S 0130 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BURAMNG-Pa.nuI KICAL - Pig]r NO. 0130
BUILDING DIVISION APPLICATION/IPERMIT PLUMBING-MECBANICAL
RGIl DING PROJECT IDEN'I1F'ICA'I'ION
- SANITARY NO. APPIACAI'[ON SUBMI'I'IAl.DAI
BUILDINGADDRESS.
%60 / NMES ro �vQ
IOWNER'S NAME: PH Ii: oCON TNAC]'DR'�NAME:,It me 0 LIC ` NIC CDMI'ROI."
le
ARCHI :CIE GINEER: LIC NO: %DDR�i �/^ O ^ LLJF/�f/ ❑
1 of
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CONTACT. PHONE BUILDING PERMIT INFO
'
❑ Consultant Pees Paid by Applicant(Initial) ELECT v U MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby aff rn that I um licensed under previsions of Chapter 9(commencing _
O0 wire Section 7")ofCivilian loot he Business and preferat...Code.and my license is RESIDENTIAL
W O PERMIT ISSUANCE.
Fm� in full Toros and ellen. �'7 Y(, 83 ❑SFDWL ❑KITCHEN RIih10DE1.
License Cl.; _ Lic.N APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
FZW Date Count mca!r
wQa - �� - ❑MULTI-UNIT ❑STRUCI'URAI.
ARCHITECTS DECLARATION PANE I S, MODIFICATION
Z C y 3 1 understand my plans shall be used as public records
OZ—, UPTO200AMPS [I INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-1000AMPS PROVEMENT EISWIMMINGPOOLS
IL 2 J OWNER-BUILDER DECLARATION OVER East AMPS H REMODEURF.PAIR ❑DEMOLITION
C W 6 1 hereby affirm that I am exempt from the Contmcmr's License Law for the [I OTHER
O yU following reason(Section 7031.5.Business and Professorial Code:Any city or county SIGNS ELECTRICAL•
fy 3 k4[��1 which requires u permit m cnnswct,utter,improve,demolish,or repair any structure
prior to its i.ssunnce,also requires the applicant for such permit to file a signed statement SPECIALCIRCUITIMISC.
00$$�Z rVa� that he is licenwd prommino the provisions of the Contractor's License Law(Chapter n COMMERCIAL
LV O (commencing with Section 70q(oof Umbinn 3 or the Business and Professions Code)or TEMP.METER OR 1101.17 INS'1'.
d qo y dint be is exempt therem and frothe basis rnr the unaged esempiion.Any violation of - 11 NEW BLDGIADDIIf ❑DEMOLI NON
l o, Sleden 7031.5 by any applicant for n permit suhicnabe npplicunt m a civil penalty of POWER DEVICES O TENANT El FOOD SERVICE
m not more than rive hundred dollars SuXE, - IMPROVEMENT
F 0 ❑ I,us moor of the partially,or my emPloyecs with wages as their sole compensation, SWIMM ING POOUELECTRIC
wildo the work,and the structure is not intended proffered for sale(Sea 7044,Business 11 OTHER I1 w P� e
end Professions Code. Gas Contractor's License law d'ws oat uppty to an owner of OVfLP,TS—SWD'CIiiis-19X'1T1RI3S P --RD
a' .. pmpeny who build,or improves thereon,and who down such work himself or through - 4
his own employees,provided that such improvements am not Intended or offered for NEW RESIDENTIAL BLLCIR SQ IT.
sale.If,however,the building or improvement is sold within one year of completion,the `Q'NT19 R�FSA... 3/SQ.FI'.
