S 0815 ANUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECT HICAL rraMTr No,
BUILDING DIVISION APPLICATION/PERMIT rl.uatkmr.-au;cuarvlCAl.
Rt11LDINC:PRO,IECl'IDENTIFICATION
SANITARY NO, APPLICATION SUBMI'1"1'AL DACE
BUILDING ADDRESS:
OWN[ N MB PHON:: CO Gov, 1
i� N/C CONTROL it
�A CT/:NGL ..R: LIC NO: ADDS ❑
CONTACT: PHONE: 'BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LI I31.EC'P I'IAMB MITCH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
11 :-:::::
I hereby afry3 11 that o lithe Balscoee,a PTonr of Chapter 9 faommcm'mg . .. IOD DESCRIPTION
pZO with Secmn]IN DIMy Iasi Jnry limmeis PERMIT ISSUANCE. RESIDENTIAL,
W is full force an R eltr,(, ❑SPDWI. ❑KITCHEN RIiMOD131,
�UU Liven: Class LIANCES-RESIDENTIAL ❑ADI31'f10N El PLUMBING RIi-PII'li
FZm Dot Cnnoon -
yaa• r RCHITECPSD ELS ❑MULTI47NIT ❑STRUCTURAL.
F y m I understand my plans shall be used r pct Ilc ru nrds UII9CATI(]N
ZOr,7j- UPT0200AMPS E3 IN'[ HIMNEY REPAIR
Or3FqyMj LicensedP All�sionol 201-1000AMPS IMPROVEMENT 0$ IMMINO POOLS
�.j2•.1 OWNER-BUILDER DIiCLARA'I']ON OVER FX0 AMI!S ❑BATHREMODEUREPAIR [I DEMOLITION
C6' 1 hereby aamt that I um exempt from the Contractor.License Law for the
g O4 U following reason.(Section 7031.5,Badness and professions Code:Any ill or county SIGNS HLECI'RICAL OTHER
ne
which requite%a permit in con%Imet,eller,improve,demolish,or unitary uncture
prion,its issuance,ith.requirectheapplicanl m,,uch permiuufileasigncommement SPECIAL CIRCUI'UMISC.
y that he is licemmmn
ed parx � n to provisionsofthe Conlrucln' License Law(Chupmr9
W 00 (commencing with Section 7010)afDlvidon 3 ofthe Businessand Pmfesrionr 0.10., 'I'1?MP.MIiTER OR POUiINST COMMERCIAL
Maoy that he is exempt therefrom and the loris for the alleged exemption.Any violation of [I NEW 131.DGIADUITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects[lie applicant m a civil penahy of POWER DEVICES ❑TENANT CFOODSERVICI
E] iy�y
~Z6 net more than Eve hundred dollars S500)..
L as owner of the Embroil,or my employees%int wages as their sole Cnmpenstaion. SWIMMING POCK ELECTRIC IMPkOVEMENT 5
$a 0 will doffic wad,and lhesaucmm N mel intendcrloroRercd for sale(See 7044,Business ❑OTHI?R
63 and Pmfessionn Curie:The Cummdor's License Low does not apply to an owner of OUILF.'fS-SWI TCHES-FIX'!
UW
property who huilds or improves thereon,and who does wch work himself or through
his own employees,provided that such improvements arcnm imm�deJ ur nRercd for NEW RHMDENTIAL til.: R SQ PT.
sale.If.however.the building or Improvement it sold within one yearofeempletion.the SQ.Irr.FLOOR AREA $ISQ.FT.
moner-builder will have the burden of proving that he did not h tild car improve for pur-
pnsc nces .
