S 1463 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLPIC IRICAL Pe ITND
FICILDING DIVISION APPLICKFION/PERMIT rLaaklN°-MBcunNlcnL 1463
ItUI1.DINC.I'RUJI:C'1'IDh:N'Tp+ICA'DUN
BUILDINGADDRESS: SAN]I'ARY NO. APPLICATIONS(Jl1M1'1IAI.DA'1'Ii
5-9-7 kvrl� ors Ifive, -W
OW 'NAMIr PffONE: C IRA R'S>WMl?:G 4409 12,,e LIC NO:
C NIC CONTHOLp
�A CHITT.CI'/ENGINHER: LIC O: Ard S: ❑
-4223
CONI'ACf: PHONE: I ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) RL ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby mrnn that 1 am dcrowd under provisions of chapter 9(commencing JOB DESCRIPTION
WIZ with Sec tion nX nr it 3e One Ra.inex.a dPm&,simmC ,and my It is RESIDENTIAL:
WOO PERMIT ISSUANCE El
FW. in full tome an a ❑$FDWL ❑KITCHEN RI!MODI!I.
Q,UyU Licensr)ilaaa�Lic.p APPLIANCES-RGSIDEN'I'IAI. ❑ADDITION [I PLUMBING RE PIPE
F Z W Dene IT/ Conumto
F❑y ARc111'1'ECTS DF.0 PANELS ❑MULTI-UNIT ❑ST)DEFECRUCI TIO
y p y Z I understand my,lam,ball be used u,pa ine retool. �,I CATION
Oz,�O UPT02RAMPS ❑IN'T'ERIOR .HIMNEY BIT'AIR
W Licensed Professional 201-leen AMPS IMPROVEMENT ❑S IMMING POOLS
a: OWNER-BUILDER DECLARATION OVER IWOAMIS ❑HATH REMODEUREPAIR ❑DEMOLITION
�CCyGG1 Q I hereby union that I nm exempt I the Contractor',Licence Law for he
O
MU following reusm,.(Scuiu 17031.5,Rurinc„and I'mde,sions Cale:Any city or county SIGNS ELECTRICAL. El OTHER
3 W E" which re,uhm.,a peratil no aoo,ru .:Then Improve,dcnmllsh,or repair any awcmre
F❑❑Na, pit, to it, 1 II pilvain lot snallperninI I le a signed statement SPLCI Al.C114CLJI I'/MISC.
❑❑❑❑!!yy mull I p . II , o C t t t 1 (C cdO ar
p0 (co 6 IIS t 91X.it a 'ni I ftl a des Ip I n violation
TEMP.MI.[FIR Olt POLI!INS'f. COMMERCIAL:
dfxs,c C Ih n io cxi np1 IhuW , , h,.b.l..i 11 alleged ,p pt Any vioinfon of El NEW BLDG/AUDITION ❑FOOD .1 ION
RVI
W m Section 9015 by any.fied den tin a It 00), l a:hjecas thwmplielm in a civil penalty of POWER DEVICES ❑"IHNAN'I• El FOOD SERVICE
of snore than Eve humored de nrx(S"up.
F C ❑ I,as ewnetofine pn,pesy,ar my clnpinyees wilt wages as mhcir sole n,mpenwm,n, FW IMMING POOL I!1.1?CIRID OTHERIMPROVEMENT
F wdldodmwark,t Ithe alna9am is not intended or offered for wde(See,70Fl,Business ❑OTHER
C m and Prnfersinm CnJc'I'Lv Contractor',Li oma Law Joe,not apply to as owner of OUTLI?'IS-SW ITCI{EG_I:IXTl11Yl?S
6 pmpaly who hail),or irepome,thereon,and who Joe,such wed himself nr through
his own employero,provided that such inmmwean nla am not intended or offered for NEW RESIDENTIAL EL EC:It Q PI'
sale.If,hme,...the building nr i:n,mvcmcnt is sold within one year of completion.theSQ.pEpF0(PIRkj $/SQ.FE
cr-huildcr will have Lc burden of proving thm he did not build or improve for par- 77�� HH
pose of sale.).
1,as...or of the property..,,I exclusively ciamennng wlroen
lh liecanu] nums 1. TOTAL: 2 O
1
,mann the,fojnem(Sec.700,ILasince,erd 1'rnf r,ions Code:)Me Counselors LI-
cause 1qk P {1
law does not apply it)an owner of pmpany who build,or improves mneon.and QTY, PLUMBING PERMIT FE. •'- e�1�
who toren,for such projects with a conlmnons)licensed pursuant to the Commences INU
Licemc law. PERMIT ISSUANCE CITY Ur vul'rm
I am escmp under Sec. ,B&P C fore
nhis ason _
ALTER-DRAIN&VENT-WATER(FIG VA OAT
• Owner Ilene .
