00020042 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 0 eoQ
CITY OF CUI'F:RTINO BUILDING-DLECI'RICAL PERMIT N(.
BIJILDING I7NISION APPLICATIONfluMMIT PING PRNG (;r IDEANIFIC _
HUILDINI:(BOJ I?CT IDEN'1'IF'IL'A'1'1lIN
SANITARY No. API'LICAIION SUBM1'I'TAE.DA]"
BUILDING ADDRP_SS
Q 590 e. /qac, eS' .16g- 37
)WNER'S NAME. PHONE,; CONTRACI'(1jI'S NAM1i: - LIC NO NIC CON'IRoil N
2r/'rr. c�orf-I, �S��o937 C)uJ✓� � r ❑
CHITECIYENGINEER: LICN(I: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG RIJ3CT PLUMB MECII
El ID ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I M1crchy.Harr that 1 an,licensed under provisions dChapter 9(commencing
DO,O with socliou700001 Vivisinn3Nthe Husinusm and l'ndesninns Cuda and mylicemely I'IiRMI'T ISSUANCE
i-�.. in full fine cock(fen. ❑SFDWL ❑KITCHEN REh10DEL
QUU LicenseClasen Lic.X N'PLIANCF_S—RESIDENTIAL []ADDITIONIJn.uMBING RE-PIPE
0.,a Dam Comeacmr
ARCHII'F.CTS DECLARATION PANELS ❑MULTI-UNIT ❑MODCCX1[O
~v=i 2 under,and my plan.shall hcu.cd vs public record. MODIFICATION
oiD z— pit Oil 10200 AMPS
p ❑IN'1'IiR101t El CHIMNEY REPAIR[—�f:•W Lacerated Pace.stocoal 2014000AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATIONUVEB!"AMPS ❑HAITI RF.MOUEUREPAIR ODEMOLITION
C C G 1 hereby affirm that 1 am exempt from the Comencmrs License Law for that
a OTHER
U following reaam.(Section 70315.Bmincss and Notm,,ons Code:Any city or many SIGNS ELECTRICAL ❑
ID a m N which myuires a permit m,A,tmurmi,alio,.tmm
Pmve.dcollnh,or area any sancBnre _
OQ pnn mit,I,...ce.also rapares the applicant for such permit to file a signed lernoms SPECIAL CIRCUIIYM ISC
f�} ehatheisliecnselpawarommepr,isionsofthe Cnlmm�nrs Licenm Law(Chapter9 COMMERCIAL:
ed ly no (commencing with Scainn 7008 of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST.
'L 6 e (but he is cxcmpt therefrom and the basis Baltic alleged exemp ion.Any vtatation of [IN'W BLDGIADDITION ❑DEb101.1'I'ION
N Smuoi 7011.5 M1y nny IWpliem'lot a perms eabjen,am applicant to a civil penally of POWER DEVICES NANT ❑FOOD SERVICE,
Ownerryt than five hundred dollars lSS(Xq, 1 ROVEMENT
Q"I,
of Ne pn+peny.or my en+phyas with wages as their solo compensation. SWIMMING POOL ELECT RIC OTHER
will Jo the work,and the structure is not intendedor offered mrsale(Sm.704W.Businc%%
aim and Professions Calc Me Comrennr's License Law Jas nal apply to,an owner of OUTIETS-SIEVE"PCHES-FI%TURES
property who builds of mhproves Ihcrunn,and who docs such work hintvclf orthrough
his ,own cm rIwer proed ch
vida(scoll Improvement,me not intended n of!d for NEW RESIDENTIAL ELECTR SQ Irl'.
sale.If,however,the building or improvement is sold within one year nfcomplerourthe SQ.IT.ELIIUH AREA 5ISV.FT.
owner will have the burden of proving that he did nut build or impinve for pur-
tn"a of xalc.). TOTAL /S A
❑ I he ..I o'cl000rly arsatonalul l' tut m
coe t thep J t(See 7094.
09 ' 's v I I hs ,CAI Cot hoc i-
come la d e apply to fpmperty h builds ' p .the J QTY. PLUMB
ING PERMIT 1e8i
Lac¢for stip 1 s 'h at r( 1 .Jparrs a.,he Caracrol.r,
License Law. IIRh1T ISSUANCE
D FJ�
9
Incxcmpt code,Sec. .Bkl'C fothis rea>nn 200
D
AI;I'I3R—DRAIN k Vf?NT—WATI3R[BA) VAI,UA'I'I(hN
Owner Date
WORKER'S COMPENSATION 'CLARATION BACK PLOW PROTECT.DEVICE By -
I hereby affirm under penalty of perjury one of Ne following Jeclamsinna: J
I havcand will maintain.Ccaificamef Cnmanuoself.insora for Workers Cotnpen- DRAINS-FLOOR,ROOF.AREA,GOND. STORIES TYPE.CUNSI'RUCTIOI
motion,am pmviJal lint by Section 791X1 of the Labor Csdc,fill perfntm
r ehc vnec of the -
workfor which chis Permitisissued.
