S 0861APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPRRTINO IIUIIJIING - ELEM RICA . PERMIT' NO,
IIUII.DINGDIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL (N OOC
v
BUILDING PROJECT IDE_NT''IFI "ION ' J v
BUILDING
�NGA ^�� IMO 121�%� Left -�.a ;L 635/9 SANITARY NO. APPLI//CA ION SUBM1IITT�A/LyDATF.
I RL
❑ Consultant Fccs Paid by Applicant (Initial)
y.
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT
1 berehy affirm thin I ten licensed under provisions of Chapter 9 (mmmencing
OdgZ with Section]0MofDivision 3 of the Businuoford professimts Code, and my licenwis
WOO PERMIT ISSUANCE' _
b- �.. in full have and effee Q _
QUI" Lice Cltr- Lim.k
IX U AI'I'LIANCIS—RESIIIEN'I'IAI.
H'Z Dal Contract
ARCHITECTS DE ION PANELSZ p t2 Z 1 understand my plmB shall W used as public records
O Z UP TO 2(w AM IS
W
Licensed Professional 2014000AMPS
1 have and will maintain Worker's Compensation Insumncc as required by Section
OWNER -BUILDER IIECLARA'I']ON OVER IBBIIAMIS
yL Q
1 herehy affirm tout I am exempt from the Contractors License Law fon the
pd CEU
fallowingreason.(Sava in 7031.5. Business .,,it Professions Coda Any city rir aunty SIGNS ELECTRICAL,
LLLL1l a3 U.
which requires a permit to construct, alcor, improve. demolish, or repair any swemre
C'LL'y
Prior to its ismanre..IsU ouprocslheappMeant forsuch Parini( o rile a signed statement SITCIALCIRCUIT/MISC.
}
that he is licensed pursuant to Improvisionsa(the Commemes license law(Chrpwti
POLE INS"r.
p0
pn TEMP. MCR OR
(commencing with Section 70XXu of Division 3 all he Business and Professions CadeI E
Dsq � tY
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
DEVICES
4.
Section 7031.5 by any oppicant for a permit subjects lure applicant In a civil penalty of POWER
W W
I, Z y}
not more than rive hundred dollars 155001E
=Q
❑ L asownerofthe pmpenyn anyemplriyeeswithw.gesas their sole compensation, SWIMMING POOL ELECTRIC
ufirnthatthem is construction lending agency Cotthe parforanow,of
will coca, work, and Utes, mwart not Inwadcdonl7cred tarsal, (See 70Ti, Business
S 3 m
amt Professions Code: The Conuacmr's License Law does not apply to an owner of OI/TLETS—SWITCHPS—IBXTIIRIS
lender's Name
prolw'rty who builds or improves Ihcrean, and who does such work himself or Through
DT
lenders Address
his own employees, provided that such impmvemenls art not intended or offered for NEW RESIDENTIAL I:LECI'R
,F., (A a mem. I agree u, comply with am city and aunty ordinances and stem I.wa.clear, t. QTY. MECHANICAL PERMIT'
sale. If,however, the huildingor improvement is sold with'mone yew ofcompladon, the _ �I
ahovc-menlimsed po Peny for in 'lion purpors 1 PERMITISSUANCH
owner -builder will have [lie burden of proving that he did not Wild or improve for put-
ut---+—\�—
liabilities,ludgmenls, coslsnad expen.ms which may in any way acme against said City AL'1'ERORADDTOMF.CH.
po of sale.).
/.
APPLIC T UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT G70 10,000 CPM)
I, us owner o the Pntpeny, oro exclusively contracting will licensed tlmintors i-
AIR HANDLING UNIT (OVER ](),law CPM)
conslrud the pn m (Sec. ]WU, Business Professions Calc) The Contractors Li-
i-npp
HAZARDOUS MATERIALS DISCI,OSURF.
a 'p0 marcon.nnd QTY. PLUMBING PERMIT
loa�owncrafpm naw mhial
ns defined by the Cupertino Municipal Code, Chapter 9.12, trod the 1[.111, and Safely
psorimprrivm.
who mmra¢fn ch Ic<Is witb ucomrw rts)I'ensed pursuannnlhc Comraclors
C] Yea El No VENfILAtION FAN (SINGLE RLSID)
License (raw. PERMIT' (SSI NCE
-
❑Inco exempt rler, .B& PCfnr this reasn
❑Yes ❑No
ALTER—DRAT IiNT—WA'T'ER(
I have readdin hasunlons malcmaH d under Cha ter b.95 of the Cull
regnia
Owner Date
joillial IiRN CO,W'ENSA' 10 DECLARATION I BACK FLA OTF.CT. DEVICH
FEE
33
BUILDING PERMIT INFO
[IV ELECT I L X71 MISCH
JOB DESCRIPTION
RESIDENTIAL
SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MUL.TI-UNIT ❑STRUCTURAL.
