S 0494 I
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-`USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUD DING-N.LECI'RICA]. PL NIT NO.
BUILDING DIVISION
APPLICATION/PERMIT r1.uXfBINc-sn•:cxnmc^I' 0 4 9 4
BUILDING 1'ROJECI'IUHNI'IF'ICATION
BUILDINGADDRISS: SANITARY NO. AP PLICATION SUBMITTAL DATE
2-2- 0 +NICE ADE,
OWNE^R'-STN' 1 N� �+���� I��'HONE0 CON�1t,ACr 01l'S n"h^-,GAJ^ Jr CYI; O NIC CON'1'Rol.N
'.ARCFIITECT/ENGINCCR: LIC NO: / j l�-fN/ "SRONSd.S,LESf J9S//Z- ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MBC
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC•PERMIT FEE 1013 D85CRIPTION
CCy with Sec�en 711110 nf1)visinnJof the BusmBnot that I.. iness elnJ PmfeasinnsCMeL1anJ nrylcense'�gs •2� RESIDENTIAL'
LLp �-�g/ PI3RMI'I'ISSUANCE Fj
mow= in full pence and efca. C$-2a/a 2�s' Td ❑SFDWL ❑KITCHEN REMODEL
. t Lmen>e Class y.^a,.,.� GLV CLo,or
omm U / ( E/�i/N APPLIANCIS-RESIDENTIAL. El ADDITION ❑PLUh1HING RE-PIPE
W Date VHsJ��`��I
�n6a ❑MULTI-UNIT []STRUCTURAL
F D rn ARCHITECTS DECLARATION PANELS
understand lshall my pans saM used as public records MODIFICATION
ZOZ-� 1 dUP TO 200 AMPS El INTERIOR ❑CHIMNEY R17PAIR
Licensed Professional 201.1100AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDCR DUCIARATION OVERIINNIAMPS ❑BATH REMODELIREPAIR ❑DP.MOLIHON
a 1 hereby affirm Thal 1 am exempt from the Corhr,o,'s License Law for the
K 6 V tollnwing reuv n.(Section 7031 5,Business and Podicssinns Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
3 LL which requires a Permit to conswct.alcor improve,deduction,or repair any stmcturc
FLL0� pricer m its issuance..lm requires the applicant fmsuch Permian file a signed stamment SPECIAL CIRCUTT/MISC.
that he islicensedpursuannnihepmvisimraftheCodtrvrmrsLicenseLaw(Chapmr9
COMMERCIAL
SOO (commencing with Section 7000)of Division 7ofthc Business and Professions Cosim or TEMP.METER OR PULE INST.
6 y o pL that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDrrION ❑DEMOLI'T'ION
WX kN. Section 7031.5 by any npplimntfor a permit sukicets thenpplicam to i civil penalty of POWER DEVICES ❑TENASH ❑FOOD SERVICE
ys� rn more than five hundred dollars($500). - IMPROVEMRNF -
❑1,as owner of the pmpeny,or my employers with wages as their sole anopcmation, SWIMMINGELLCfBIC
will do the work,and the structure is mot intended o nlfem
d for sale(Sec.7134,Business I' , ❑OTHER
W and Professions Cade:The Contmcmr'a Liceme Law does net apply m ua count of Otp LEES- HES-FI%TURI35
pmpeny who builds or improves thea.,and who arcs such work himself or thnmgh
his own employers,provided that such improvements am not intended m offered for NEW RESIDENTI ECTR SQ FT.
sale.If,however the building or improvement is sold within one year ofenmpinion,the SQ.FI.FLOOR AREA $/SQ.PT.
ner-huilder will have the burden of proving that he did not build or improve for pur-
p ux of edo.), .
