30475 APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELRCYRICAI. RMIT NO. 3� ,r4 `5�
BUILDING DIVISION APPLICATIONMERMIT PLUh1BING-MECHANICAL
BUILDING PROJRCI'IDENTIFICATION
BUILDING ADDRHS: O/Ef" O ^O�DO Vl. � �I� �� ��0 SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAMIIZ Y PHONE: CO?/z
NAME: el� / LIFO
_oAreEw SNv d 2u- �/ LIEF IIS OY I�+'g (aaV C,III b� NIC CONTROI.p
RCHITECUENGINEER: LIC NO: ADDRESS: ❑
3E04% II-AY
ONTACr: I', I 1( .-E PHONE: i BUILDING PERMIT INFO
D�-VI O Hu� Af'1 �w/ ❑ ConsuHanl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DfCI,ARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 vat licensed under prnvisinns of Chapter 9 Icammencing JOB DESCRIPTION
aZ with Becfmn 7101pnf Uivisinn3ul the BusinessonJ PrnleadmosCde vndmylibenseia RESIDENTIAL:
O Oall PERMIT ISSUANCI3
��. L ease Lss effect 6 O p `� []SFDWL D KITCHEN REMODEL
U11gk-il Date Class and
u APPLIANCES-RPSIDFMIAL ❑ADDITION C3 PLUMBING RE-PNE
a Dvte Con FDELL ly AR CHIT EC TS DECLARATION ❑MULTI-UNR N
❑STRUCRAL
6PANELS
O 7a I derstand my plans shall be used as public recalls MODIFICATION
un
�
ZUPT02WAMPS ❑INTERIOR []CHIMNEY REPAIR
F Licensed Professional 201-INXIAMPS IMPROVEMENT
�kd OWNER-BUILDER DECLARATION OVER 1000AMPS C BATH REMODEURBPA
IR R []DEMOLITION
66'' I hereby vf(rtn that 1 vat exempt from the Comnselm's License Law for the
U fallowing reactor.(Section 7031.5.Business and Proficksmns Code:Any city or county SIGNS ELECTRICAL ❑OTHIiR
^O I�' which requires a permit to conmuct,alter,improve,demolish,or repair any structure
.a7f prior no its issuance,also requires he applicant for such permit to file asignednmement SPECIAL CIRCUPDMISC.
d� that he is licensed momant to the provisions of the Contmeaar's License Law(Chapter 9
00 (commencing with Sectinn]fMN17nl'Divisinn 3oftbe Business and Pmfessions Code)or qP.'IiMMETER OR POLE INST. COMMERCIAL:
S c a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION D DEMOLITION
,^may Section]031.5 by any appliWam far o permit subjatsthe appliero m civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not more Nan five hundred dollars($500).FIMPROVEMENT Z6 []1,as owner of the property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
SFO will do the work,and the structure is not intendedrnoffeml fmsale(Sce.]I)44,Business []OTHER
dand Profesxinns Coale:The Cmducioo's License Law dues not apply oto an owner of OUTLETS-SWITCHES-FIXTUR&S
property who dui Ws or improves domain,and who does such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RCSIDEN MAL MECfR SQ Fr.
sale.If.however.the building or improvement is sold within one year ofcompletion,the SQ.Pr.FLOOR AREA 9 Q.FT.
owner-builder will have Ne burden of Forcing that he did not build or improve for put-
pose of sale.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:lik
consumer he project(Sro.70 ,Business and Pmfessions Cale:)The Content.,a Li- (�rpp�� n 1996
cense Law des not apply m anowne,of pro,ody who builds or impmves neuron,and QTY, PLUMBING PERMIT FEE SEI' 37 x996
who cantracis lin sued projects with u contmcmr(s)licensed pursuant to the Contractor's
License law. � 1
C] I am exempt under Sec. ,B&P C fundis reason PERMIT ISSUANCE, � II I V t-V' 1-1111
Owner
ALTER-DRAIN&VENT-WATER(HA) VALUATION
Date
WORKER'S COMPHNSATION D17CLARATION BACK FLOW PROTIiC..DEVICE
E hereby,fWr m under penalty ,I pe jury moor the following declarations:
I havem will mainwinaCenilieatcof Consemwself.insurefor Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
moon,as provided for by Notion 391X1 of the Inbar Cede,for the performance of the -
work for which this permit n issued FIXTURES-PER TRAP
.p.3nJ I have and will maintain Worket's Compenkwon insurance,as required by Section
9]OF of the Labor Code,for the performance of the work for which this permit is issued. GAS-RA.SYSTEM-I INC.4 OUTLETS C.GROUP APN
M Worker n ti nsu now caro and Folic nuLryr)as�
Gemmae [.[�� /N)a
Policy No,Y 1�`(—(�7C GAS
-EA.SVSTEMOVRR4(EA)
CERTIFICATE P EXUMPfION FROM WORKERS'
COMPENSATION INSURANCE GR W SFJINDUSTRL WASTE INTERCEPTOR
Missectian Decd not be completed HBs,Kninut is fmonehundteddollars HIM) BUILDING DIVISION FEES
of IessJ GRFASE TRAP PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM W.200 FT.
not employ any person in any manner ao as to become subject to the Workers'Compen- ENERGY FEE
O z xmion Laws of California.Date WATER HEATER W/VENT/ELECTR
2Applicant - GRADING FEE
rNi NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
6'r , become subjeet to the Workers Compensation provisions of the Labor Code,you must - SOILS PEE
Gforl comply with such provisions or this Permit shut ha,attracted!invoked. WATER SERVICE
Q
CONSTRUCT ION LENDING AGENCY NEW RMIDIlIMAE,PLMB. SQ,FT. PAID
U O Iheruhy tdBrm that them isv ennswetion lending agency fonhv perlimnuneeaf m Date Receipt in
W E the work for which this permit is issued(Sec.3099,Civ.CJ '
O (~ Lenders Nome TOTAL:
U) Lenders Address TOTAL:
Hy 1 rem y that I have read this application and nate that Ne above infomwtioa is BUILDING FEE
EI correct.I agree to comply with all city and county ordinances and state laws miming to QTY. MECHANICAL PERMIT FEE
U 7- building construction.and hereby autharim representatives of this city to enter upon the SEES MIC FEE
above-mentioned property for impaction purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iivbilities,judgmcets,costsend expenses which may in any way accrue against said City ALTER ORADDTO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(HE 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCIONTAX
Signature of Applicant/Comracmr Date EXHAUST HOOD I W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haurdous material MATING UNIT GO 100,000 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health end Safety
Castle.Section 25532601 HEATING UNIT(OVER IM.000 BTU)
❑Yes [D No
VIiNT1LAT10N CAN(S[PULL RUSE D) PAID
Date Receiptof
Will the air ow a or futon building by the B y A equipment or Marta which BOILER-COMP(3HP OR 100,000 BTU)
:nit hezeNnus air contaminants as definad by the Bey Arca Air Quality Management TOTAL:
41istrin?
❑Yes ❑No BOILER-COMP(OVER 100,00)BTU)
I have read the hmmJousmmerims acculturated,under Chapter 6.95 of the Cut- AIR CONDITIONER ISSUANCE DATE,
forma Health&Safety Code,Sectlons 25505,25533 and 25534.1 understand that if the NEW RMIDENTIAL MUCH. SQ.FT.
building does not currently have a mnnm,that it is my responsibility to notify the occupant
of the requirements which must be met prior to issuance of it Ccrif am of Occupancy.
Owner or authorised agent Date TOTAL: ISSUED BY:
OFFICE