S 0533 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELI.(,rRICA], I-FERN'
NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECRANICAI. S 0533
_ BUILDINGpROJELT IDEN'1'II'ICATION.
BUI'INCADDRIi55: --- _ - _ SANITARYNO. AI'1��(INSUBMIITALDA'IT
~w.If
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OW F,R'S NAME: PIIONE. NTRACTORS NAME: LIC NO:
Ex✓LN/4rfleK V�J✓ LLC NIC t�olv/lx�ol.x
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
COSTA I �. PHONE: BUILDING PERMIT INFO
Q4 Iv�- c r ) "4";w1--5377- ❑ Consultant Fees Paid by Applicant(Initial) I ELIiC[ FIREMR
CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ICF Jrv�(.
I hereby afrrttt that I am licensed under nrovlainnx afebaptar 9(cmanemiag JOB DESCRIPTION
W acwith Seainn]INq)11 NNW...30111 liminevsnnJ Prvfenvinnv Cale.anA mylicenmas IJ TI '
PERMIT ISSUANCIi
FKLLF Ucamfmceand effect. 'PDWI, ❑KI'ICI11iN ItIiM0111!1.
QUV License Class Lic.» APPLIANCES-RF_SIDBNTIAL [I ADDITION ❑PLUMBING RF,-PIPE
F Z W Date Cia-muclor
viQd ❑MULTIUNIT ❑STRUCTURAL
ARCHITECT'S DECLARATION
PANELS MODIFICATION
OZO=E luntemand my plans shall beunct as public records UPT02MAMPS
El INTERIOR ❑CHIMNEY REPAIR
r4t:W Lfecm,d l'ntcWotal 201-1000AMPS IMPROVIiMEN'f JSWIMMINO POOLS
OWNER-BUILDER DECLARATIONOVER IfNN1AM1'S [IBAI'If REMODEUREPAIR ❑DIiMO1J'I ION
C C Q I herebyWinn that I our exampt from the Contractor's License law for the
p
X 31 U follmving reason.ISedian]nl LS.Easiness and Ymlasions Cate:AnY oily ar nnmy SIGNS ELECTRICAL OlTiliR
I are
W LL ti which requires a penton m comlrma.alter,improve,demolish,or repair any Ithimb re
FSO<
poor to itsissuance,also q e prapplicantif such permit signed...¢moot $1'CCIAL CIRCUIT/h11.
(that hewars licensed n va tl 0 pct n' of e nl lar License Law(Cbdptvq COMMERCIAL'
Olda p FCZ—
o that he is c1caha Scurour and h Dfvi'i 3 I th c ave J P ,, a alma or 'I EMR MI?'f1iR OR I'OhF
d 6 e a that he is 31.5 b tacrcfmm and the basin fm the ch,dia exemption.Any vlmanon of ❑NEW 1{LDG/ADIII'I'ION ❑DEMOLITION
^m net mahm t1han fee any hundred
delta mupennil.mbjecte the xpplicanuoa civil penally of POWER DEVICES C1 TENANT El FOOD SIiRVIGE
net more than Ew huntrctl dollars 1351X)1. OTHE VEMENT
=1-s12 ,a owncndthe propeny.or mycmployceswfth xrogcsmlMfrsvlensmpenwtion. SWIMMING
S-SWLELE-FI
F will do the work,amd theswnurc ie nm intended nnsffernl for sale lSec.]DYl,llucinees ❑OTHE
W 3 m and Pmfcoions Ude:The Contractor's License Law docs not apply In an owner of OUTLETS-SWITCH&S-FIXTURES
pmporly who builds or improveu thereon,and who docs such work Hoover or thraugh
his own amplayces,provided that ouch improvements arc not imewcd or oticred for NEW RESIDENTIAL ISI,1?LTR SQ 1-n
w1e.I1huwevcr,Ihc1u61diugor imp rumor ismld wfthinoneyear of C P,euan,the ^v .F 1 )�][rn'fp� 56Q.I1'.
