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NO PERMIT NUMBER APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY IF Iry/ y qF-- CITY OF CUPFRTINO BUILDING-KI,BCTBICAL PHRMIT NO. BUILDING DIVISION APPLICATION/PERMIT i'ING I-ROKC11)unNIFIC 50001 IIUII,IIING 1'ROJFCI'IUF:N'rl4'ICA'1'10N NEW SANT IARY NO. AVPLICATIUN SUHhII'19'Ah DATI If UILIIING ADIIkESS� l© rv/R,v7tAN1Tp- Cr. SI1 ► ,00 /6 2 4 0 171'S AMI.: PIIONIi: CONTRACTOR'S NAME: LIC NO: NIC CONTROL, I&/ 6Ro ws 317 03cc� c.a7F r �,vs E(.>'GT1G ❑ .RCI ITECP/ENGIN Iv?R: LIC NO: gDp}tf 1. � 1 c Sol It's CONTACT: / PHONE, f/(G,t O BUILDING PERMIT INFO (q,5) _71 _0&ob ❑ Consultant Fees Paid by Applicant(initial) BLDG I;l.ECI PLUMB M CH FIAIrtF/ ❑ C, ❑ ❑ LICENSED CONTRACTOR'S DECLABAI'ION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION 1 hicehy alfrnt that I am licensed under provi cions of Chapter 9(commencing M Zrwbh Section7p00lofUoision3ofthe Businessand Ihofcssiom Cade,and mylicenseis RESIDENTIAL: 500 intuit mrcconAcffcc,.C�O SIII� PERMIT ISSUANCE ZSFDWI, ❑KITCHEN REMOUEI, aVV License Class Lic.a APPLIANCI'S-RESIDENTIAL ❑AUDI'T'ION [I PLUMBING RfiI'IPE HGiDate Contnmor ❑MULTI-UNIT ❑STRUCTURAL yy�r ARCHITECT'S DECLAR I'1)N PANELS 1=1 Z 1 und,toanJ my plums shall ha used as public records CHIMN CA'f10N OZ�O D UP Ill AMPS ❑INTI?k10R ❑CHIMNC:Y REPAIR I::let-ad Licensed l'rore...o:wl 4111-Igk1AMPS IMPROVEMENT' SWIMMING POOLS %adE; OWNER-BUILDER DECLARATION _ OVER IIgIBAMPS ❑BATA RI7MG REPAIR [I DEMOLITION C C d I hereby affirm that 1 am exam,,from the Contraemr'x License Law for the ❑OTHER xC=L U (avowing ream..(S«,ion](131.5.Bmim,mtd Professions Cade^.Any city an many SIGNS 171,ECrkICAh 1+13 w y which requires a permit,o construct,alter,Improve,demolish,or repair any swcame FI_'OQ pmorn,its - el: 4 :thppl on maroichP ti,t II .timed"aterneffi SPECIAL CINCUI DMISC. +�Y Ihan lie is licensedpursuant the provisions offlacConterame%l c L (CCan, r9r ' COMMERCIAL ldl ..' , mIExl'Mlk OR O1. INST a0 (nmnenungw with ]UntB of Division n3 nth Business ss : C ty did he ix exempt thc rlmot entire basis far the alleged exemption.Any violation of [JN HLDGIAODI'1'ION ❑DLMULI'I'ION Section70315 by any applicant for a permit subjects the applicant u+a civil pcwl,y of I'OWLB DEVICES ❑TCNANT [I FOOD SERVICE ma nime than five hundred dollars O50B. IMPROVEMENT ESQ11.asmvnerol'he propcny.,,myenployms with wagcsax their sole cnmIonsmin I . C will Aa,hc work,anJ,he stmewrc is nm intended orolfercd Tarsale($¢.]qt4.Bos;ne ❑OTHER IllF S "'m and 14nlessions Code:The Conoacmrs License,Isis,doe..nm apply n+nn owner, ca 3 pro,.,who builds to improves thereon.and who Jaen such xork himselfor thmu NEW RF,SIDLNTIAL ELECfR 5 IT. his own employees,provided that such Improvements are not intended or onbmd fur SQ.IT FLOOR AREA g/SQ.FT. sale.If,however,the building or improvement is sold within one year of completion,the ncolouilder will have the burden of pnming that he dial not huild or ingsmve far pur- Prsc of otic.). 