00010041 J APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINTDPEN
b-ONLYIGAI Q V I U U /
/ CITY OF CCPERTINO
BUILDING DIVISION APPLICATION/PERMIT 1'hUMBING-MFCIIAN]CAL
BUILDING PROJF,CT IDEWIFICATIOF
BUILDING ADDRESS: SANITARY NO. A/'LICAI'1 . 'ALDAII
L r r�� ZU 02�
0 ER:S NAIR. /^ a/ ,,pPHONEc CO RACI'O 'S NAME: LI N
Ver/ L•./ �j {Jp i,] �/ r NIC CONTROI.p
CHII'ECIII3NGIN 13R: LIC NO', G gDURESS: . ,a f0 ❑
CONTACT: PHONE: V/ ,,( V BUILDING PERMIT INFO
17 15� yv -3 7y 631/ ❑ Consultant Fe"Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑
LIn that I a CONT'RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEIS
(heresy )of mal1.n licensed under provhhmsof arChaplet9(mmmenseis JOB DESCRIPTION
1- 0 with Section 700fp of Division of the Business and itofnsiaos Code,and mylicemeis RESIDENTIAL
W O p In i' ( PERMITISSUANCE
F W. full force anJ df 7 ❑SPDWL El KITCHEN 0.1iMODR1,
�UF' Licrntt us hicX
Q U AYPLIANCFS-HFSIUENTIAL DDITION ❑PLUMBING RE PIPE
F Z W Uum Coo.....
v96a. 1 r,ULTI-UNIT ❑STRUCTURAL.
ARCHITCCTS DECLARATION
zgO,Z l understand my pia hall he used us pathp resflI1 PANELS MODIFICATION
C)Z—n ` � Up I'D PNInMI'S L1 INTERIOR ❑SWCHIMNEY
MINGP OL
¢m F'W Licensed Profesemtml d4 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
YY ;
OWNER-BUILDER DECLARATION OVI3E 1000AMPS ❑BATH REMODEIJRF.PAIR L3 DENVILITTON
C Q 1 hereby affirm that I em exempt from the Crmmnor's License Law for the
as L U following reason.(Section 7031.5,BusinessandProfessions Core:Any city or county SIGNS ELECTRICAL OTHE
y LL O N whish ittlnbez a pemso requires
e sires the
alter.improve,demolish,lir repair any statement
OU�G q dQL�
that he in cerovdgalournto testhoskplica I .such Permit m TileasLine(Cha mrnl SPECIAL CIRCUIT/MISC.
S�y'� mut he In license)pununnuuthepmvisions til Phu CunvucmQ Liccnsc how lChofo
ysCO (cammcosing with Section7")of Division 3 ofthe Business and ProessionsCore)u- TEMP.METER OR POLE INST. COMMERCIAL'
a.c.e C that he is cxcm,sl therefrom and the until for the alleged csemption.Any violioi s.of ❑NEW BLDG/ADDITION ❑DEMOLITION
x�m Section L5 by any applicant apermitsubjece,he applicant to a civil Penalty of LOWER DEVICES ❑TENANT LOGO SERVICE
not moa than five bunJrcd dollar,($SW), IMPROVEMENT
�0
ED 1.as owner al the property,or my employees with wages as mcirsole compensa0on, SWIMMING PHIL ELECfRIC
g.. will do he lamk.and thesmmr
uce is not iarandWm--term for aale(See 70W,Business El OTHER
,afm slid Prafossions Code:The Cmnmmor,License Law does net apply ,,un senor of OUTLETS-SWITCHES-FI%TURES
peolrerty who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL CL[CTR S ler
sale.11,hnxxvep the huilding lir int,snwemcnl is sol)within one ycand atmplmion,the SO.FT.FLOOR AREA ESQ.FT.
caner-builder will have he burden of,serving that he did not build or improve for pur-
pose of sale.).
