S 0877 APPLI(,ANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
* CITY OF CUPERTINO - BUILDING-F.lOacIKICAI. PER"r No,
BUILDING DIVISION APPLICA'ITON/PERM IT PLUMBING-MECHANICAL S Obi 7?
BUILDING PROJECT IDENTIF'IC'ATION V vv
BUILDING ADDRESS: _ SANITARY N0. APPLICATION SUBMIITA1.131'1'1;
VNENAM^ 1'IIONIi IRACORS yGLIC : N/C CONTROL.#
Z�a� VI6ILOTIINGINEER: LCNOAtIRESS: ID
DID
P . n
14
CONTACT: PHONE: q!5-5-3C3 BUILDING PERMIT INFO
❑ Cnnsidtanl Fees Paid by Applicant(Initial) - BLDG ELECT PLUMB MECH
❑ ❑, ❑ ❑
LICENSED CONTRACTOR'S DECLARN'ION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed under pmvixions of Chapter 9(commencing
Z ih ScGi,m70yY.fDi,i,im,3 aflhc B.,inessund Pmfessi alCdeand my llromsis RESIDENTIAL:
OZ wt Q PERMIT ISSUANCE t-1in full force anJ"Bgl' —1 GSFDWL [I KITCHEN RCMOUI[I.
seU V License Class -�� Lic.x i3 I Q
F Z(y Dam ContraL 301 1 APPLIANCES—RPSIDENTIAL []ADDITION -(]PLUMBING RH-PIPE
W6a ❑MULTI-UNIT ElSTRUCTURAI.
y MODIFICATION
F-= ARCHITECTS DIiCLARA'1'ION PANELS
Ozrn Z 1 understand my plans shall M usd as public records
�O UP FO 210 AMPS ❑INTERIOR CI CHIMNEY REPAIR
F..~.W Licensed Professional 201-1000AMPS IMPROVEMENT OSWIMMING POOLS
�.j -I OWNER-BUILDER DECLARATION OVER 1000AMPS O BATH REMODEDREPAIR 0DEMOLITION
% Q I herchy affirm that I am exempt from the Convacmr'>License law for the
xLx p U following reason.(Section 7031.5,Business and Prokswons Calc:Any city or county SIGNS ELECTRICAL. ❑OTHER
W 3 0 y which requires a permit m c...mot,alter,improve,demolish nr repair any s ruelme
F"LL'�� prionoits issuonce.elm rtquires the a"licam foisuch Permit rile a signed statement SPECIAL CIRCUIT/MISC.
E�N Ihmheisheadindpurs...O.,heprnvisinna of the Comrecmrs License lawlChaperY
�4p0fcommencingwiNSection7")of Division3ol the Business and Professions flak)or TE-KIRMF!ROR I'OLEINST. COMMERCIAL'
6 S cy that he is exempt therefrom and the basis for the alleged exemption.Any violation of CI NEW BLDG/ADDITION 0 DEMOLITION-
X^,N Section703 L5 by any applicant for a permit subjects theapplicant m o civil p:wlty of POWER DEVICES []TENANT ❑FOOD SERVICE
t more Nan five hundred dollars($500), PROVEN
ANJ
ESC ]1, owner ofthe property,or my employees with wages as their sole compensation, SWIMMING PYX)1.ELECTRIC <J{ McAt"
[- will do the work,and the structure is not inlnndedoras oRemd for sale(Sec.7M4.Business
OT
L 3 and Professions Cale:The Conomcmrs License Law does not apply t.an owner of OUILETS—SWITCHES—FIXTURES W It
property who builds or improves thereon,and who does such work himself m thmugh Q 1
his own employees,provided that such impmvenrcnts ate not intended m offend fm NEW RESIDENTIAL EL.ECI'R S
sale.if.however.the btildingm improvement issold withrture year ofeompletter,the Sr�OOR LSQ.f4.
ser-builder will have the burden of proving that he did not build or improve for pur-
pose of rale.). TOTAL0 I,as ower of the property,am exclusively correcting with licensed contract',,m iznswct the project(Sec.70Y1.Business and Professions Cede:l Use Commctors Li- -cense tawd.esootapplymaoonerofpl,,enywhobu,ldsor iop.vertbcrc.n,and QTY. PIAMBING 1iRMIT FEE who contracts for such projects with a contmctor(s)licensed pursuantto the Contracmr'.v �aLicense Low. / PERMIT ISSUANCE d"ffrI] I am exempt under Sec. .R&P C far this Oras..