1,as owner of,he prup,my.ant exclusively contracting with licensed contrncturx to container the project(Sec.]M4,Business and Professions CaJc:)ITe Contracn+rs se Low Jas not apply w an owner of pmprny who M1ulldx nr intpmvas,hersenn. N who commets for such project with a coneacions)licensed command to the Contract License law. I lam exempt under Sec. ,B&PC 1pr his ALTER-DRAIN&VENT-WATER(EA) VALUATION wrox Ume WOR BE R'S COM VENSAI'ION DECLARATION BACK Il,QW PROTECT.DEVICE 1 hereby M.under penahy of Perjury one of the following decfamtiom: I have and willonainfainn Cenifcam of Consent 4nelf-;mute fur Workers Compen- DRAINS-FLOOR.ROOF,AREA,COND. S'rOR1IS TYPE CONSTRUC'1'10'. ration.as provided for by Section 3]q)of,he I-AM+r Cade,for the Pelfmrtaan a of the work for which this eron,;s ,l cd. FIXTURES-PER TRAP P 1 have and will mainmin Workers Compensation Insurance,as reclined by Section 9]IHlul'thc Earn,Code,lin the po,fomam ofihe work for which this permit is issued. GAS-EA.SYSIFM-II .4 OU'TLIirs OCC.Gk MC; y.I,,: ' rpyV,*V'ssyragy(pyler�olie,NaY n� Rf.YtI. p!{ GAS-G.SYSTE IVEB4(IiA) CERTIFICATE OF H%EMPI'ION FROM W(IRKEBS' I-(— GREASFJINDU :RCEPTOk COMPENSATION INSURANCE 13UILUING DIVISION PL'ES Haivsectim.madombacnc,leted ifthepermit is fo..mehundreddollars(SRg) GREASE'IRA PIANCIIECK FLT. re".) Toy any thminthe any maer... ,,.bekhvwhichths the Walker"Co Lshxll SEWER-SAN,TARY-S"10 li Ill lrl'. ENERGY IBiIi man employ any pc,snn in any n,unncr sn us,o Mc+me xubjem,o The Walker"Compen- Z cation laws of Califomix Dam WATER 1117ATBR WIVEN'fTL i GRADING FLIT Z0 A,,heant 1 .N. NOTICE TO APPLICANT:IL after making this Cenificmc of Exemption.you stunner WA'IE SYSIF ffREA'1'ING SOBS SZ17 become s.hj cI to the Worker's Compensation provisions ultra Lhor Curia,you mus, factional comply with such pruckiomonhis Penni,shall be deemed revoked. WA'T'ER SERVICE a � 41MILECIIANICAL CUNS'1'RUCTIONLENDINGAGENCY NEWRIiSIDF.YIIAI.PLMB, SQ.IT. PAIDZIhereby affmn thatthem is a construction lending agency for the pertommnes,of2 ,he work fur which,his pami,;s isued(See.300,Civ.C.) e� TOTAL:Lender's Name TOTAL:I) LandersAJdreai �'• I ccnify fhm I have read this application and statethar the above information isQTY. MECHANICAL PERMIT FEE 2 7 V Zabove-men,ionW propcnY fonmryctlon purposes. PERMITISSIIANCE(We)agree to save,indemnify and keep hanNess the City of Cupertino against Iiabilitics.judgmenu,costs and expenses which may many way uccmcagainxt said City ALTER OR ADD TO MECH.ime ..sequenceof the granting oftbi,pe.I,. APPLICA NT UNDERSTANDS'AND W ILI,COM PLY WH I I A LL NON-POINT AT R HAN DLING U NIT TrO I(kgp CFM) L SOURCE REGULATIONS. n D 9 AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX 'T S-igbrtine 'ApplicanUC rant Dam EXHAUST HOOD(WIDUCT) HOUSING MITIGATION ITE Z DOUS MATE . DISCLOSURE ;n me apo nrtuwrc huilJingoaupum ntnre or Inn the hasxNaus mahoud HEATING UNIT(TO 100.001)BTU) m defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) Cade,Sullivan 25532(.)? p yes 0 N VENTILATION PAN SINGLERESID) FAH) - Dale Receipt a Will,he applicant or fumrc bwlding necupant use ceu;pment or devices which BOILER-COMP(3HP OR 100.000 HTU) . O< .mit tumnlous sir cnmmninams as JmineJ by TOTAL. the Hey Arca Air Quality Management I District? BOILER-COMP(OVER 11,000II1U) ❑Yes El No AIR CONDITIONER ISSUANCE DATE I have Saferad h ode.Sections 5505. 533 a s under .I and 6.9 understood 'hethat Cali- / r fom;:a Health a Safety Cade Sections ,that i 25533 and 25534.1 i nMusunh ac 11 the NEW RCSIUEN'L'IAL MISIL SG IrT', builAing Arcs nae,curmotly hove n moan,,that h is my rospansitil'ny m notify the atcapum 2- 7 of the requirement ich mus be met ri o issuance of a Cenificmc of Cc vpaney. Ownero au, mmd ogcm )ate TOTAL ISSUED BY: OFFICE