S 1045 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUP
ItUD"HNG-n..ECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT -LUMBING-MECDAN Ir,AI. S O
BUILDING PROJECT IDEMI'BcPU TION
BUILDING ADDRESS: ANITARY NO. APPLICATION SUBMITTAL.DATE
�}3 ewb e �(�C C)- (�-(+
OW Mal
PITON^ O�' CONTRACTOR IS NAME 1cw(cy 5a5�]7T N NIC
Cl1N fROLtl
.� ARCHITECT/ENGNI?L?R; LIC No ADDRESS: ���� i" .1 I/JCONTACT: PHONE: !VIna BUILDING PERMITINFO
/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
LICFNSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT 'FEE
I hereby affirm mm Iran deenmd ower Previsions of chapter 9 bemm�,anemg JOB DESCRIPTION
CaZ with Section AXIU)of Division Aofthe Business anJ l'mfessiuns Code.nnJ mylimanseis
W O p PERMIT ISSUANCIi
�W.F.� in full force and ef(en. 5�17N WL ❑KITCHEN RIiMODIiI.
<ZU 1;ium Clas Lie. �r�It �aA pppL1ANCPS-RIiSIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
an<i Dae Gunmen. ❑MULTI-UNIT []STRUCTURAL
Fly ARCHITECTS DECLARATION PANELS
Z p Z 1 understand my,duns shall be used as public retuNs MODIFICATION
pZ O UPT0200AMP5 1 ❑INTERIOR ❑CHIMNEY REPAIR
r.4
Licensed Professional 201-I000AMPS IMPROVEMENT (]SWIMMINGPOOIS
MG 'OWNER-BUILDER DECLARATIONOVI?R IINI(IAMPS ❑BATH RE (]DEMOLITION
y� 1 hereby affirm that I ren exempt from the Commot,n's License I.e.lin de
C C�C.) Tolowing reason.(Section 7031.5,Buainesc and Nomxsion.Code:Any city or annoySIGNS N.LEC'1'RICAI. ❑OTHER
31+• which requires a penal w enalbo 1.rice,anprove,demolish,or repan any similar, l�l
0 prior to its Issuance,also requires the applicant for such Permit to file a signed stmenmat SPECIALCIRCUIT/MISC.
�;!{} 'bathe is licennedpuzuanuo the pnvnionsofdw Contractors License Law(Chapters
W_COQ (commencing with Section 7")ofDi,bbm3 affil Business and Pmfessums Carmine TEMP.MLTIiR OR POLE.INST. OMMER CIA '
a a c eG Ihot he is exempt Iherefmm and the basis for the alleged exemption.Any stallion of ❑NEW BLDG/ADDITION ❑DEMOLITION
�y Section 7031.5 by any v,Plic.m far apxiona inahechthe applicant a a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F. at mare than five hundred dollars(5500). IMPROVEMENT
71.us owner of the prnpai or my employees with wages us their sole compensation, SWIMMING POOL ELECTRIC
�.` will do the work,and the structure is not intended proffered for sale(Sec.7(94,Business ❑OTIIER
and Professions Cade:The Contractor's license Law 6,e1 not apply a na owner rel' OUTLETS-SWITCHES-FIXTURES
property who build.or improves thereon,and won does such work himself or erengh
his own employees,provided that such improvcmro
cs arc nal intended or offered for NEW RESIDENTIAL ELECTS SQ PT
sale.If,however,Ne building or impmvemem is sold within one yemof completion.the A13 $ISQ'p'
owner-builder will have the burden of proving that he did not build or improve for pur-
,aeafmwne OCT 61997
❑Las owner of the property,am exclusively contracting with licensed camnnon m / T AL: 1
mnsWcl Ne project(Sec 7 X14.Business and Profession.Cade)The Cantmnnr'x I.I.
ase Low does not apply it)an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT F F.
