30746 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY,
CITY OF CUPERTINO ' - BUILDING-ELECTRICAL PERM]p NO. 3 0 7 4 6
BUILDING DIVISION APPLICA'11ONIPERMIT PLUMmNG-MECHANICAL
BUILDING PROJECT IDENTIFICATION
B U�INGADDRESS: �� � / • ,. rSANITARYIN APPLICATIONSSUUBMITTAL DATE.
OW /S�NAM'� PHONE: �/ COM ACTOR'S NA III d' �p N : - `" •�
/ 'U S J('�YSZ //R/(g/'7)� (��/�J C" /yfkr/i.y,��fi- RIC COM'ROLat .
��4RCHII HC'PUNGINh:R: .. LIC NO', a AID/D l S //e�/Ar B 6�!//"'i_" ❑.:. . . '
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CONTACT: ,.PHONE. - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLLLxxxDDDG ELECT , PLUMB MECH
ED ZI
p LICENSED CON'1'RAC E)R:N DECLARATION QTY. ELECTRIC PERMIT FEE
I heeby affimt that I atm licensed under provisions of chapter 9(commencing QTY
DESCRIPTION
,Q„=Z wim Section7(Xk)of Division3aflhe Businessandl'mfessinns Ctdaandmyl
Ficenu is RESIDENTIAL:
,
OO P MIT ISSUANCE
q' full force and effec
6VfF-I-I License a. Lic. ❑SPDWL CKITCHENRF,MODEL
r_ r� p,q�S APPLE ES-RESIDENTIAL ., ❑ADDITION C)PLUMBING RF F'IPE
+ Ill Date Gmtruv _.
(.Lard ' AIiCHIFGC'FS I]ECLAI1AF10� PANEIS ❑MULTI-UNIT n ❑S'I RUCTURAI, x
ZO'n,VFj lundersw yplmu allR��yygll be usetl es public records • MODIFICATION
OZ- •/a UPTD200AM '
F 4 t W Licensed 1� ❑INTERIOR �CHLMNEY REPAIR
201-IfXg1AMP5 IMPROVF.MINT
OWNER-BUILDER DECLARATION .
��Q 1 hereby affirm that 1 turn xem
exempt from the Contractors IM)AMPS'v Licence haw for the _ ❑BATH REMOIl1iIlRCPAIR 0 DEMOLITION
O0.U following swan.(Suctimi.911.31.5.Businc,,unit 11...maskers Cherie:Any city err con vy SIGNS ELECTRICAL. ❑OTHER
F' which requires aperrou to construct.alter,impnwe,demolish,or repmr any strunure
prior to its issuance.also requires the applicant for such pnmii to file v signed saran'oni SPECIAL CIRCUIT IMISC.
P�} that he is licensed' n matito the provisions of Ibe Cmduse ere.License Law(Chapter9 '
CIII.CC (commencing with Section 7000)of Division 34 he Business and Professions Ceded or TEMP.METER OR POI ,1NST. COMMERCIAL-
0.q C a mat he is exempt therefrom and the buffs for the alleged exemption.Any violation of [I NEW BLDG/AUDITION El DEMOLITION
^m Section]031.S by any hDakam far a Permit suh]tax iheapplicwv m a civil penalty of POW17R DEVICES „
F, omi
f mom thfive hundred dollnru(5500). - ❑TENANT FOOD SERVICE, ..
Q ❑1.as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING PD ,I?LECTRIC' ` ROVEMENT
will Jn the work,and the xWclure is not intended oroffered for eale(Sea]044,Llasinees 1ER
3 and Professions CWC:The Commcmr's License Low does not apply m an owner of OITILE- s ITCHES-FIXTURES
Property who builds or improves thereon,and who does such work himself or Ihnmgh
his own employees,provided that such Improvements are not intended or offered Por'• NEW RE. ENTIAL ELECT R SQ Ip.
sale.IT,however the building to improvement issold wlthlnonc yav m emole.lon,Tho - _ �Q�FT FLOOR AREA , °S/SQ.PP.
er-builder will have the burden of proving Thal he did not build or improve I'nr pur. -
pose of solcJ.
