinexs and Pvnfe.csions CodeO'rhe Cnntracurzv I,i-
xeLaw does n0lnpplyl0 anowerrof pmpnn,who hailds or inmmvca thereon.i I QTY. PLUMBING PERMIT FEE
who umtmco f—fele to...is aide;,sonmmtmlr)licensed pursuant o the Contrnotor's
Liccnm Law, PERMIT ISSUANCEE] I am exempt under Sec. B A P C Fir this reason
Owner Date ALTER-DRAIN As VENT-WATER RA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of Ne following Jeclarsiants:
I have and will maintain a Ccailicme of Comentto xelfmovere for Worker's Comper- DRAINS-FLOOR.ROOF,AREA,COND. ST(lR1IS TYPE CONSTRUCTION
sadon,as provided for by Section 3700 of the labor Cade.for the performance of the
work for which this Permit is issued. PINT -PER TRAP
[] 1 have and will maintain Workers Cnmpenedion Insurance,as required by Section
7900 of the Lahor Coda for the performance dDhe work forwhmh thispenult is iss.W. GAS-I .SYSTPht-I INC.4 OUTLETS OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy confer are:
Caroee Policy No. GAS-EA.SYS'I ILM OVER 4(CA)
CERTIFICATE OF EXEMI'I'ION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUti1R1,WASTE INTERCEPTOR
(This aeetimn Deal nrn h asmpletW BUILDING DIVISION FEES
if tho,sonet iv formic hundred dollars(SIM)
or leis.) GREASE TRAP PLANCHECK FEE
I certify that in theparterraborof,he work for Is hie this pennil is issued.I shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner 9y yJm WmIsn'CUmpn- ENERGY FEE
Qz xmion laws of Califomia.Uem` ma 1•m M.)mx•Tsu a'7 /K WATER HEATER WNEYIELECR
Z Applicant b 1 l Ak �1 GRADING FEE
= NUrICE TO APPLICANT.IL after basing this Certificate of Exemption,you should WATER SYS'rI:MGRHATING
Mita..subject to the Workers CndnpsI....pmviximnv of the Lubar Cute,papa n.nst SOILS FEE
Lk7 bmlmw llh e0omply with such provisions or this pcoff shall be deemed(evoked. WATER SERVICE
6.
UO CONS'mUCT10N LENDING AGENCY NEW RESIDENTIAL1'LMB. SQ.IT, PAID
I hereby affirm thnuhcrc is acansmctinn lending agency for the performance of Date R<'iplM
P the work for which this permit is issue)(Site.7091.Ci,C.)
Q Lender's Name TOTAL:
Laral Acell TOTAL:
1 certify that I have read this application and state that the above information is BUILDING FEE
h comes',.I agocam comply with all city and county such tuncesandxmm lawx relating 1. QTY. MECHANICAL PERMIT FEE
V Z buildingmnstmetion.and hereby authimm mprevcnulivesofthis city menmrupmthe ^ SEISMICFEE
alnvomemioW urp
nproperty for inspection purposes. PERMIT PERMIT ISSUANCE 3 ^
(Wit)agree to save,IWenmily and keep harmless the City of Culwnino agaimt ELECTRIC FF,E Q
iahilllinsLee ce rms,cmhandcal+nscswhich mayinany way nccmcugninsl saidCity ALTER OR ADD'IOMECH.
¢gacncc nfmhc anting o-Ihispn'TIL PLUMBING PEE
APPLICANT UND STANI AND WILL COMPLY WITH AL1.NON"POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCEY IDL IONS. MECHANICAL FEE
k / AIR HANDLING UNIT(OVER 10,00st CFM) CONSTRUCTION TA
Sigrmt a pUsanUContmmUr I EXHAUST HOOD DVLDUCTE HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE d D
Will the applicant or future building occupant store or handle hazardous material ?--MATING UNIT(TO 1040,00(l BTU)
as def ted by the Cupertino Municipal GWe,Chapter 9.12.end the I Icahh and Safety
Code,Section 25572(a)^ HEN]ING UNIT(OVER IM."BTU,
DYes Nn VENT ILA'1'ION PAN(SINGLE RESIDE PAID �-
f
Will the a applicant or future huildoo luseani East apt
pp g ty'he fl I prem lily M;ccs which
nnh0endnlmus air cnmmninunm uyf�IlncJ by dFc Huy Artn Alr QunlilY Mdtnugcn¢m BOIL."IiR-COMI'(IIlY OI1100,IX1(1 BTU)
DiavicR a4N REDILE,R-COMET(OVERIW,"BTU)
❑Yes No
Ihuvertadthehma u materialsmquimmentsunder Chapter 6.95 of the Cali AIRCONDITIONER ISSUANCE DATE
Jorma Health A Sof v C .Sectiom 16505.255.3 aW 2553E4.I mNervarm that if the NEW RESIDENTIAL MITCH. SQ.FE
Wildingdtcs n ea tam ,that it is my¢sMnsibility to notify the occupam
of the
require m
missuan¢oA Crnifcatc mf(Xsupancy.
Owner ar au + t Date O F11 7 ISSUED BY:
OFFICE