S 3173 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CCPEKrINO BUILDING-ELECTRICAL, I'IiR�e��M+1IT N(l.
BUILDING DIVISION I APPLICATION/PERMIT PLUMBING'MECHANICAL, V - 3173
BUILDING PROJECT IDEN'I'I FTCATION
BUILDING ADDRESSSANITARY NO. A' IN SUBMITTAL DAT'
/00 �S rrih Aw CtA, r��',„ co g5-L71'/ /�— 2 3 —9
OWNER ri 't'tire A NQ ri(�nyy Cf PHONE ^7 J� 'ON'fRACT(IR'S NAME: LIC NO:
1 I -( N/C C(1NTROLq
•I ARCHITEC'LAINGINHER: LIC NO: ADDRESS. ❑ ,
CONTACT: PHONE: os� BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ L ❑ ❑
LICENSED CONTRACTORS DECLARATION Q'TY I ELECTRIC PERMIT. FEE
I hereby affirm Ili I am licensed under pmvislm s of Chapter 9(commencing - JOB DESCRIPTION
W Z with Section'R0B)of Division 3 ofthe Business and Professions Cede,and mylkenmic PI3RM1'I'ISSUANCIi RESIDENTIAL'
F ty_ infull fmceandeRecl. - ❑SFDWL ❑KITCHEN REMODEL.
�UZU ].¢rose Class Lica APPLIANCES-RIiSH)FIsGIAI, ❑ADDITION El PLUMBING RF.-PLPE
NQ L D:ne Contractor
(_stn ARCHITECTS DECLARATION PANELS
C)MULTI-UNIT ❑S'I'RUCfURAI.
Z O uo Z 1 u Wcmwnd my plans shall be t ud as public accords MODIFICATION
OZ 14� IIP 1021x1 AMPS2-01 ❑INTERIOR O CHIMNEY REPAIR
a4Fq-] Licensed Pmtexsiawl 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
el rg, OWNER-BUILDER DECLARATION OVER 11X0 AMPS BATH REh10DEl/RIiPAIR El DEMOLITION
C Q 1 hereby affirm that i am excmpl boards,hCnntmnnr's License Law Burns,
O y U following rasam.(Section 7031.5,Puniness..,it Professions Code Any city nr county SIGNS MRC')R1CAL ❑OTHER `,h-,¢I-
FO y which tortilla,a permit ,,awcomncL alma improve,demuli.d,m repair any structure > &/
yQ,
prior to sissuance, 1. y thefruch pemiu 11signedtmnem SPECIALCIRCUITIMISC O(/ S
pp( }
'hill he is licensed pursu nt to the p I the C I t r License Law(Chapter9
w 00
(coulannencia,is i Ili Seat 700E)of Division 3 ofll Business' f Prafiessiom.Cod0or 'TEMP MillI'IiR OR 1101.E INS'll COMMERCIAL:
d e rL
Ih,a lie I,exenpl therefinaland the h;six for he alleged cu opt on Any violation of ❑NI?W BLDG/ADDITION ❑DEMOLITION
Seaman 7011,5 by any applicant for a Permit subjects the applicant o a civil Penally of POWER DEVICES [I TENANT ❑FOOD SERVICE
F„ mol mom our five handled dollars(S5BB7. IMPROVEMENT
D I,osowncroftacino,am,.ornry enmPlnycen wi@wages xs their sole cnmpen.wtinn, SWIMMING POOL ELECTRIC
O will dalhc work,and Orn xrrucurrc Ivan intended nroReral fmwte(Sou.7044,13nsince, ❑0'1'1IER
eeand potassium;Code: I'be Coalmoctnr's License law AI
nes not apply to an owner of OUTLETS IFS-FIX FUREsi
a 3^ prepeny who builds or improves thereon,and who does web walk himself or through
his own employees,Provided that .all improvements an ma amended or nmamd far NEW RESIDENTIAL IdLF.CI'R SQ FT.
,at..If,however,the fiuildng or impmvcmenl innnld wamnous yearnf cnmpaetion,the SQ.FT.FLOOR ARIA $/SQ.FT1
mer-builder will have the burden at proving tam he did not build or improve for pur-
ryrse of sale.).
