S 1013APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO [%Oil DIN(: - ELECTRICAL
BUILDING DIVISION APPIACATION/PERMIT PLtIntB1NC.. MECHANICAL
BUILDING 1'ROJECg IDENTIFICATION
IT RM IT NO.
S 1013
RUILDINGADDRESS.
0 400
SANITARY NO.
APPLICATION SUBMITTAL DAT Ti
OWNER'S NAME: n� V ����_�U�I
CQ�(T,A . }„ J NAME: LIC �.•�z C�V�
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\RCI 111'ECUFNIGINEER: N LIC NO:
APDRRS. (j �t �
9(,c) VY,
CONTACT; PHONE -
NU ILDING PERMIT INFO
BLDG HLEC1' PLUMB MECII
Er � � ❑
MAA �tv`6 94a-Zzz(
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
I hereby aB'mn that I am licensed under provisions of Chapter 9 (commencing
with Satinn]fIf10)o(Division3af the llusinnsxnd Professions Code, enJ mylacenxe is
in Poll RC, and cRat. 53 s3 U�
L¢ensc Class Lic.p 7
Uale Cmnra
QTY ELECTRIC PERMIT I� FEE
JOB DESCRIPTIOI`l�
RE I� DFNTIAL,
Q, K//
❑ SFDWL ITCHEN REMODE11
❑ADDITION C1 PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCfURAI.
MODIFICATION
[_1 INTERIOR El CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POLLS
'AIR [_1 DEMOLITION
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PERMIT ISSUANCIi O
APPLIANCES — RUSH ENT1AIL C�
ARCHITECI'S DECLARATION
I understand my plans shall he used as public records
PANELS
-
UP T021NIAMI'S
Licensed Professional
OWNER -BUILDER DECLARATION
I heathy nffian that 1 am exempt loom the Contractor's License Law far the
fo]Isnving mason. (Section 7031.5, Business and Profusions Cade: Any city or county
which requires a permit to construct. aline impactor, demolish, or repair any 'mature
poor its issuance, atm requires the applicant for such permit m file a signed statement
that he is licensed pursuant the provisions of the Contmcmrs License Low (Chapter ')
201-INMAMPS
OVER EWAMPS
SIGNS ELECTRICAI.
SPECIAL CIRCUITYMISC.
C) n loop
�e5
L y e f�
X m LL
y
C
L Ee
(commencing with Section 7000) of Division 3 of the Business and Professions Colt or
thud he is exempt therefrom and the basis for the alleged exemption. Any viol.] or of
Seetinn ]03 L5 by any applicant for a permit suhjats the applicant m a civil penally of
nm unnro than foe hmdred dollars (E$(m),
y crop Y' g Pens°
❑I, un nwnendthe prnpeny, or Imes with waesas lheirsolc sono lion,
wu 11 do the wink, and Neat 2Imv k nal imendcJ nrnlfered fo... le Sec. 7044, 11milm"
and Pndessions Cade: The Contractor's License Law dcee not apply m un wner of
property who builds or improves thereon, and who docs such work himull or othrough
his own employees. Provided that such improvements are not intended or offered far
sale.1f,howuer. the building or improvement is sold withinone year of completion,the
TEMP. METER OR POLE INS'1'.
❑ NEW BLDGIADDIT'I N D DEMOLITION
[I TENANT El FOOD SERVICE
OTHER
POWER DGVICIiS
SWIMMING PCOL EI FC' I' RIC
OUTLETS— WIT LEs— FIXTURES
NEW RFSIDEN'I' illi SQ FT,
EISQ.I'f.
ter -build" will have the battle. of pmving Nal he did not Wild., improve for par-
qua of sale.z 1, as owner of the progeny ten exclusively contracting with licensd contractors io
construct the project (Sec. ]W4. Business and Professions Corea The Comrac aura I.,-
cen« law docs net apply to on owner of property who builds or lmprovicelhe.m..,,it
K
QTY. PLUMBING PERMIT F .
who eommrm for such projects with o conduct (a) licensed pursuant to the Contractor'N
License Low,
El con esempl under Sec. . B & P C for this pe:.son
PERMIT ISSUANCE T
VALUA'I']ON
�% �7 �/ / /; &V
v
Ml
Owner Uma
WORKER'S COMPENSATION DECLARATION
T hereby aBiaan under penalty of perjury one of the following drelaamiom:
Iban and will maintain aCendicamofComemtoself-insure for Worker's Compete
cation, m provided for by Section 37M of the Labor Code, for the performance of the
w ak for which this permit is issued.
