00010145 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY coo 1 0 7
CITY OF CUPERTINO BUILDING-ELECFRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL C
BUILDING PROJECT IDEM'IFICATION J
41w—
BUILDING ADDRES SANITARY NO. APPLICATION SUBMITTAL DATE
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WNERANAMYore6bI — PHONE_ / 80 C( w RCT'Q SyAME:InC LIC NO: N/C CONTROL
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kRCHITF.C'I'IIiNGINIiIiR: LIC NO: 6 AUUItF.S14MGr/1o(Pcc)dr J Gvs. n SCur I ❑
CONTACT: PHONE: 1lA BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT 11MI MECH
ElEl ❑
LICENSED CON'I'RAC OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Jinn I am laenal under provisions Of chimer 9 Unmmencmg JOB DESCRIPTION
wd'Z wih Sector,70(to fUivisiun3 fineloconessand Pmfeai sCalc.andmy icenuis RESIDENTIAL:
1 U`12 in PERMIT ISSUANCE
FW�F full fore,and,dee. / ❑SFDWI. [I KITCHEN REMODEL
Q,UU I.iccnne Cl _ [,ic.N At'1'LIANCES-RESIDENT'IAL []ADDITION [I PLUMBING RF.-PIPE
� YIsc
Dum Commcuu
FOm ARCHITECTS DECLARATION I
PANIi1S ❑MULTI-UNIT ❑STRUCEURAL
Z O h Z 1 uoderee us
enJ my plain shall bed as public records, MODIFICATION
OZ—a UPT02MAMPS [I INTERIOR [I CHIMNEY REPAIR
h.4 t:w Licensed Pone,,manl 201-10ARAMPS IMPROVEMENT SWIMMING POOLS
C C Q RATI
1 hereby affirm that N am exepmR-RER mC he Contra tor's License Law fur the OVER 1000 AMPS ❑BATH REMODEIIREPAIR C]DEMOLITION
yxj'}i c..E Ibllowing reason.(Section 70131.5.IEOmvsa and Professions Code:Any city 9r county SIGNS ELECfRICAL C1 OTHER
which require.,a permit a,e n,lool.alma improve,demolish or reps any suucmre
I_'LL'O poor to its issuance.also requires the applicant for such Permit file a signed statement SPECIAL CIRCUIT/MISC.
E gal hal he is licensed pumu:mt to hnlyda
e provisions ofthe Coors License Law(Chapter 9
adipo (commencing with Section]IX)(Oof 1)....ran 3ofthc Business and Pndassions Codclor TUNER METER OR POLE INST. COMMERCIAL:
E E c C that he is exempt beef iom and he basis for he alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ad Section]031.5 by any applicant for u Permit.subjects the nPPhlicat to a Civil penalty Of POWER DEVICIS ❑TENANT ❑FOOD SERVICE
t more than five hundred dollars(3500).
F Z} IMPROVEMENT
6 0 Lo the work.
and
the gnyor tnycmplended wlhwaga as sale
lei(See compensntlon. SWIMMING P(l(IL ELECTRIC
ca will daaM1ewmk.Codes hoCureicurnot iLicaednraw do is notapply as an earneir of
❑OTHIiR
a 3 m and arty who b Cale:The Conmaeoh License Law does not apply s an owner of OU'Il.ETS-SWITCHES-FIXTURES
a, ,o n who builds or improves thsuch i and who rasa m n work himself or bed for
his ,on employees,provided thw such impmvancme am nm intended or altered for NEW RESIDENTIAL ELF,CTR S fT. 14
sale.IL hmvever,the Wildingor improvement issold withiro,yearol compleriem he SQ.ET.FLOOR ARGASISQ.FT.
nerrbuiWer will have the bM
uen Of proving that he did not Wild or improve for pam-
,,a of role.).