who contract.far such projects with seminarians)licensed pumttam lathe Conracnrs
License law. PERMIT ISSUANCE.I an exempt under Sec. ,B&P C Retina mason
ALTER-DRAIN&VENT-WATER(BA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW I'R(TI'ECT.DEVICE O
� •� I herehY aRmt under penalty of pepury one of the following declensions:
C] [have and will maintain aCerificate ofConsent to self-insure for Workers Compel DRAINS-FLOOR.ROOK AREA,CONED. S RIES TYPE CONSTRUCTION
nation,as provided for by Section 37M of the Labor Cade,for the performance of the
work for which This permit is issued. FIXTURES-PER TRAP
EJ 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Lahor Crile,lin the performance of the work lin which this permit is issued, GAS-EA.SYSTEM-)INC.4 OUTLETS OCCGROUP APN
Ca Worker's Compenmlinn lnyylIr�nee aortic.and PolifXnn6e're �2„ GAS-F.A,SYSTI?M-0VER4IEA)
My Wrc O kF_Lation I policy h(if L7
CERHPICATBOFEXBMPTI- PROM ORKERSGREASFIINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DI VISION FEES
(This section need not be completed if the Permit is for one hundred dollars ISIas GREASETRAP
or less.) PLANCHF.CK FEE
I«nify that in the performance of the work far which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FE
not employ any person in any manner so as to become subject to the Workers'Conpan ENERGY FEE
rZ Nation Wws of C.Ilfo me Dale WATER HI Al PER WNENT/ELECTR
7�7 Applicant ' GRADING FEE
G NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSD?M/TREATING SOILS FEB
Mcnme subject n the Workers Compensation pooWnns of the Lobar Code,you must
forthwith comply withmeh PnviO...onhis Permit shall be deemed resulted. WATER SERVICE
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLh1B. SQ.FT. PAID
V 0 I hereby affirm that is a construction lending agency for the peefotmance of Dam Receipt,
IL (~ the work far which this,crmit is i...d(See 3097,Civ,C.)
0 U Lender's Name TOTAL:
Lender's Andress 'TOTAL:
G 1 certify that I have read this application and own that the move information is BUILDING FEE
A ennect.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building construetion,and herchymboria,represenutivesofthis ciy to enterugmthc SEISMIC FEE
above mentioned Property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep bemless the City of Cupertino against ELECTRIC FEE
)i ,
ies,judgmenly,cnsts and expenses which may in any way accrue against aid City' ALTERORADDTOMECH.
sequence o(Ihe graining ofthis permit. PANT UNDERSTANDS AND WILL COMPLY ALL NON-POINT AIR HANDLING UNIT(TO 10.001)CFM) MECIIANICAL FEF.OLATIO S /
�Q AIR HANDLING UNIT(OVER 10,01M CFM) CONSTRUCTION TAX
aIr
nm im'60,plicanl/Commcmr ')'it'
EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIAL., :CLOSURE
Will Ne applicant or future building weapon store or handle Immucous material HEATING UNIT Off)100,000 BTU)
as demed by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Suction 25532(.7? HEATING UNIT(OVER 100,000 BTU)
C]Yes VENTILATION PAN(SINGLE RESIDE PAID
Will thea licmo r furore building t tine t or devices which Date Receipt M
Pp goccupan component BOILER-COME'(31111 OR 100,000 BTU)
until hazardous air comuminann as defined by the Bay Area Air Quality Management TOTAL:
❑inhinp
EI Yea Y BOILER-COMP(OVER 100J0I1HU)
I have read the hvNre
aous materials requirement.tiller Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fond.Health&Safety Code,Sections 25505,25533 and 25534.I undersand that if the NEWRESIDENTIAL MECH. SQ.FT. ( " ,16 - 77/Gm ^
building does not currently have a emmt.that it is my responsibility to nofify the occupant �` o T
ofthe requirements which mans he met pnoraissuame nfa Cenifiwu of Occupancy. ODF, / j
O
Owner or auNunned agent Date TOTAL ISSUED BY:
OFFICE