9910004 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFC PEKITNO BUILDING-r.LECTRICAL PERMI NO.
BUILDING{DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL
BuD.DING Pauu:cr ID"TjrlcxnnN
BUILDINGADDNESS', SANI'1'ARYNO, APPLICATION SUBMITTAL DAI
a,5-7C) awle, /,n -8_
OWNER NA �� `/,r�_ ,v ' Hc)Wk _ ONE C'IY)k:ti AMI:: m , LIC.NO' / NIC CONI ROLIMIL ;, A
RCHI'1'ECT/ENGINEIIR; Cy//Nv/`ILICC NO. ADDRESS: S ❑
'MPEONGAC'L PHONE: BUILDING PERMIT INFO
iU 'j,r.,��y / e•���/�,/7G3 ❑ Consultant Fats Paid by Applicant(initial) BLDG IiI.E❑CT PLUMB MECU i
LICENSED COM'RAC'lTyR'SS DECLARATION / QTY ELECTRIC PERMIT FEE LrL Imo/
I hereby idlink that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Oaz with Series. Sof the Bmarid,tad Profession,Cody.and my license I, RFSID!?NTI�z
1+100 wr i PERMIT ISSUANCE.
FUSF- in full fnrre end cffca � 3 ❑SFDWI. KITCHEN REMODIiI,
QZU Liccnx�lic.p C APPLIANCF'_S-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
Q,L Date O Camtacmr.
F,pr/s ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑S'rRUCTURAI.
z O m Z I undersand my plans shall he used.,public records MODIFICATION
Oz-q UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�.E'.WLicenced ProfeWorel 201-IWJAMI. IMPROVEMENT'
w pwy 6 1 herthy affirm OWNEthat I R-BDhAERpt om he Conlrnunh License Law loathe OVER 1 WO AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
U [.Ilowing macnn.(Seuio.7031S.Bi sines,mid Vhold,am,Coda:A,y ehy or curry SIGNS I?LHCTIIICAL C1 OTHER
1+1311 cA which rtquims.perm t to aeasvuO..],a,.improve,demolish.or rapab any.a em. �
F-uy'O5poor,,,its i....rc,ulso.,area,thcapplicant far such permit t.file.signedstamment SPECIAL CIRCUIT/MISC. f
!7!!Bj1y that he is licensed pursuant to the po,vi,iohohf1hr Cn hrccoh Licenx Less Whaparift 9
C.00 (commencing w'iN Sectinn]u1X11 kf Division Sof the Business and Profession.Cadet or TEMP.METER OR POLE INST. COMMERCIAL:
6 LL c¢ that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑ BLDG/ADDITION El DEMOLITION
X W Section 703 1 S by any applicant fire permit subjects the applicant ,,a civil pcmdty of POWIiR DEVICES
not mom Nen five hundred dollars(5500). ENANT C1 1700D SERVICE
1PROVEMPNT
KEG ❑L�s,,wncndlM propcny.mmyemployaswiN wages as theirmlc compcnwtiun, SWIMMING POOLELf:CTRIC 1 OTHER
X. will Jothw04
enrk,and thenruenne,,not intcnJeAnrnRcmdfr.ale(Sec.94.B.cree
W 3 end Pmfesions Code:The Cementite,License law does nal apply to an owner of OU9'LETS-SWITCHES-FIX]ORES
pmpety who builds or improve Iherean,and who does such work himself or through
his own employees,provided than such improvements are not emended or offered for NEW RESIDENTIAL ELEC1t SQ F1'.
sale If.however,the building(it improvemcnl issnld within one yemof temple,laa,the —
e $Ql1(. 1�RE $/SU.IrI'.
r-builder will have the burden of proving Nat he did not build or improve for put- (1/{ OSS a
p meol'cale]. if
E] h ro
as owner of the ppeey.ani exclusively contracting with licensed contractors to TOTAL D
emumn euhe project(See.704kL Business and Professions Code:)The Contractors Li- 1 r }-
c se Law does not apply to an owner(if pmpety who hands or improves thereon.and QTY. PLUMBING PERMIT FEE I�f ")�l D 7
who comidctsfnrmeh projects with a commcmgs)licensed punuanuo the Contractor's f O 9 9
License law. PERMIT ISSUANCE
I]I um csempt under Sce. .B&P C for thi,nervour I IX
ALTER-DRAIN&VENT-WATER(HA) LUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury(me of the following declaration
'Ih.ve.nd will mnimmn a Cenificemof Comenunxlf-Imam for Warkeev Co.,.. DRAINS-FLOOR.ROOF.AREA.COND.
