S 1896 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.EI,E,CTRICAI, Pli IT NO. 1896
BUILDING DIVISION APPLICATION/IaERMI•T PLUMBING-MECHANICAL
INILBING PRO JECi'!DF\TIF'ICATION
IIf1ILDING ADDIiGSg: SANITARY NO, APPLICATION SUBMITI'ALDATF
as os-I&wa&
(IWNITI'S AMIE: PII Nli: CIIN RAC(DR'S AMIi: LIC NO'.
9 NIC CONTROL#
AR III'T?CI'/ENGINEER: LIC NO: A F.SS: ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) Pl4r. ELECT PLUMB MECH
AI]ON
LICENSED ofce Busing and ndcs_,'IRens Cale,at QTY IiLECTRIC PERMIT. IeGE
nmrebr wfrm Inas am ueml,aa ander provLdm„of elallaer v leollnncndmg .10B DPSCRIP'fION
O d'Z turn station 1(001 Dr it rylicenac is RESIDENTIAL:
W00 in PERMIT'ISSUANCE
Fw. foil liuce an 1 ❑SFDWL ❑KITCHEN REMODEL
Fan Dale se s, Com APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS O ❑MULTI-UNIT ❑STRUCTURAL.
Fpm �yJ���� PANEtS M 114CATI(IN
Z O H Z unde,ra J my plan,shall be used ns public records ,.1��
O O
UP I( 2IX1AMI'S ❑IN'I'IikIORLHI,MNEY kI?I'Alk
1-.,F.W Licensed Professional 201-10WAMPS IMPkOVEMENT C], MMING POOLS
OWNER-BUILDER DECLARATION FAIR IOW AMPS ❑BATA REMODEIJRT:I'AIR [:1 DEMOLITION
m w l I hereby affirm that I am exempt Gum the Cotiomic,Lkintse Law far the
O L U fulloming reason.(Section 7031.5,Baines'and Professions Cole:Any oily m county SIGNS ELECTRICA[. []OTHER
W W C N which requires a permit m n
con, ucr,alter improve,deand,h,o,repair any,tmnme r
prims its i a smnagal,nruryd
ine mnppan
licaul 'such lapadd In file a"Eland'untrn...u SPFCI AL CI RCUITIM ISC.
r�}� m a
that he is licensed porsuam t.the povi,mmof the Cnmracmr's license Law(Chapter Y
1i1�p0 (commencing with Section 70110)of Division 3 of the Business and Professions Cole)or TEAIR METER OR POLE INST. COMMERCIAL:
d y m C that he is exempt mcnifrnla and Thu basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a amerit subjects the applicant m a civil penalty of POWER OFVICFS El TENANT CD FOODSERVICE
� } not more than five hundred dollars(SSW), - IMPROVEMENT
sZsd ❑ I,m owner of the property,or my nnpl.yees with wages as their sole nnnpensmion, SWIMMING POOL ELECTRIC
'SFO
"IlJnihe work,and the structure isime mtenJcdmotimed forxalebas.11X4,Business ❑DTIII?R
a 3 and Penh lion,Cut The Companies License Law does noI apply man owner.f
OUTLETS-SWITCIIIES-PIX'1'l1RES
property who badd,or improves Ihcr.on.Ind wan dors such work himself or dme,fa
his own nnplryccs,pnrvidul Ilett web ingnuvemcntx am nal intended ur otten"l for NEW RESIDFNTIAI.EI,FGTk SQ FT.
sale.IL hrnWist.the building.,i........mi,wlJwithinaneyear of completion,the or SQ.FI'.I'hGOk AREA $ISQ.Irl'.
owner-builder will have the burden of proving that he did not builder improve for pur-
pose
1,owner of me property,am cxcleliaedy contracting with Incensed rnntre'l no TOTAL;
consumer the project(Sec.11W4.Business and Professions Cola)The Connect,,Ia-
w ,a Law does, I appdymanownerofpmperly who haddsor improves thereon,and QTY, PLUMBING PERMIT FEE
ho contmtIs finsuclt projects with a mntrun ab,)liean,d punnanu.the Cammao's
License Law, PERMIT ISSUANCE
1 am exempt under Sec .B&P C for this reason
Owner Mute ALI'HIR-DRAIN&VENT-WATI3R(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEJ (�
I[,,,any ultirn,under penally of perjury one oldie following de'l aatiom' /J
L3 I have and ill mainwina Ceniliculeof Corson,In selftiaurafnr Warke,Compcn- DRAINS-FLOOR.ROOF,AREA.GOND.
sada,as provided for by Section 3]00 of the Iabof Cock,farina ped on merec of 0c STORIES 'I'YI'i?C HIICfLO.
