B 0497 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECpRICM, PERM]T 1,1006
BUILDING DIVISION APPLICATION/PERM[T PLUMBING-MECHANICAL SOON 0497
i r- BUILDING PROJECTIDEN'I'IFICA"ION'
IIU11"DING ADIIRIS$: V/r t ANI'1'ARY NO. APPLICATION SUItMITTAh DAI'li
OWNER' n ? PI la C'ON'ErRAC'RR'SNAME; LIC NO:
NIC ^ CaN'I'ROL/M�
ARCH .IC NoADDRESS: ❑ /_///I) / i
CONTACT: FHONIH - I BUILDING PERMIT INFO "
/ x-e� •n El Consultant Fees Paid by Applicant(initial) 81 Dc, F.Lf': PLUMB MECH
Ion
L ENSED CO T
ACOR'S DECLARAL/TION V `
QTY EI TRIC PERMIT • FEE '
1 hereby nlRrm hal l am IicenseJ under provirinns of Chapter 9(camnsncing _ _ J04DESCRIPTION
1400azz wile Scetion701NB of Divi n3nfthe Business nu r odmyluemccis TI
00 PERMIT ISSUANCIi
�_ AL
mlidllmrzundciccl, ❑KITCHEN REMODEI.
<UV hicenm Class Lic.N APPLIANCES-RESIDENTIAL ADUrELON El PLUMBING RE-PIPE
NQa Dalt-------��� Conimclmr
RCt11TE(.TS DECL M11UI:T1-UNIT ❑STRUCI URAL
z c)m z 1 unJersmnJ my plans shall be nxcJ as puniic ranrds PANELS MODIFICATION
0--4-0 UPT020"AMPS ❑IN'fliltlOR ❑CLIMNE REPAIR
F,4.F.; Licensed Professional 201-IgX1AMP5 IMI'ROVEMIENT SWIMMING I'OOIS
s .ct OWNER BUILDER DECLARATION OVER 1000 AMPS ❑BATA REMODHURFPAIR El DEMOLITION
yWy 1 hereby arbitration I vm exempt from the Counconh License Law for the
{y�3 W F hdlnwing must (Section 703 1.1,Business and Professions Cude:Any city nr manly SIGNS ELECTRICAL DTIIIeR
U.m which re arms a permit rat construct,eller,improve,demolish,or repair any structure
.05 prior to its issuance.also requims the applicant for such Permit to rlc n.cigneJ statement SPECIALCIRCUIT/MISC.
E} hal he is licensed parsma;nrat the powisionsofhe Cotnmcmr's License law lChapter)
a'� (cmnmencing with Section or Division 3 ofthc nosiness and Prfiessions Code,or �� ..COMMERCIAL
u1 P�00 b TEMP.MIiTER OH POLE IN: n I-)
a than he is esent n herefnan i I he basis for the alleged exon Winn.An baron of _
Section 7031.5 by any applicant for permit.subjects he applicant)acvil violation
of POWER DEVICES '-y \, 1 f I&ANT
00SLUGADDITION ❑FOOD .ERVIy ll - [_1 FOOD SERVICE
Fz6not mom than Five ft h he pro,pa dollars y iia k i'ROVEMfiN'T
Q Lasowner
,awok, mittepenym myempl,armal hhwages beredh stheir mlecompem.....- SWIMMING POOL ELECT
O will do tnc wons node The Imre ac sol s License Law dos not apply
an,Rosiness AY 5THER
andProfessionswho
Code TheContractor'sthrum Licenselawdoesnot work
hi toff owner of OU'1'1,151'S-SWITCHES-I TURES
property who builds or improves thereon,unit who does such work himself or through
his own empinyces,ptovidel that such improvements are net intended or nfheard for NEW RESIDENTIAL ELE R� SQ ET.