ALTER—DRAIN & VENT'— WATER (EAG
BACKFLOW PROTECT'. DEVICE
DRAINS—FLOOR. ROOF AREA,COND.
STOOLS
T'YPECONSTRUMION
FIXTURES — PER I RAI'
GAS— F.A. SYSI'EM.I INC. 4 OUTLL PS
have and will maintain Workers Compensation Insurance, as required by Section
3900 of the Labor Code. for the performance of the workfoprlw�fh'ic�h thisLp�e`yr�.mit is issued.
My CarierrrkergCggppxcmipTV F1'^ePnh.Y No.Y�l euO""3—��
]I['1CUR�TIFICiA'1'H
OCC, GROUT'
MIN
GAS—pA SYSTIiM-(1VUN4(P.A)
GREA51/INDIISTkL WASTE INTERCEPTOR
01`: EX EM PTION FROM WORKERS
COMPENSATION INSURANCE
BUILDING DIVISION FEES
OZ
Z O
(—' L,)
Wforthwith
a
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d
CA
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(Thissadne need non M completed if the permit is fortune hand.,]Jollars(SI INE
or laara
I certify that in the Performance Ortho work forwhich this permit is issued, l shall
er � us m become subject to the Workers Coulter.
not employ any person n any mainn
action Laws of California. Date
Applicant
NOTICE TO APPLICANT, If, oft, making this Certificate of Exemption, you should
became mbject to the Werkera Compensation provisions of the Lehr Cale, you mon
comply withsuch pmvisinns or this perntilkill M deemed revoked,
CONSTRUCTION LENDING AGENCY
Iherehyaffirm that them iso comtruction undingugency for the peribrnuaccof
the work for which this Permit is issued (Site 9119], Civ. C.)
Lmtder's Name
GREASETRAI'
PLANCHECK PIiG
SEWER—SANITARY— S'fORM EA. 200 FT.
ENERGY FEE
WATER HEATER WIVENTIELECfR
WATER SYS'ITMG7REATING
WATER SERVICE
GRADING FEE
SOILS PIE
PAID
Date Be ptM
NEW RESIDF.MOAI. PLMII. SQ. Ff.
'TOTAL [
t]l'AL:
Lender's Address
is
BUILDING FEE O
I certify, that 1 have «ad this application and state that the above information
conal l agree to comply withal] city and county ordinances and state laws miming m
building conswetion,ond hereby outhctrize representincesofthic city memeruptmthe
QTY. MECfIANICAI. PERMIT FIiE
SEISMIC ItiE 3
PERMIT ISSUANCE
ALTERORADDTOMECH.
ELECTRIC FE[
.Montnentirmed property for inspection purposes.
(We) agree to save. indemnify and keep Its the Cary of CuPenlnn ugaiut
liohilities,judgmenu. costs and cape .whic mayin nywaysecmc agnimt said City
in conscgcten fthe gran ting oft s
APPLICA U.'DER. ANDS A LI, CO 111LF 'ITH ALL NON -POINT
S IRC REG[ ATI S f1 �/ (�
l✓—Ij'7
PLUMBING FF.
AIR HANDLING UNIT LTO 10,IXp CFM)
MECHANICAL. FEE
AIR HANDLING UNH'(OVER l(L.CFM)
CONSTRIICTIONTAX
is
InmreofA marevCom a Tums
HAZ S MATERIALS DISCLOSURE.
Will the applicant t mac building occupant store or handle haeerdnus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Sudety
CWe, Section 25532(x)"
EXHAUST GOOD(WIDuc n
HOUSING MITIGATION FEE
HEATING TIN IT TO l IN1,(Ng) BTU)
HEATING UNIT (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RLSID)
[3 Y. No
.
PAID
Dam Receipt M
BOILER—COMP(JHP OR 110,000 BTU)
Will thendoms air licant or nt Bay A aAir ent or Quality
s building occupby nagees hint
it hazardous air contnminamx ax defined by the Bay Area Air Qmlily Management
contaminants
T TAL:
h.Jnct I
❑Yee ❑Nn
BOILER—COMP (OVER 100,001) BTU)
AIR CONDITIONER
I have mail the hazardous materials mluircments under Chapter 695'of the Cali-
Portia Health & Safety Code, Sociams 25505, ]5539 and 25534. 1 tmdenatin l but If the
huilJing does not currently have a tenant. that it is my responsibility to notify@c occupml
ISSUANCE DITE�/
NEW RESIDEN'UAL MT:CIL SQ. FT,
of the requirements which most be mel prior to iswuna of a Certilicam of Occupancy.
ISSUED BY:
TOTAL:
Owner or amounted agent Date
OFFICE