kfIrl'is Ith permit lx issued FIX TURES-PERT'RAI'
I hnv and will maintain Wnrkcr's Compcnxatiun Insurance,as reyulmJ by$ttllun v
rhe Labor Cade.foyrdhho perhrtmanceol the work(a,,hich)/'t,`his(/�Jpryissued. GAS-17A.SYSTFM-I INC.4 DUE LETS (K GROUT' APN
r WnIpi p�•y�ytlir//J�JImeP�id cyN rw-1—� CnS-EA.SYSTEM OVER Gmrie 3 3S7o/oy
CERTIFICATE OF IiXEMFI'ION FROM WORKERS'
COMPIENSNHON INSURANCE GRP.ASFANDUSTRL WASTE INTERCEI'I'Ok
BUILDING DIVISION FEES
(I h1,_,.etian nro-1 itaI s,'canpdeled if the nem it j,fon in hmaloal dolor,($100)
.r less) GNIiASE T'ItA1' PLANCHECK FEE
Icenifytenhima NdfoemaneanOhe xmkon,which,hi.,..moil is issued,[,fall SEWER-SANITARY-STORM ITA.200 P1'.
a.I employ any ninon in any murmur so as to become subject.r the Workers'Compcn- ENERGY FEIi
Zz 'inion Laws of California.Data WATIIR HEATITIf W/VIENT/0-ECTN
Q Applicant GRADING Fill.;
ti NOTICE TO APPLICANT':IF,after making this Certificate of Exemption.You should WNI ER SYSTENUTREATLNO
a , bmmne subject In the Warta-Cnmpematmn".'Win"id Ihu Labor Cn le,you nnroi SOILS FEE
R7 forthwith comply with such provisions mfld.,pectin shall he deemed rooked. WATER SERVICE
a �
UO CfINSTRUCTiON I,IiNDINOnGENCV NEW RESIDENTIAL I'I,MU SQ.FI'. PAID Dam RecciplN
1 hereby afford that i,a conshunion lending agency for the perfnnnanee of
the work for which this permit is issued(Sec.3091.Civ,C.)
u" U Lcndem,Name TOTAL:
I<ndcrs AJdre,s TOTAL:
1 certify that I have read this application and state that the above information is BUILDING 141
IF-t ( cones J."'a h.emird withallciD.ndcotuvy oNinances and seta lows relmingm Q'I'Y. MECHANICAL PERMIT PEE
L) Z building coratmatinn,aal hcrehy uuthonze reposentatlyesofthns city m nt
ccrnpm the I SEISMIC REE
.Nocon atinn ti propc,ty forimpactionpu,pa,es. PERMIT'ISSUANCE
(We)agree to save,indemnity and keep hannic.ss the City of Cupertino against ELECTRIC ITH
in Ilahiline,judgment,co,1,and......ties whichnmy n any way arnmcaguin.a said City ACI'FRORA,,TOME H.
consequence of the granting of this permit. PLUMBING Plili
APPLI UNDERSTAND'AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT'(TO 10.100 CFM)
sou ;�Oley, RION.' MecunNlcnL.FEE
G�4 A11211ANIlLING UNIT(OVER IB.IMO GYM) CONST RUCTION TAX
SIIIigbatnre ofA mantrC •••a//av/��/CCC...e�_� r Date`rL EXHAUSTHOOD(W/DUCT)
HA. RDOUS MATERIALS DISCLOSURE HOUSING MITIGATION PF.F.
Will the applicant or future building usimpamnnre or handle hvardowc malarial HHA'1'INGUNI'I'OD100,IN0BT11)
as defired by the Catarina Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Section 25532(a)t HEATING UNIT(OVER 1110,1X111 BTU)
❑Yes PAID
n
VIiN'1'ILATI(IN FAN(SINGLG R&SID) Date Receipt tr
Will the upplica r fu..re hit Iddng mmnpam use eguipmcm nr deviaes which
card hw.adoa,olr comominunt as defined by the Bay Area Air Quality Management BOILER-COMP(311P OR 100,00[HU)
District? oT .
❑Yes /�y�r✓/sp/ BOILER-COMP(OVER 100j)(0I BTU)
I have read the h.,.I Ionalf,"mmmems under Chapter 6.95 of the Cali- AIR CONDI'1'IONFIt ,f ISSUANC17 DKFE
fomiu &Safety Cale,Section,255115,25533 and'3534,I understand thin if the NEW RESIDENTIAL MECH. SQ.FT.
bd agd. not eu •nllyhav lenanl.Ihatilistnyrespnm nsinihlyodly are evpmn
ne
int ,et pct door ars er 'f nor
ante ed agerI f5mr, TOTAL: ISSUI?U BY:
OFFICE