MODIFICATION
El INH ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMM1IINGPOOIS
❑ BATH R17MODEUREPAIR ❑DEMOLITION
❑ OfIIER
BW BLDG/ADDITION ElDEMOLITION
TENANT El FOOD SERVICE
❑OTHER '
Q
SQ In
T A : dii3 ^dp1lA�,p1 II S9
Path WrCOrII
FEE C7 % T V 7. go,(
I
-
j rynn nfthc lulhwing eecmrvumns:
I hOmb, ofto under pennlry of pe`11`211,t
❑Ihavetrndwill aimxina Cenilicme of l tself-insure for Worker's Compen- DRAINS -FL00 GOF.
fan, as Provided or by Senioo 3]IIQof he La r Code, far the performance of the
rk for which this peril is issued. FIXTURES— PER TRN
1 have and will maintain Worker's Compensation Insumncc as required by Section
37W of the labor Code,for the performance of the work for which this permit is issued. GAS—IiA.SYSTEM1 NC.4 LE 5
My Worker's Compencm inn Insurance carie, and POP, another are
GAS — ITA. SYSTEM-OVE EAI
Comer: Policy No.:
CERI1E4CATE OF EXEMPTION FROM WORKERSGREASPPANDUSTRL WASTE TNI'. ''PTO
COMPENSATION INSURANCE
TI'hiswiaiminaednm be cm,Iamd ifine pemtil is tritium hundreddollars Mad CREAS17TRAP
_
or leaa.)
he Performance which this Permit is issued, IshAI SEWER - SANITARY -ST(yRM EA. 21g)FI', a
lay
any,halt
a I. a,
as o
not emplriyany Pe yma e o I Mtvylp no W�prs'Compen-
ria
0 Z cation Laws a Da X91 Q WATER HEATER WNIiNT/IiLECIR
PApplicant
NOTICE PPLICAM : If, cr making this CeniOcme of Exemption, you should WATER SYSTEM/IRPAGNG
a."t
become subject to the Workers Compensation provisions of the labor Cndq you mous ,
i�
forthwith comply with such pmvisionsanhis permilshall he deemed revokW. WATER SERVICE
L1.I
Q
as
CONST RUCTION LENDING AGENCY NEW RESIDBNTIAL('LMB. SQ. P1'.
V0(hereby
ufirnthatthem is construction lending agency Cotthe parforanow,of
the work for which this petit is issued (Sec. 3097, Civ. C.)
lender's Name
0
DT
lenders Address
Lvlt
0. I certify that 1 have read this application and state that the above information is -
,F., (A a mem. I agree u, comply with am city and aunty ordinances and stem I.wa.clear, t. QTY. MECHANICAL PERMIT'
U Z building construction. and hereby amhodsx teprexenlmiver wafts city to enter upon the
ahovc-menlimsed po Peny for in 'lion purpors 1 PERMITISSUANCH
- (We) agra to save, indemnify end keep harless the City of Cupenim against
liabilities,ludgmenls, coslsnad expen.ms which may in any way acme against said City AL'1'ERORADDTOMF.CH.
in consequence of Ne granting of this permit.
APPLIC T UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT G70 10,000 CPM)
S ' EGULATI0
AIR HANDLING UNIT (OVER ](),law CPM)
nmurco ApplicanVComranar D' a EXHAUST HOOD (W/DUC )
HAZARDOUS MATERIALS DISCI,OSURF.
Will the applicant or future building r'ccupwo store or handle huwdous matenal HEATING UNIT TI'O 101,000 BT U)
ns defined by the Cupertino Municipal Code, Chapter 9.12, trod the 1[.111, and Safely
Code. Section 25532(a)? HEATING UNIT (OVER 103,00O BTU)
C] Yea El No VENfILAtION FAN (SINGLE RLSID)
Will the applicant or farm building occupant use equipment or devices which -
emit lannu lous air contaminants as defined by the Bay Area Air Quality Management BOILER —COMP (3HP OR I W,O(X) BTU)
Oktricr] - BOILER —COMP (OVER I W." LOU)
❑Yes ❑No
AIR CONDITIONER
I have readdin hasunlons malcmaH d under Cha ter b.95 of the Cull
regnia
fomia Health ra Safety Cak, 25533 mid 25530. I understand that if the NEW RT:SIDENTIAI. M13CH, SQ. FT.
.0 maty .11 i nl
rrentlywhich have ivmy reofa
Ise met.Ihulo
Craficonmifymepancy,
of the tequiremen¢ which most be met prior m issuance of a Cenificam of Ocmupancy.
of the eats
Owncr or trmhnd call .gent Unte CUM
OFFICE
273
STORIEV
OCC. CROUP
z
E CONSTRUCTION
APN
l DING DIVISION FEES _
PLANCIIECR lE
6V
ENER,Y :E
GRADING N7,
SOILS ITiE
,
PAID
ye
alk
IV
TOTAL:
allll I11Nf PIiE �
� � n
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL IT
CONSTRUCTION
HOUSING MITIG
PAID
Dae Meceipa
10'1'AL:
��ISSUANCE DATE
,�
ISSUED BY. =\_J 0