PIK'fURES—I'IiIYTRAP
I have and will maintain Worker's Compemation Insurance,am required by Section
3]Bluf the Labor Cute.for the perfommnCAS com he work for whivh,his Near,is issued. EA SYSTEhI-I INC.J OUT LETS OCC GROUP ^ AIN
tidy Worker's Compensation Insurance carrier and Policy number ate: GAS—EA.SYSTEM-OVER J(in) IY /
Carter: Policy No.: -
C13B1'IIgCATEOI'13KI?MiMONI'ROMWORKI!RS GREASE/INDUS IRI.WAS'1Il IN'I'ERCEPIOR'
COMPINSATION INSU RA NCP. BUILDING DIVISION FEES
(finsembumneeJ not be complemJif the permit is Torose hunJtN dollars(Slip) GREASETRAP
I'IANCHECK PER
or less.)
lcondom.,in the p.,aninvo- of the work for whlah'his it,.W.for,C shall SEWER—SANITARY—SIYINM EA.2W PC
not cngtoy any Penton In nny numnursn usmbccnnho xuhjatmthc Wnrkcrs'Cnlnpcm ENERGY FCC
,Z cation Laws cf Codunnia.Dam WATER BEAT 17R WNENT113L11C'I R GRAVING FEE0 O Applicant 1
Z
Z)
N NOTICE TO APPLICANT:If,after staking this Certificate of Exemption,yon shnuW WAGER SYS'HiM/iREM ING SOBS FEE
a Tit become subject m the WorCompenrmiprovisions of the Latin Coda you must
fonM1wilh comply wish suchh.mvisinnsanhi,is pemhit shall be decnreA tevokcd WATER SERVICE
PAID
CONSTRUCT ION LENDING AGENCY NEW RESIDI3N"TIAL PLMI3, SQ. Dale Receiptof
V Q Ihereby affirm that there is acanarainton lending agency for the performance of
the work to), permit
r which this is issued(Sec.3097,Civ.C.) TOTAL
LL, F, Lendcr.m Name :
W LcnJer,Addmnn TATA L:
ly I modify that 1 have read thin application and time that the abtwe Infm
nratino is itlJil"DING FEE
CL. ceg QTY. MECHANICAL PERMIT FEE
Gilding agree to comply hereby
and representatives,
oftis slam laws upon m SEISMIC FEE
U ,Z, building construction.and hereby amhons reprc.mmatires of this city to enter upon the
nMwonhetnioned property for neons ion purposes, PERMIT ISSUANCE FIX TRIC FEE
(We)agree(I,nova Inkloody and kap hatntlevv the City III Cupertino against
Iiabilitica.juJgmcnes,cogs and expenses wAiehlnoy inany way acme again.axaid City ACI'ER OR ADD EG MECII. PLUMBING 1'1713
in consequence of the granting m this peound.
APPLICANT UNDERS'(ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CIO 10,000 CPM) MECHANICAL PHE
SOURCI3 REGULATIONS,
0— /00
AIR HANDLING UNIT(0 ER 111,IX111 CPM) C(hN5'TRUC'r1UN'I'AH
lgnmme of ApplicanVContricon 0.1. ItInAUST tolls (W/DUCT) IIUUSING MI'11GATION FRI3
1 IA]I.RDOUS.MATERIALS DI 'LOSURE
Will thc.ppllcantorfuture huildingoccupam norcnrhirdle haaardea.matelot HEAPING UNIT(TO 100.000 BTU)
err sionAl by the Cupertino Mnneipul Cute.Chapter 9.12,nurture 11-Ith and Safe'y ❑MATING UNIT'(UVEB Moons)II'I'U)
0.1"Stanton 255321n1!
(]Yen ❑NnVENTILAFION PAN(SINGLE!BESIDE ('AID
Date Receipt
Will the applicant or future building occupant use equipment or devices which BOILER—COMP CHIP OR 100.008 BTU)
lit andons air coamts inanits defined by the Hay Area Air Quality Management 'IOTA[ P I
( h:¢ nt
,rid? 11011-ER—CAME'(OVER 110.X1011'ME
❑Ycs F1 No
1 have read the M1auNoun titans 15 5,25533 an under Chapter understand
of the Cali-
AIR CONDITIONER S$UANCE DATE
hotI I Health&Safety Gxle,Sc'tiom 2.55(15,25531 and 25511.1 wWcamnJ Nm if the NEW RESIDI3NI'IAL MECII. SQ.FT Z
huilAing Jacvm lennelnly bnvmt mnnnh lhm it ixnry rcxpmsihilitymnulily hhc ceAlpum k .�
of th ems jachm IMocegrin Ilicme of Occuponey.
C Z_ .QV
O � thomeJ.gem
Dam TOTAL: ISSUED BY:
OFFICE