mer-builder will have the burden of proving that he did not Wild or improve for par- V V'tl y �MFI• )
Fare of sale). TOTAL. CITY/'r
❑I,as owner of the property,ren exclusively mmtmnimg with licensed contractors to C I V t;upEkTlNp
,,mon et the project(Sec.V44,Bmines,and psome,tom,Code:)The Conunc'or's Li- - -
censelawdresnotapplytoanownerofpropertywhobuildsorimprovesthereon,and QTY.. - PLUMBING PERMIT FEE
who contracts for such pmjmis with a vontmeer(s)licensed pursuant o the Contractor's
License law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this lemon
ALTHR—DRAIN&VENT—WA'ITR(CA) VALUATION
Owner Date
• WORKER'S COMPENSATION DECLARATION BACK FLOWPRITTLC..DEVICE QOQ
1 hereby affirm under penalty of perjury one of the following declmntions:
I have and will maintain a Cenificam M Consent o self-insure for Wmates Copper DRAINS—FLOOR,ROOF,AREA,COND. STOB TYPE.CONSTHIICI'Iot
,.tion,as provided for by Section 7700of the Latin,Code,for the Ni-fr mmee of the
work rwhichthis permaisissued. FIXTURES—PI7R TRAIT
have land will maintain Worker's Compensation Insurance,as required by Section
3700id the
,WM,Code,for the peerrfgrn-i�are,of the work far shiith�this mat is mood. GAS—EA.SYSTEM-1 INC.4 OUTLITIS OCC.GROUP AI1N
My CartWrkcS,� C ryJg�ts)fl nsYl/NVI'nl cy Noand Ynurn
O GAS—EA.SYSTEM-OVER 4(EA)
l /CF.RTI FICATE OF EXEMPTION FROM WORKERS' GREASI%INDl1S'BI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION HES
(Thiseenlonneednothecatnpined it thcpenmit lafnronchundreddollm„05110) GREASETRAP
or Passat PLANCf{F:CK FEE
.I cerifythm in the perforinnmce of the walk for which this permit is issued,1.hall SIIW17R—SAN]TARY—STORM CA.200 FE
I.,employ city person In any mutmmer all.,to heals subject m the Wm1wex Compere ENERGY PER
,. Z cation laws orcahbonia.Date WATER DEAL Elf WIVIWI'q!I.FC'I'R GRADING FEE
NOI1CH TO APPLICANT:1L N'ter ranking this Cenifcare of Exemption,you should WATBR SY51'EMO REAPING SOILS PEE
E~ N” becomeobject to the Worker,Coortwe cilion pmvi,ions of the Lnbnr Code,you must
ai rs fnnhwith comply with such pr.,i,in is laroa,permit shall he dee ardrevokol. WATER Sf:RVICL
W O ,
�. CONSTRUCTION LENDING AGENCY NEW RF:SIDIiM'IAL I'I,Mn. SQ,17, PAID
I hereby.ffinnons
n that ctruction lendingagency for the Perfmmmneeof Date Receipt#
U H the work for which this permit is Issued(Sm JO97,Co.C.7 O
T TAL:
Q U Lender's Name TOTAL.
W Lenders Address
I certify that I have read this application and state that the utswe information is s - BUILDING FEE
,Fr 0 correct.I agree tocomply with all city it county ordinances and one lows relating m QTY, MECIIANICALPFRMIT FEE SEISMIC FEE
U Z building constrection,and hereby lonori>c representatives of this city'.enter upon the
sr above-mentionerl progeny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liahilities,judgmems,costs and expcnas which may in any way uccme ngain,t said Ciry ALTERORADDTOMECH. PLUMBING FEE
in consequence u(the granting of this permit.
APPLIC NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To 10,0(10 CFM) MECHANICALFTE
SOUR( REGULATIONS.
1�yYLcr�^�` AIRIIANDLINGUNI'1'(OVER IgtMNICPAII CONSTROTIONTA%
SiV,o(ApplicarJU-n tm Data EXIIAUSTHOODOVIDUCT) HOUSING MITIGATION FEE
HAYARDOUS MA'I'F.RIALS DISCLOSURE
Will theapplicunt lar ounce building oocuf,rm store or handle hazardous mammal HEATING UNIT(TO I(LOW BTU)
as defined by the Cupertino Municipal Calle,Chapter 9.12,and the Health and Safety
Code,Section 25532p0P HEING UNIT fOVHR I W,IKXI B'fU)
❑Yes ❑No VT:ATNIIATION PAN(SINGLF RF_SID) PAID
Date Receipt b
WIII the applicant or future building occupant use equipment or devices which BOILER—COMP OHP OR 1110.00(1 BTU)
emit haeardoux air emnumioums as defined by the Bay Area Air Quality Management TOTAL:
Dlsnlctl❑Yex 7 N BOILER—COM P(OVII R I 00,M)II I'M
1 have te:W the hazardous materials rnryircmfieats under Chapter 95 of the Qdi- AIR CONDrHONER - - r .ISSUANCE DATE
fnmia Ileuhh&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr. ,
huddar imsnat ertrcntly have.let I.(list It is my revponsihdii,lousily the oetrpent
of the irenmme wh'¢h must M� et prior to isnaaceof a Certificate of Occupancy.
i7j; rauthoimed agent Dxm - TGIAE: ISSUED BY:
OFFICE