1,as owner of the property,am exclusively contracting with licensed contractors et TOTAL'
instruct the ptnjecl(Sec.7044,Restless and Professions Cola)The Commctor's I.i-
scope Law does not apply to an owner of property who builds or improves thereon.and QTY PLUMBING PERMIT FEE
who contracts hn such projects with a contmemr(s)licensed pursuant to the Contractors
Liecnse Law. PERMIT ISSUANCE
❑1 am exempt under Sec. .H k P C for this room
ALI Ell-DRAIN&VENT-WATER(EA) VALUATION
Dam
WORKER'S COMPENSATION DECLARATION BACK PEON'PHOTIiCf.DEVICE 30"7g
ve and will
mai under penaltylorjuryo:mal to oselfrelWwingttarkers Co
;-3"llool
Iheve anddwie maintain eioCertificate7of ComeborCod.forthe Worker'sce of the
DRAINS-FLOOR.ROOF.AREA,CON[). STORIES 'TYPE CON$'1'RUC'1'ION
,m provided for by Section 77110 of the Lubar Cade,for ma performance o[mefor which Ihis,sermil iv issue). I9STUHCS-I'fiR'TRAP
have and will mi imal,Worker's Compensation Insurance,as recurred by Section the Labor Coe.for the performance of the work for which his permit isosucd, GAS-EA.SYSTF,M-I INC.40UTLETS OCC.GROUP f APN5,,r
My
Carrier:
")�C pe foothill.free cartiermd Policy nu ✓! GAS-EA.SYSTEFOVER4EA) L-. J
LiLII P Ilcy N¢: Y 9
CERTII'IC OMPEN AI ION( N(ROM WORKERS' G0.FASFlIND1/STHL WASTE INrCRCEI'fOft C-•-.
COMPI3NSATION INSURANCE BUILDING DIVISION FEES
issedie.never.he completed if the permit is count,brindled dollars l$11X) GREASETRAP
lir tette(ThPIANCHECK PLC
I cenifylhal in the perfnnreliever the-akfor which this permit is issued,[,hall 513WEk-SANITARY-STORM hA.2fN1 FT.
not employ,any person in any manner sr as be-nmcsubject to the Workers'Counter- ENERGY PELT
Z ,ation law.til tnrnia. , �'�d-Co WATER HEATER WNEN1'IELECTR
Z O Applicant ^+� GRADING FEE
IZ r_Ni NOTICE TO APPLICANT.IL after making this Cenifcam of Exemption,you should WATER SYSTEMI TREATING SOILS FEE
P' become cubjeal m the Worker's Cmu'recal a prorvisons of the IaMr Code,you now
forthwith comply with such provisions lir this permit shall me deemed revoked. WATER SERVICE
Q
4' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI-MB. SQ.Irl'. PAID ^I1atc Rcccipla
U O I hereby affrnnhat there is a construction lending agency for the performance of --• —i—�—• —
E•' he woe for which loris Permit is issued(St 3097.Civ.C.) m _
C) U Linder',Name 1 �•� \ I '1'U'TA :
r Lenders Adilmo, TOTAL: I �IIr
4 I certify the 1 have read this application and x,am mot the alxwc information is I L BUILDING F<li
N aarel,I agree...molly with all city and county ordinances and state laws relining to QTY, MECHANICAL PERMIT FEE i
U Z building construction,and herehyuuthor..em resenwtivesol 1111,city m enter plan the SE.1 1 zuuu 1111
above.mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ugive to rave,iodovmify and keep Inanities,the City of Cnpurtinn against ELECTRIC FF.E
Iiabilines.judgmenls.costs and expenses which truly in anywayraeme against mid City ALTI3N OR ADD TO MEC4L . PLUMBING FIiIi
In ,of mve gra n,of this per nit
APPLICANT . _
UNDERSTANDS AND WILL.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,001 CPM) L"- MlECHANICAL-FEE
S(1l E REGULATIONS.4�
• r AIR HANDLING UNIT(OVL'R 110.00ICPM) CONSTRUCTION TAX
OfAniti
Slum of Applifam
raor Ilalc EXHAUST 41000(W/DUCT) HOUSING MITIGATION FCB
HA7A
HAYAH WUS MAI pa DISCLOSURE
Will the applirmurfmuru building
acceoccu,sam nom or handle hazardous material HEATING UNIT(TU IW.(I(p BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12 and the Health and Safety
Gee,Section 25532(n)P HEATING UNIT(OVER HX).0W BTU)
El Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Dole Eeccipt a
Will tire applicant or hours huilding b do,Bay A e.Ail est at devicegement BOILER-COMP(JHP OR 100,000 BTU)
.ail hvaMous air umtarninants as define)by the Huy Arca Air Duality Management '1'OTA.. �
r District' Yes No BOILER-COMP(OVER UKTTKM BTU)
I haecmodmha,
col hanlnus;naleri;J.t m ircmu enunder Chapter 6.95of the Cali- AIRCONDITIONI3k // / ISSSUTANCE DATE
forma Health A Safely Core.Sections 25505.25533 and 25534.1 understand that tribe NEW RESIDItIAL MECH. SQ.FT.
building does not currently have a tenant,that it i,my renpmsiladity to nearly the ocmpmn ///
,,title reg lis wh¢h mud former priono i"unces of a Cenificam til Occupmmy.
Owner v.h mill agoal Dam TOTAL: ISSUE[)BY.
OFFICE