1,ax owner mine prnpcny,am cxclnsively a doweling with licensed nmtmdam it, pA T
mlmcl the project(Sec 7144,Easiness rod I'rdessions Cn la:)The Commctnr's Ll.
cense law does not apply to an owner of parpeny,who builds of improves thereon,and QTY. PLUMBING PERMIT FEE
who ontrmts forsuch projects withacommnmAs)licensed pumomnuahe Conmmmrs
Liam,Law. PERMIT ISSUANCE,
❑ 1 urnexcmpl undarSea. .13&P C for this mason
J ALTER (EA) VALUATION
7.P
r'D VSCOMPHNSA'1'10N DECLARATION BACK ROW PRGI1zCT.DEVICE
1 herch�QR'mm un er penally of pejury one of the lirllowing declarations:I have and will mormain a Certificate of Cormentto elf-Comm for Worker's Corona.- DRAINS-FLOOR,ROOF,ARBA,COND. SrMKPTYPE CONSTRUCTION
salon,as provided for by Section 3710 of the Labor Calc,fm the performance of the
work far which(his panni(is Issued. IE XTURES-PER TRA I'
[i I have and will maintain Wnrkcr's CmrdemnJno Insurance,as myvired by Seen I
3700of the laMm Corte.for be performance of the work far whichthis permit is ismad. GAS-EA.SYSTEM-1 INC.4 OUTLETS .GROUP APN
My Warker'x Compsmanion Insumncc eerier and Policy number are:
Carrier: Pullcy Na.: GAS-li
CERTIFICATE OF EXEMPTION PROM WORKERS' GRP.ASIJ. D STRh 4T� 'FIiNCB I)R
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi.,wenonnecdnnl be cnmpined iftlmrmt
git is Luanne bundled dollars(Slab _GREASE '
or lass.) PLANCHECK 191E
Icandy that in Weped'mmance al the work farwhich(his pennil is issued,Isirall SEWER- TA t4 at R2 I .2
not employ any pemno in any manner so as tohistoric subjectto the Workers'Comport. ENERGY FEF.
zZ motion Laws of California,Date WATER TBR WNEWMI.BCI'R
Q Applicant GRADING FEE
y NOT ICE TO N'PLICAN'E If,nfer making this Cannicam of F.xmnpot n,you should WATER: . :M/i'BEATING SOILS PEE
a ; hecnme subject to the Worker's Compm
Compensation provisions of the Labor Cole.you ust
fy n.r forthwith comply with such provisions or this pennil shall be deemed mended. WATER S Hol
a Q
CONhemis a const LENDING AG agency NEW RfSIDENTIAI.PLMB. SQ.FT. PAID
r�7 z (Jac Receipt of
UQ Ifhereby which'hi Iran iissued(Suctinnaendis.agencyfor the performance of
the work for which this Permit is issued(Sm.J(D7,Civ.CJ
f'+ Lenders Name T(YI'A 1:
U Lender's Address - - 'I'11TA1:
I cenify that 1 have read this application and Stam that the above information is BUILDING FEE.
F' fn correct.I agree to comply with all city and county ordinances and stem laws relining Ili QTY, MECHANICAL PERMIT FEE
U z building con,soclion,and hcrchy mnmuire na'nawmdivesm'this ally tnemea apart Ilia _ SEISMIC FEE
aMwe-mentioned property lir impainam Pmprwn. PERMIT ISSUANCE
(We)agree to save,indemnity and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgma'nu,cost%and expenses which may in any way accree against said City ALTER OR A DO TO M ECIL
is canseyvenca of the granting alibi.,permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNI'T(TO BkOg)CFM)
SOURCEJW:GULATIONS. MECHANICAL FEE
IVU✓ 1) 440 AIR HANDLING UNIT'(OVER 111,000 CFM) CONS'IRUCI'[ON TAX
Sign,///ITT'/I�^'l,^c�aoVCnmmctnr Data EXHAUST'HOOD(W/DUCT) HOUSING MI'TRIAT10N IEE
HA9.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building arupanlsa.m.,handle hozallous material HEATING UNIT(TO 110,(1(0 BTU)
as defined by the Cupertino MumicipA Code,Chapter 9.12,toed the licmta and Safety
Code,Section 25532(07 (HATING UNIT(OVER IfilLoW BTU)
El Yes ❑No VENI'11ArION BAN(SINGLE RESID) PAID
Will the a Iieanl nr talmc bui1i in nt use c ui mcnl or devices Which _ Dom Receipt x
PP gO00a 4 P BOILER-COME(31 IP OR 100,X0 BTU)
emit hasuNnus air contaminants as refined by thee(lay Area Air Quality Management TOTAL
DistdaP
E]Yea [D No BOILER-COME LOVER Ihall itrut
Alit CONDI'1'IONEk
I have real the Code,Sections t 155 requirements under Chapter 415 of the Cmi ISSUANCE DAl'E
fomiafleeas&icamer Cede,e.tr2datit05,29511amt25514.1 understand Real if 0e NEW RESIDENTIAL MECH. SQ.1.7,
building Aces unicamerally huve a tenant,that it is mry reapfa Cality nr malty Ihu Lr ricy.
of the reyuiremen(x which nnut Be met priono issrunce of v Certiticme of Qcupaney.
Ownermamhomed agent Date TOTAL ISSUED BY:
OFFICE