❑1,hs owner of the Property,am exclusively contraming with licensed ci ntrannes m TOTAL: -
construct the project(Sec.7044,Business and Professions Casky The Contractors Li. '
Ise Law does not apply to an owner of property who builds or raptures thereon.and QTY. PLUMBING PERMIT FEE
who concepts for such ph)[ems wim a comrahu(,)licensed pumuant io the Cmdua Tar's °•
License Law. I'EItMIJ'ISSUANCIi
❑I am exempt under Sec. ,B&P C for this reuan w
ALTER-DRAIN&VENT-WATER(EA)Owner Dae VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
• Iherehy nffiimunderpenallyofpenuryonenl'the fnllnwi ngdechm,tioiis ,�/�C YI, O�
❑IhavcunJ willrainminaCcrificete of Cnn.+Conn,mlf-insumfor Worker's Cnmpery DRAT FLOOR,ROOP,AREA,COND. l"✓'' 6��P �V(I/
Ration,as provided for by Section 39W of the LUMn Code,for the perfomtance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FTVI LIU'SRPER TRAP -
D I have and will maintain Workers Compensating Insurance,as required by Section
3700 of the[..bar Code,far the performance fthe work far ammitnis pentdt is issued GAS-EA.SYS NM_ INCA DO :TS
MyWa , Cayce pgmrmn)ign c���'vnd Policynumb r OCC.GROUP APN
Cartier if G A/Q / Iicy No. ��� GAS-EA.SYS'I'1iM VI.1 ) ° '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPJINDUSTRL WA. INTF.RCH17OR
(This section need not IN,completed if the Permit is far tine hundred dollars(SINB _ RUILDIED DIVISION pfyl
or less.) GRPASf?TRAP I'LANCHECK FEFI 124
certify that in the perrournmen of the work far which this permi t is issued,l Shall SEW lila-SAN ITA It Y STORM .211111W..
not ampiny nny'crsoa'.any mm�ner xti ax pyfyt•. In mw'm e Workers'CmnlENEIit3Y FEE
Z sabot Lawn of Cah(arry/Data 5�/ ix
.Z O
Applicant .lL,/A.• WAHEATER /VIiNT/ELELTN
PP GRADING FEE
N NOTICE.TO APP CA far making IM1is Cmificate of lixemption,you should WATER SYST MHATING
a7 become subject to the Workc,'s Compensating pmvtsions of the Lunn Code,you must SOILS FI?E
forawth comply with such provisions or perinit shall bedeemed mankatWATHk Sr.R ICF.
aQ
CONSTRUCTION LENDING AGENCY - NEWHEM CNUAI.1'Lh1B. SQ.Ff. I'NO
U O Ihcreby affirm that there is aconswcuon lending agency for the performance of a Receipt#
F' the walk for which this permit is issued(Sec.3097,Civ.C.)
O Lenders Name TOTAL:
WLender's Address - q'OTAL:
y , ' 1 cartily mal I have rend this aDdicalimt unit same mat the above information isPllll.11 G FEE
VI correct.)ogrcc to comply wim all chy and ammy ordinances snit smm laws relating io QTY. MECHANICALPERMIT PE8
U Z buddingcon.stmaion.and hereby authorize representatives of this city to enter unshoom SBISMICF -
above-meniional progeny far ins'ection purposes. PERMIT ISSUANCE
(We)agree to sore,indemnify and keep harmless the City of Cuperinn against ELF.CIRIC
liabilities,judgments,costs and expenses which may at any way accrue against said City
ysIJfdRORADDTOMECU.- PLUMBING FE
in asimpine a of the gramingaf this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR TILING 61,411(10 Igooso
SOURCE RED LATIONS. ^ MECHANICAL.hRI?
.�. (�S//J� AIR I{AND GUNIT(OVER I )CFM) CONSTRUCTION TAX
Signature or AP m turomor lJ Dole EXHAUST H00 W/DUCO - HOUSING MITIGATION FEE 1 '
aHAZARDOUS MATERIALS DISCLOSURE
Will oho applicnvt or fuwm huilding nwupum sorra orhunJle lmr.Nous tamer Ld HEATING UNIT(TO ,OO BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ieahh'and Safety
Code,Seai(,n J532hol I HEATING UNIT(OVER EOB BTU)
❑Yes ❑No - PAID
VENTILATION FAN( NGLE 'SIDE Dam Receipt#
Will the am ca nni or fn, i M1 denting by III I t use equipment or desires which
Dist he aid nit covmminnntR ns Acfined by the Euy Arev Air Quality Mmtmgancna POILIiR-COMP(7 POk 100,000 TU)'
tdca:' BOILER-COMP OVER 100,000 BTU) 'IY)'IAL:
❑Yea FIN.
. I havercad the hmrdousntamrials AIR CONDITI EH ISSUANCP,DATE
rtyuiremems under Cha'mr 6.95 of me Cali
Sam.Health&'Safety Care,Sections 25505,25533 and 25534 1 undcoard that if the' NEW RIi511 :NTIAI,MF;CH. SQ.
building dace not cureally ha is a tununt,that It is my responsibility m nodily the occupant l 1 4 r
of the regnim is which an •metlain ioicareaceofa Cees' yo' agcy.
Osmaccuem ad401, / Date TOTAL: FSSIIED BY:`-
OFFICE