WORKER'S COMPENSATION erjuTION DECLARATION PACK FLOW I'k(TI'1:CT.DEVICE
I handy off sunder pemlfy of ofConencofthefnsure for declandWorker's
❑Inave and wtalto maintain Certificate ofConsent acre for Workersca of
DRAINS-I'LOOk.ROOIi AREA,COND.
nation,as provided for by Section l9W of Lc labor Cede,for the peRormance of m0 ORIEL TYI'fi C(JNSTRUCIION
For which this permit is issued. FIX I URES-PERI RAP
µ 1 have and will maintain Workers Compensruion Insurance,as required by Section
'4I Ir the Labor Code.for the performance ofthe work for
wwhich
�this pe9mitlis/tissued. GAS-EA.SVSTI7M-ILNC.4000.I7IS OCCGROUP N'N
My CvrWork�[�IJI' 1t16n In ylyp�Ptp Pubv,No,n^' •�_
�]I p I t tL GAS-F.A.SV5'fEh60VEH 4(HA)
C17RI IPICATH OF EXEMPI]ON FROM WORKERS'
COMVENSNL'ION INSURANCE GRIiASFIINDIIS'THI.WAS'I'li IN'I IiHCI?IHOR
BUILUIN(i DIVISION IIiIiS
(Thin section need nal ho vnnmlcm,l if Lepennim lx furnne hundred dollars(SIR) ---- ---
or leg's) GREASE TRAP PLANCHECK FEE
eerily)hmin due pctl'ornanacoDhe work kit which thla,cmmit is rsucd,lahall SEWER SANI'T'ARY-S'I ORM i?A.21X1 IT
not employ any pamm In any manner ao ns In hunnm-,abjmm m the Workers Compere- ENERGY PEF.
anion I.."on Cu31'un:iu.Date WATER HI?ATHIR W/VFN'1IIJ.1!C'I'It GRADING FEE
Applicant
NOTICEtoAPPIACAN'1%11-dwnnecking this Ccnoxatc of Exemption,you should WA'I'HRSYS'II?M/TREA'T'ING
b,Iman zoned m Lha W.. Cumpuncons,provisions of the LabCodeyou man SOII.S PEE
hmi with comply wim mmh po,vi.inne a lois unman Mall the decmed revoked. WATER SERVICE?
7
CONS'I'RUC'I'ION LENDINGAGENCY NEW RI?SIUP,N'I'IAI.I'LMN, SQ.PI', PAID'� IM1ereb f3rin that inure Lucnrotnminn lendln forme formvnmof Rc7eiptN-
y a s ngeney pm
C) Lewers mr wn?nn Lis penmen is issued(sec.iron,em.e.)
� f•• Lender's Nome 9'OTAL:
U Lender's AJdrcns 'IOI'AI'1 _
y I rarity'but av
et 1 he mail mitiona
,applican and e fe
that the imo,c inmntion is BUILDING FEE
Zn correct.)agree e,comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PI2RMIT FEE
V Z huildingenn,waticn,tnd herebyeamorim nprosennti,xsnfhak city lomnerupmn the SEISMIC FE
above-nmemioned propeny for inspection pmry,sex. PERMIT ISSUANCE
(We)agree In save,indemnify and keep harmless the City of Captains,against F.LECIRI FEE
Iiahilitie.v,judgmems,cows and expenses which may in anyway amre againnsaid City ALTER OR ADD*10 MSCI I.
RMI
his permit. PLUMBIN .E
AAND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITf1O 10.000CFM) MECHANICp FcE
S 'L'qP AIR HANDLING UNI'rpovER dkabacEM) CONSTRU(TRO. TAX
Si amrc of ApplicanUComr. , Date EXHAUST HOOD(W/UUCT) HOUSING MITIGA ON FEE
HAZAR AJS MATERIAIS DISCLOSURE
-
Will the applicant or future building occupant atom or handle hazardous material HEATING ONE*[('10 FROM BTU)
m def nod by the Catamaran 7N,'
pal Com.Chapmr 9.12,and the Health and Safety
Cale,Section 2553300? HEATING UNIT(OVER 100,001 It LB
❑Yen. VENTIIA"110N I'AN(SINGLI?RI:AIU) PAIDDene dpt4
illtapplic
uilding occupant use equipment or devices which
40 emit hazardous nirnnunlninulull sl by me Hay Arcv Air Quality Management BOILf!R-COMP(3HPOk Il111,IX11111T11) TAI.
Disaim'!
❑Yes BOILER-COMP(OVE jE.nIX)B'IU)
I hove rued the hvsnlol:.malarial,mgei,c:nem,under Chapter 695 f,ha Cali- AIR COND]'HONER ISSUANCE DATE
imniu &Snlay Cuda.Sccfnnn 25505,25519 nnJ 255]X. JcntunJ 010 illhe NEW ItESlpi?N'I'IAI.MI?Cil, sQ.PI'.
bnlldl IT nolcurl"uly hav .I OnL thio it lx 1ny 17epnnslh' tY n nli mho nccup t
nfth qnl n 1 .tlm 1Y Prior to ixxuunm ol' i ante, IrK
Ow r aul,n ved ugcnl pant 'I'OT'A L: ISSUED By.
OFFICE