❑1,us,owsner of the pmpeny,um exclusively contracting with licensed cnmrucum to OTA(
annlmm the project(Sec.76W,Bmsiness and Ihnfeaslo,s Coul The Cnmrncmr's Li- - PAID
lac Law docs not apply to an owner 01 property who holds or improves thereon,and QTY. PLUMBING PERMIT PEE
who commets for such projects with a contractnr(s)licensed Foucault to the Contractor's
License law. PERMIT ISSUANCE
El I ntn exempt under See. ,Ii&P C for thisma,mi �� )
ALTER-DRAIN&VE.NI'-WA'1'ER(EA) A IATION
Owner Date
WORKER'S COMER NSAT1ON DECLARATION BACK FLOW PROTECL DEVICE
. 1 herehy affirm under penalty of penury one of tire following doer's miom:
❑I have and will mummin a Cenificme ofConum In selLinsum for Worker's Compen- DRAINS-FLOOR.ROOF,AREA.CONDSTOIZI17S TYPECONSI'RUC'1101'
sminn,as provided It,,by Seaton 37111 of the Labor Code,far the perbrnnmcc of he
work for which this permit is issued FIXTURES-PER TRAP
I have and will maintain Worker's Campemation Insurance,as required by Section
3700of the La or Code,Im db Ferfnmmneeof the work for whi his r "I". , OAS-IIA.SYS'TEM-IINCAOUTLETS OCG GROUP APN
MY Ws bon r¢rjq c
Pormol licy
No GAS GAS-EA.SYSIP.M-OVER 403A)
Cariet 7 C VV�g Policy Nos
RTIPI A'I .OF EXEMPTION FROM WORKERS' GREASIJINDUSTRL WASTE.INTERCEPPOR
COMPENSATION INSURANCE BUILDING DIVISION FF.CS
(This stiction%cad oat he cnmplmed iflhc pemlit it fornachundreddolurs($IW) GREASE TRAP
or less) PLANCHIiCK FEE
I cenifydam in the perfannanceoOhe work for which dais permit is I...ed.I shall SIWER-SAN]TARY-STORM EA.2W IT.
not employ any person in any manner so as to become subject In the Workers'Cnmpen- ENERGY FEE
,z cation Laws of California.Date WR'I'ER BEATER WIVEMI'/ELECI'R
z Applicant GRADING ITEE
p'Zi y NOTICE TO APPLICANT:M Tme,making this Cenilicme of Exemption,you should WATER SYSTIiMaREATING SOILS TE
become subject to Ibe Worker's Cmmpcnswmian pnoti,ioof the Wu nest —
W forhwida comply with such provisions or this permit shall be deemed meeked. WATER SERVICE
Q
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PhMH. SQ,Em PAR) Dam eiptp
L) 0 (herehy afErtn thauhem isaconslmction lending agency for me perfonnonce of
ti the work bur which this permit is is..ed(Ser.30TD,Civ.C.)
0 F Lender's Name 1(YfAL'
ULcndcr'r Addmss TOTAL:
G 1 verify that 1 have read Ihis appliwtinn and em a that live above information ix BUILDING •E'
:.I h correct.l agree locomply with all city and county ordinances andstate lnwsrelating to QTY. MECIIANICALPERMIT FEE O
U SEISMIC FEE
Z building commotion,and hereby oulhorin representatives ofthis city to enter upon the
above-mcnlioned property for inspection purpose, PERMIT ISSUANCE
( l agree to save,indemnify and keep harmlesx the City of Cupertino against F.LE
WeCTR IC FE
liabilities,judgments,costs and especies whichmay in any way scene againsl said City ALTER OR ADD TO ME CH. PLUMBING FEE.
In come pasne,of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) M17CHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
Signature o'ApplicanVContmclor Dole EXHAUST HOOD(W/DUC) HOUSING'MITIGATION 111
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicanl to furore building occupant Bare.,handle hmoNnus material BEATING UNIT('10100.0!10 B'1'U)
as defined by the Ctlthin Mun,,,i000'yyyaI Code,Chapter 9.12,and the Health and Safely
Collo,Section 25532(7)1 ((HATING UNIT(OVER oRboo11TB)
E]Yev VENT]LATION CAN(S I NGLE RESID) PAID
Dam Receipt M
W II the applicmd fuwrc building occu tint use equipment or devices which NOILER-COMP(3HP OR IW.IgW BTU)
emit hazallous air conmminomr a definN by the Bay Area Air Quality Management IDTAL:
Dlxlncl7
❑Yes BOILER-COMP(OVER 100,00IIBTU)
Ihav� the hnza materials requiremenl.r under Ch:ger h95 of the Cali- AIR CONDITIONER ISSUANCE.DATE
fomia H JOS u ry Code.sectio 05.255. and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildi im d ave .thalil virrom nsibiloymaoli(ydaececupant
of die.-Ime In moose f ac Ito
Owner or aulhnriutl agent Date TOTAL ISSUED BY:
OFFICE rrry