owner-builder will have the burden of pouning that he did not build m improve for par- �1�(x
pose of owner
O a
1,a,oowner of rate propcnr.mm exclusively Lo
ely eaaing with eamtactam m �� N I IND
connroet the project(See.]INa,Bushms and Nufa,iom Gmal The Conn-to,,Lf-
c ,c Law drcsnm apply man owner OF Property who lmild,or improves thereon,unit QTY. PLUMBING PERMIT FEE 16/'s
who rnnwctn fursuch projcax with u nnnructodvl licunad Purvumm m the Cnmmcwr's 7.T7
License10 ' ��..,^,////,�fX,,��'I�r �i/ /ice PERMIT ISSUANCE :0 11❑I am exrg39J/�(mr/�CQ Bd�NI doMRtt :0
AI TER-DRAIN&VENT-WATER IEA) VALUATION
Owner , Data
• RKER'SCOMPI?NSATION DECLARATION HACK FLOW 11107TF;CT.DEVICE
hen y affirm under pcnak,utperjury one at the following dechumnium:
I have and will muinmin a Ceniliaate Ot Comem In wit-imme for Worker a Compcn- DRAINS-FLOOR,ROOF,AREA.CONI). STORIES F 1'YI.17CONS"IRUC'I'ION
safion,as PuMiud for by Section 3]00of the Labor Cade,Iia the Itadminu n.c of the
work for which this permit is issmad. FIXTURES-PER TRAP
❑1 have and will maintain Worker'.,Compensation Immance,as requitnd by Session
37Wofthe labor Cmle.for the perfnnnnnccofthe wank far which this perm tis issmd. GAS-EA.SYSTEM-]INC.J OUTLETS OCC.GROUT' AI'N
My Worker'.,Compensation Insurance carrier and Policy number are:
Cartier: Policy N`� GAS-EA.SVS'TIiMAVER a(EA)
cERTIVICA'I'1701`EXEMPTION FROM WORKERS' GRIiASF/INUUS'I Rh WASTE IN'1'IiHCIiITOR
COMPENSATION INSURANCE HUI ]VISION PUGS
(Thi,wetinnneeAnolhceomplemd iflhepemo,i,ounnehuodrcJtollme($100) GREASETRAP
or las.) PLANCIIECKP is �
I certify that in the performance ofthe work for which this permit is issued.)shall SEWER-SANITARY-STORM ITA.2(X)PT.
not employ any persin any manner m m m become subject to the Workers'Conifer- RE
on �x
UIV
O Z .cation Law—II Calffmniu.Dunt WATER IIITA'II:R W/VENT/ELECIR GRADING ITE
Z O Applicant `
NOTICE 10 APPLICANT.If,sitar making tM1is CeniEcote of Exemption,you should WATER SYS'IIiM/TREATING
F 54 become sub echo the Workcrs Compensation f the labor Code.you must SOILS 19i1i
a .J i peons pmvntnmo
LtnM1wiJt comply with tach pmvisians onhis pcnnn shall MJeemed reveled. WATER SERVICE
QPAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. Data Rccci If
V O l hereby affirm that there isa utmtmpefor
etion lending agency for the rmance of
L4 F me work I whaB dOs forntit in issued(Sec.3(xI Civ.C.1
p T(yTAI.
lender's Name :
r G Lender's Address _ BUILDING FEE �J
y 1 ccnify ohm I have mad this application and smle that the above informnhon r,
FN correct.I agree to comply with all city and county ordounnces and alae laws relating to QT'Y. MF,CIIANICAL PERMIT EEL SEISMIC FEE
V Z building cnnaounion.and hereby amhorice representatives of this city m enter upon the
abovemcnlinmcd propeny for innpcctu'n purpsn" PERMIT ISSUANCE ELIiC'I'RIC FEE
(We)agree to vme,indemnify and keep hurmless the City of ctoarano againnl
Iiabilitics,juJgmcros,costs and cxprnsea whicM1 may in any way accmc tvaidcay ALTER OR ADD'L'O MECH. PLUMBINGFEE
. oouucc ttnf the 8' ting of this pe Iy. �7�y/' y�{�Q�6,y„'
ppptS6EmT )' 1s1(4'_ - / TTH
AIR HANDLING FIRE'1'(TO ROOF)CPM) MECIIANICAL FET:
SOI' F
W d AIR HANDLING UNIT(OVER I(LINXI CIMI CONS TRUCI'ION TAX
S" n a A pl mhIContmcmr Dtc EXHAUST HOOD(WIDUGq HOUSING MITIGATION PEE
e HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazurdoue material IIEATING UNIT(TO I(N).(MXI BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,ani the Health and Safety
Code.Section 25532(m)? HL'ATING UNIT(OVER 100.001 BTU)
Vex E]No VENTILATION PAN ISI NGLL'RITS III) PAID Dove Receipt» O
WIIl the npplinmnm lhmre huddingomupant amu cgnipnicnlor devices which BOILER-COME'(31 Ill OR H)OIXN I{'IIT)
mit ha'eurdam,air containment,as defined by the Hey Arca An Quality Management TOTAI
Dmmct? BOILER-COMP(OVER 100pN)BTU)
❑Yen C]No
Ihuverea,the owad...musnalsrtquinmcnts antler Chapter 6.95 of the Calf- AIR CONDITIONER ISSUANCE DATE
"ar
making
aki Hcallh na Safety Cate,a 11tfona .drit i 2s ay and 25536.1 understand the lithe NI?W RESIDI?NTIAh MECH. SQ.FT. �1\il
huthe nadoes nm currently have th¢nasal,mal o is my meof a C fl'ny le Wady the ocsvpont
i lithe quilentann whish munibemel poor to issuance a(uCcnilicmof Uceup.mry
Owner or authnnzed agent Doc L: ISSUED BY.
OFFICE