TOTAL:
L as owner of the pru crty,um exclusively contracting with licensed contractors to
construct the project(Sec.7M4,Business and Professions Code:)The Contramor's J. r n y -
,mad,Low rises nm apply nanownerour pn.Ferry who builds nr improves t hemom and QTY. PLUMBINGPE.RMIT FEE
who cmdoracir(crouch projactswith.contract o pro licensed punuanno the Contractor's r
License law. PERMIT ISSUANCE
❑ I am exempt under Sec. .B&P C for this mason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
� WORKFiR'S COMPENSATION DECLARATION BACK FLOW PROTF,LT.DEVICE '
I hereby affirm tinder penally of Perjury one of the following declarations:
I have and willnudiumn.C'aniftcmcdConscnno scllinsutn for Workers Congwn- DRAINS-PLOOk,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Sectinn 77W of ate Luber Cade,for the perlbrmnntt oI'the -
work for which this permit is issued. PIXrFURE5-PER TRAP
Fl I have and will maintain Workers Compensation Insurance,as required by Section
7700 ofthe Labor Cale,for the performance nfthe work for which Nispennitisissued. GAS-LA.SYS HEM-1 INC.4OUTLETS GCiRUUP MIN
My Werke i n lnwmrme,camierand Policy rrr�gqtn S�y7ss'�//s.s /r
Carries Policy No.: L '/'/V l6S- GAS-ISA.SYSTEM-OVER 4(EA) sD
CERTIFICA'T'E OF EXEMPT ION FROM WORKERS' CREASIJINDl15TRL WASTE INTERCEPTORItIJILU
COMPENSATION INSURANCE ING DIVISION FEES
(Thisoectiod need am hacompleted Irma pa...it i,fonmohrndreddellia,SIgB OHEASP'I'RAP
nr lessd a PLANWIsIIlC((-GEIdrrW
I cemifythat in Ne pedmmunce ofthe cod forwhichthis permit is lesueA,Ixhnll
SEWER-SANI"TARY-STORM EA.201 F1
not employ any penin in any manner so as to become subject to the Workers''CmnPen- - ENERGY PER
Z union laws of California.Dote WATER BEATER WNESIVELECTR
i2 Allies., ( GRADING FEE
y NOTICE TO APPLICANT:If,after making this Coo ificam of Exemption,you should WATER SYSTEM/TREATING SOILS HE
a^' Woman'tmom m the Worker's Compensation Pamioim,of the labor Cede,gnu amt
4[1 L.t+ forthwith comply with such provisions or this pemtit shall me deconalmvnkcd. WATER SERVICE'
Q CONSTRUCTIONLT:NDINGAGENCY NEWRESID13N1'IAI
w z .PCMB. SQ.pC PAID
U Iherehy uffrmr thntthore lsa comwcdmr lcndingagrney for the ponnrn.neonl" - Dutu Roaeiptq
LIL, 0 T
the work for which this pcnmit is issued(Sec.3097.Civ,CJ
OU Lender's Name _ O'TAL:'
WLanders Addrew - TOTAL:
BUILDING CB
ly I comity that I have mad this application and state that the above infnmwtinn is
IA cancel l agree to comply with all city and county oninaness and state laws relating to QTY. MECHANICAL PI7RMIT ( FEE
building constriction,and herebyamhome representatives ofthis city mercer upon the SEISMIC PEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE 3S11ZJ ELECTRIC FEE(We)agree m save,indemnity and keep harmless the City of Cupmino against -
Ilubilitiex,judgmells,costs unit cApcmes which may tinny wary acemorgatiml said City ALTER OR ADDTO MECII.
PLUMBING FEE
nsequence of the granting of this Permit. -
in
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Uk(XMCPM)
SOUR�L RF$jILA 1 V'1 Q S. CONSTRUCTION
N T
`rI]N'LA` NIrJ�/v_s-r_x�.� AIN HANDLING UNIT(OVER III,IXM)CPM) CON.TTRUCI'ION TAX
Signature of ApPicanlContrecmr Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Tatum building occupanr score or handle hamNous material 1113ATI NO UNIT(TO I(0,(I(111 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
1113AII NO I NIT(OVER 100,000 It'IU)
Coda Section 25532(a)? /q0
❑ -D
Yrs QN. VENT]LA TION I-'AN IS]NGLL'RBSIDI PAID
/' Date Receiptp
Will the air comm or future Wilding by he R use equipment lor ilyties M..s which
emit hazardous air cnmeminums as definN by the trey Arca Air Quality Management BOILER-COMP(JHP OR I(Xhll(OItTU) TOTAL:
Divrier? ��•///'''
Cl Yes Na HOILER-COMP(OVER 100,(X10 It ITB
_
Bt Q.']�•'%z'�$ (/����Fl
I have ud the humNnm
us am
terials qro
.a counts tor Chapter Cull- AIk CONDIq'IONF.R 60 ✓s •T•+ ISSUANCE DATE:
m
Timor Health&Safety Code.Seciions 255115,2.5577 odd 25574.1 undentunA tom if
(tthe NEW RESIDENTIAL SUCH. SQ.FT. 1 '1 -
building does not currently have uonal.that it is my oespov,flolay to nmil'y the wermarn l L
of the rgairements which must W inet or to issuance ol'a Cemificam of Occupancy.
Own<r or emhnrizeJ agent Dam TOTAL: �r30 ISSUED BY
OFFICE