STORIES TYPE CONSTRULTIOf
rink,as provided Ga by Section 3700 of rhe IaMrr Cade,fur the performancc of the
w rk lid which this permit is i.wted FIXTURES-1'ER TRAP
1 have and will maintain Worker's Comitenmtion Insurance,ac required by Section
of the Labor Code,forNe performance of the work for which Nis Fenn,,is'ssued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APNO
My W.rkeytlnsumncc currier and Polley—� 15
Carrie:// Polley No.:� GAS-EA.SYSTEM-OVER 4(13A)
CERTIFICATE OF EXEMPTION FROM WORKERS' 611
GRIiA$FJINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thisxmlonneadnmbccomplded ifthepemul isforovehundreddoll.rs(Snou GREASETRAP
or less.) PLANCHECK FEE
I certify tha in tiro performance of"the work fur which thislconit is issued,l shall SEWER-SAN["rARY-STORM EA.200 FT.
not employ any person in any mannerist as to Become subject to the WokenCempcn- ENERGY FEE
O Z ..tion Laws of California.Data WATER HEATER W/VENT/ELECfR GRADING FEE
Z Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTCMCREATING
I-' N become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such poeskions or this pcmut shall be Jcemcd revoked, WAT12R SERVICE
CONSTRUCTION LENDING LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FE PAID Dam Rcc ipt
L)Q Ihereby affirm that there is construction lending agency for performance of
L)2 the.,,,it far which this Families issued(See 3197,Civ.CJ
O U Lender's Name TOTAL:
fir Lender's Address TOTAL:
y 1 certify thm 1 have read this application and state that the above information rs BUILDING PEE
oF. N
connect.I agree to comply with all city and corny ordinance%and state,law.,mining to QTY. MECHANICAL PERMIT FEE
U z built ng cnnnwatinn,und much,mrhorim reprewhadvesaf miserly m enter upon the SEISMIC FEE
(We)agree to save,indemnify and keep hornless the City of Cupertino against
above-mentioned propeky for inspection purpexs. PERMIT ISSUANCE 1?LEC7fRIC PCB
Iiabil ties,judgments,cow.s and expenses which may in any way accrue against said City ALTER OR ADD TO MECP{,
PLUMBING FTE
in consequence of the granting of the.permit.
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON POINT qB HANDLING UNIT(TO IO.g10 CFM)
qqq MECHANICAL FEIi
SOUNCf:JtAA
/� 1 r _ AIR HANDLING UNIT(OVER 10.0u)CFM) CONSTRUCTION TAX
Sign;pure of Applrcanr Date' EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS b MA'I'ERIAI ti DISCLOSURE
Will the applicant futurebor fuuilding.ccupam wort or hamlle hazallouz mamriul HEA'T'ING UNIT(TO IULf)(MI FIT U)
as defined by the Cupenims Municipal Code.Chapter 9.12,and Ne Health and Safety
Code,Section 255321x)'1. HF.AI'INO UNIT(OVER Hlol%sl BTU)
❑Yes ° VENTILATION PAN(SINGLE RESID) PAID
Will thea Ikvm or future building t use equipment ar devices which Dam Receipt X
pp dby thea,, BOILER-COMP(3HP OR 11X1,000 BTU)
i t hazallous air nmaminvms as defined by the Bay Arta Air Quality Management l'OTAL: a
^rl,let? BOILER-COMP(OVER 100010 BTUI
❑Ye.s N`r
I have mad rhe ha,mexhi ,material,myuiremha
cros under Cpter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE.
famiv Health&Safety Cade,Seaions:5505,25533 and 25534.1 order I t t ii me NEW RESIDENTIAL MECIL SQ.FT.
building I annually have.tenant'hal it,,my res,anobility to no fyth .pant D /
ofmet anaissuooccaf.Cc fi m f
� ar r, 7� 9 11I Ism
o,co6riatalumnizedaigent Dan TOTAL: ISSUED BY:
OFFICE