0 I,os owner of the IF per,,em exclusively c moraon g wih licensed contractors m TOTAL'
comauum he project(Sec.7044,Business and Professions Codes)The Calnraea's Li
-
cent,Law does not apply to an owner of property who builds or impraves hereon.and QTY. PLUMBING PERMIT FEE
who commas for such projects with a contranor(x)licensed pursuantto the Contra,,.,s
License Law. PERMIT ISSUANCE
1 am exempt under Sec. .B&1'C for this reason
ALTER-DRAIN&VENT-WATER(EA7 V UATION
Owner Dines WORuKERnder
salty PENSPNJ erjury
on DECLARATION BACK FLOW PRO]ECT,DEVICE
I hereby affirm server penalty of perjury one of the following forWdeclamations:ker
�It,as and will maintain ation 37M of Consent toLabor Code,
for Workersce of the DNAINS-FLOOR.ROOF.ARFA.COND. STORIES TYPE CONSTRUCTION
smart,as providedor rthis
for by Sermon 3]00 of the Labor Code,for the PcHormancc of the
have and will maintainxWorker'.s Compensation Insurance,as required by Section FIXTURES-P[R TRAP
3100oOcEdhow Cade.(a,the performanccnf the work for which this permit issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP /A APIN /,�ae�/�
My Wor en.�timins mcecamelblcy NtcYnu_�r� GAS-EA.SYS'T[M-OVER4(EA) 't ���V
CER'II9CATE OE E%EMI'110N FROM WOR ERS' GREASFJINDUSTRL WAS'TF.INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
OHIO%.xection need not he completed if the Permit is for one hundred dollars 6 l 00) GR17ASETRAI'
m late") PLANCHECK FEB
I certify hat in lhelxrf:m,nec afire work for which his pencil is issued,Ishall SEWER-SANITARY-SFORM EA.Xk)FT.
emoy an
ply person in any mam m
manner so sex becoe vibjecCo.,.-
to he Workers CamENERGY FEE
Z ,lion Laws of Calibunhe,Dam , WATER HEATER W/VEN'DELECTR
z Q Applicant GRADING FEE
NOTICETO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMTREATINC
1-^ N become subject to the Workers Compensation peation provisions of hW
e Isr Cade,you man SOUS FEE
Wforthwith comply with such provisions or this Permit shall be deemed revoked WATER SERVICE
0
Q' CONSTRUCTION Id; DING TOTAL;
ING AGIiNCY NEW RESNIiNI'1AL 1'1_MB, SQ.PL PAID
V O (hereby affnothal there is a annstruction lending agency for the Performance of Date Rewip
Fthe work for which Im,permit is issued(Sec.3097,Civ.C.)
Lender's Name T
U lenders Address T09Ah
>. WBUILDING FEE
I ttnify that 1 have read this application ad smm don the above infomlaion is
OH. faA correct.l card,to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z hadd.,.in,mactin r.and hereby uuth9rim represemmives of his city to enter upon he SEISMIC FEE
ahave-mentioned propcny for inspection purposes, PERMIT ISSUANCE
(We,)agree to save,indemnify and keep hornless the City of Cupcnino again- ELECTRIC FEE
tubi titins.judgmears,<nan and expenses which may i n any way among against said City ALT ER OR ADD TO M ECH.
PLUMPING FEE
in nsequnme of the granting of this permit,
APPLICANWDRSTAN�DS AND WILL COMPLYWITH ALI.NON�POINT AIR HANDLING UNIT(TO IQOIXI CFM)SOURCE RMECHANICAL FEE
AIR HANDLING UNIT(OVER IQWOCFM) CONSTRUCTION TAX
Signature Of Ap tmaor Dam EXHAUST HAD) W/DUCT) HOUSING MITIGATION FEE
ALARDOUS MATERIALS DISCLOSURE
Will he applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,0001 BTU)
as delincd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Curie,Section 255321a):' HEATING UNI'('(OVER 100,00()B'TU)
Yet n
VENTILATION FAN(SINGLE RESID) PAID Dae Rttcipt p
'01Will the applicant or future building occupant use equipment or devices which BOILER f3HP ON IIX1,0Mp BTU)
ail hauvdous air contaminants as defned by the Bay Area Air Quality Management TOTAL: S.5'
`Incl' Yes NVNo BOILER-COMP(OVER[00,000 BTU)
I have read he Factitious readmiRrcymm� Ix under Chapter 6,95 of he Cali- AIR CONDITIONER ISSUANCE DATE
forma Hcallh S=J"
ey Cafe,Sections 255U5,25In,end25534.I understand that if he NEW RFSIDfNTIAL MECH. SQ.FT. /Q�
.1thengdne tt trrattlyuodrou nbnatn,inset itixmyreslamaibilitymnotify the«eapam I`6`l9
ofhc rty ice must is ma prinrm ixsunncx tufts Cutifcum of Oc- cy. SP-
OFFICE
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Owner or am : I Da``te ' TOTAL: ISSUEDBY ,P-
OFFICE