AUIFR—DRAIN&VENT—WATER BA) "n L—VALUAHON
Owner [)are �k 'I(�Q
WORKER'S COMPENSATION DECLARATION BACK MOW('ROTI;CT.DEVICE 0V 2 6 997
I hereby affirm under penalty of Perjury one of the folbwing declandoms:
I have and will maintains Cenilicme.f Cor-onin self-insure fill Workers Campers- DRAINS—FLOOR,ROOR AREA,COND, STORIES TYPE.CONSTRUCTION
.mins,as pmvideJ for by Satins 3]0(1 of Ibe lahnr Cedc,for the performancenI the
nook ser which this penph is issued. FIXTURES-PER TRAY rd pin Hilt PECTION If EPARTM .NT
0 1 have and will maintain Worker's Cmnpenmtion Insunmce,nv required by Suction
3700 ofthe Latina Cedr,for the pedommen,eof the work for which this permit is Issued GAS—HA.SYS'I'EM-I INC.4 OUT 1,
O�¢�Rp�m APN
My Worker's Comperedion insurance canter and Policy.umher ore: YOF LUf Lfl" LINO
Carrier: - Policy No.: GAS—HA.SYS]'HM-OVER4(EA)
CERTIFICATE OIr EXEMPTION FROM WORKERS' GRIiASIVINDUSTRI,WAST 1i INTERCEPTOR
COMPIiNSAI'[ON INSURANCE ICI N D SION PERS
(This section need not he Completed;fun,permit is for one hundred dollari($lox)) ❑RIIASE'I'RAP
or levsJ PLANCHECK
I cetifythm in the perfinmunc.ill'the work linwhichlNspvrmit is ixened,Idoll SEWER—SANITARY—STORM HA.210 FT. '
not employ any person In any manner so us t9ja anus sooLbjgyt R,the Wndrrs'Cennpmt- GNLROY
Z sat nL ' Dt - e7�L'D1 11 11 -1 _- WA I hR HIiN FR W/VEND/F"LGC'IR GRADING .. `
n.t to Nn
NOTICE TO APPLICANT If II rmAk 6th. C al t dUxcnpton yot Id WAI ER SYSTHM/I READNG
abecomesub,lecuotheWorkersC.nlwrradenpnIIvse1'tlel.horCrde,ymnail soB.sifflS( Uri' 4UtkH{I�VQ
{1a forthwith comply with such pmviouns or this permit shall he Acnnesl revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NIiW HIiSID1iN'1'IA1.I'IA113. SQPAID
'FT. Dam Receipts
L1 V. O I herchy off mt that there is n canslmctian lending agency lar the performance of
U0 thewarkf',r which this permit is issued(See9(197,Civ,C.) - -
0 TOTAL Lenders Nome _`
TOTAL'.
Lenders Address . '71•yv
y I candy that I have read this applicmina and state that the shove iofnrnaction is BUILDING FEE
tai fA correct,I agree m comply with all city and county ordinances and stale laws miming to QTY, MECHANICAL PERMIT FEE SEISMIC FEE
V z building mnsamcime,and hereby authorize reprcsemmisev of this city to enter upon the
abavomcminned property for mvierfloat purpmes. ' FERMI'P ISSIJANCIi ?ELECTRIC FEE(We)agree m save,indemnify sod keep taintless the City n!C.'einn nguinst
liabilities,judgmems,constant cnseswhich mayfaulty way scnueugaionsaid ChY ALTER OR ADD'1'0 MUCH, PLUMBING FEE 90
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT 7ALR HANDLING UNIT(TO 10,00OCFM) 13 Q MECHANICAL FEE
VW7MWF REGULATIONS.
AIN HANDLING UNIT(OVER 10 CFM) CONSTRUCTION TAX
0.(X
Signamre of ApP]eant/Contmcmr Dale EXHAUST FOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding rccupant store or handle hazanlaus material HEATING UNIT TO 100,10)BTU)
as defined by the Cupenino Municipal Code.Chapter 9.12,and the I1.11h and Safety
Cede,Section 25532(x)'! 1RATING UNIT(OVI:R I000M)BTU)
❑Yes XNo VI?NTI IAI']ON FAN(SINGLE RPSID) PAID Date Receipt#
Will the applicant or future building aaupant use equipment or devices which
v nit hazardous air contuminams mdefined bythe Bay Arca Air Quality Management 13011.HR—COA11'(3EP OR 110.IM0 BTU)
TOTAL
mnc1P BOILIiIt—COMP(OVER I(0,fifX1 BTU)
❑Yes KN.
s L base orad the hataxodm`xnmtonsa rcquimmentx under Chapter 6.95.E the Cali- ALR CONDITIONER / ^ 1pq Ui./�Aryp
Enron Heath&Safety Code.Sections 11505.25533 and 25534.L understand that if the
NEW R[61DFN1'IAL MECH. SQ.PT. [��"
building ears;not currently have a¢nam.that it is my nespmsibilky ht ratify the rccupant
�(�R��u• rements wh+ich mo ran pct1_m;;;acme n(a Ccnificam of Qcupa/�cy�a '
1 t1-I hi r � &Y I IA TOTAL: ISSUED BY:
woe agent Dam Q
OFFICE