sale.If,however,the building or improvement is said within care'am
ofcompletion,the SQ.17"FLOOR AREA 4/SQ.lef. -
w,sr,mlWer will have the burden of pmvingthm he manor huildor improve fnr par- .�-�� ,00
/e�k
ry'ca of sale.). TOT 3
I,as owner of hpc
e pmny,am lu
excsively cmmmaing with IiaN n
nsCtmlret)6 e, 1
courono t lbs pn,joct(Sem.7044,Business unit Professions CWeU Tile Contractor's Li-
cense Law docs not apply to an owner(1r property who build or hnproves'here,,,,,and QTY. f PLUMBING PIZR IT ' FEE,
who contracts for such projects with it coneremrra)licensed parsaam m he Conamemrx ', ' r ,ice 2�
License Law. PERMIT . UANCE' `) 3,J
❑ I am exempt ander See ,B&PC bans mason
ALTER-URA .NT-WRIER(EAI01
VALUATION
Owner Date C2 � �
WORKER
underp COMPENSATION DE CIARATIfnN ' HACK ROW PROIE IiVI
I hereby aRrm under peralry factor,of perjuone of the following Jeclaratinns:
❑ Ihuve purl will malnlainmG:BifWte nl Cnnseat to self-irtsury for Wnrker'i Compete DRAINS-FLOOR,ROOF,AREA,CONII, STORIES TYPE CONSTRUCTION
moon.as pm,ded fnr by Sectio 3700 of he Loner Code,on he perrnmatmc of the
work for which Ibis permit is brined. FIXTURES-PERT RAP
❑1 have and will maintain Waimea Cnmperourbon Ino anct.us repaired by Section
3700oflhe�lp Mn Code,forthe pe fn��� ^T ofthe—akfurwhichl is ermuisissued. GAS-HA.SYSTEM-I INC.4 OUTLETS (ICC.GROUP APES
My Workf auppnsatiun Insurincret:;lir'r A "a,
ic t h e -
MyWc: rr1l //�! /AIII l J GAS-EA.SYS'I'HM-OVER 4(IIA)
RD CATE OF EXE IPPION I OM WORKERS'
COMPENSATION INSURANCE GREASFANDUYI'RE.WASTE INTERCEPIUR
BUILDING DIVISION FEP_S
(Thixue mnryJ ll,1lMlhpge/yt I or thundreddallars($IW) GREASE TRAP
m los.) `xAi- xf'(./(Jf/ P� PLANCIIECK PEI:
I cenil ml innlnrfarm td n ¢itis punnit is ixsuml,l shall r ^
no,employ an SEWER-SANI'T'ARY-STORM EA.NX11'1'.
p any in any mannerso us lm become subject mar.Worker:Croatian- ENERGY FEE
,z, carbon laws of California.Dre WAT17R HEATER W/VENT4!LI:CTR
O Applicant \ - GRADING FEE
.~N. NOTICE TO APPLICANT:IL after making This Comficale of hxcmption,you should WAI'17R SYS'I'ENIG REATING
a ,
become subject to the Worker's Compensation provisions of the labor Code,you must SOILS FEL'
minwith comply with such provisions or this permit shall he decimal revoked. WATER SERVICE:
Q
7z C<INSTR is
cION LENDING AGENCY NEW RHSIDEN I'IAI.PLMD SQ.t1'. PAID
U O lImmli'af6tmhal there iso cnmlruclion lending agency for the"burnanceof Doc R<ceipiN
tire work for which this Amort is issued(See.3097,Cie C.)
L1. F'' Lender's Name TOTAL:
y� V Lender's Address ''OTA ' /
C I cenily that I have rend his application and stale hal the uhnve information is - - BUILDING FEE �t
in coredf l agree to comply with all city and county ordinances and state laws rclatlngto QTY. MECHANICALPERMIT 1FEE,
U 7a" building construction.and hereby authorize representatives of this city to enter upon the SEISMIC FEE -3
above-meminncd properly liar in,victinn...ar,ase,, PERM1'r ISSUANCE. /�
(We)agree to save,indemd k
nify aneep Immdnpe
s the City of Cmnina against ELECTRIC PEP. ::21:1 %
Iiabilities,judgmems,costs and expenses which may in any way raceme against said City ALTER OR ADD DO MECIL
yyCC The gmming of hiv permit. PLUMBING FEC
APPI AT19 UNDERS'rA S AND WILL COMPLY WI"11 L NON-POINT AIR HANDLING UNIT(TO IQ000CFM)
SOU rI EGULAIiOM1' MECIIANICALFI!1:
AIR HANDLING UNIT(GVER I(Lons1CPM) CONSTRUCTION'1'AX
Sign eor APpdca C r [)ale EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOS JREi HOUSING MITIGATION FEE
Will lhcappllcam or fmare building occupant sbareur handlehazardous tomenal HUAI'ING List 1('101(10,000 HT U)
as Defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'J HEATING UNIT(t)VER 100AX)BTU)
Elan VI:NI'ELATION IAN(SINGIH RESID) PAID
-
wthe ainm fore Irking use ei or devices which
Dam ecep't b
r mit hazardous air contaminants as defined by the Bay Area Air Quality MnnaemeBOILER-COMP(3HP OR 101,000 BTU) TO
TAL
District' :
El Yes v BOILER-COMP(OVER 1011,100 HTl])
If, read thehamrdou matoim,requirernemz music Chapler Assaf he Cali- AIR CONDITIONER ISSUANCE DATE
fomis Hen h Safety Cale,Sections 25 5,2553)vas 25534 1 ndma it but if the NEW RESIDENTIAL MECIL SQ,FT
nhldla '•x rnevtmtulynavealgpan rti..my reapmnain"t t ��a/"""''yyym��`�('pppy��kyyylee ucaapam
of the qu ra Cnrzw.l t be rat f u upuncy.
Owkyrf;71 eat r, /�[)am 'TOTAL: ISSUED BY:
OFFICE