S 1373cool W &UTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE ?•
CITY OF CUPERTINO BUILDING-FL'lEl "C
BUILDING DIVISION APPLICATION/PERMIT
3NAC
'PFITNO
1373
BUILDING ADDRESS:
eco av ��cpuLTl`u, 956
SANI'T'ARY NO.
APPLICATION SUBMI FI'ALDATE
14Y.WS NAME: 1'HONF.:
'�Q
LA~ARCH
CONT CI :S LICNO:
N/C
❑
COM ROL#
IIIiCl/CNG I N I IFR: LIC NO:
vvh"S:
CONTACT': P NE:
BUILDING PERMIT INFO'
❑ Consultant Fees Paid by Applicant (Initial)
BLDG HI.ECT PLUME MECH
K_ x
LICENSED CONTRACTOR'S DECLARATION
o
I hartby alErt mm late Limited ander ray..inn. of Chapter' e nandmg
QTY ELECTRIC PERMIT FEE
- -
JOB DESCRIPTIONL'Z.
_rin
7V
<a
D m
so
wan Section lglo)of Division Sof the Basinmsane Pr..evsimm Ceda,und Lcanuia
full forte and effect.
Licenac Class- - Lic'#
Lure Computer
PIiRA11T ISSUANCE
RESIDENTIAL:
❑SPDWI. ❑KITCHEN RIiAlOUHL
❑ADDITION ❑ PLUMBING RIS PIPE
❑ MULI7-UNIT ❑ MODIFICATISTRUCTURA.
MODIhICATION
0INT17RIOR El CHIMNEY REPAIR
API'LIANCIiS- kESTOP PIAL
ARC141TECTS DECLARATION
I undersand my plans shall he used a puhlic ro nods
PANELS
UP'10200AMPS
Licensed Posesloal
201.10MAMPSIMI'IiOVEMENT
qq lQ�i
❑SWIMMING POOLS
2,
Y Q
1 U
jy
Nthat
OO(commencing
m C
0
Z r
6
3a,
OWNER BUILDER DFCLARA'I'[ON
1 herehy affmm the. 1 um caempl Tann the Cmnmcmr's Liccnu Law far be
following rens.., (Seaton 703 1.5, Imsireae vad Professions Cale: Any city or county
which pe tires v pcnan In aons,... alter, improve, dup... kh, or mp.ir any "min ,
prior to its issuance, also requires the applicant for such permina File a.signeJ stmem^enl
he is licensed pursuant to the pmvisaws of no Caricatures License Law(Chapter 9
with SCcdom7LlXgnf Divisinn3 afthe Bmina.sund Pndesrions Cade)or
that he Is exempt duantrrm and the basis liar the Alkali esemmian. Any violation o[
Section 7031.5 by any applicant for a permit subjects the.,m a civil penally of
not more than five hundred della. 155001.
❑ Lasow rrofthe property, on my employees with wages as their sola eompemmnioa,
.7044, sinoss
will dathe work,andthu.mumnrc lx not intended m offetal formle(SwHu
and potassium Code: lie Contractors lusi,am Iran Joe, not apply m an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, rmvlded thin such Improvanems are Dat intended or offend far
sale. If. however, the hulldingnr improvensam is sold widti a ant yenral enmplmion,the
pobuilder will have the burden of proving that he did not build or improve for par -WWII!
sy o,taxne
❑ BAI'H REMODEUREPAIR El DEMOLITION
❑ CI'HEN
OVER 1 WOAMPS
IGNS ELECTRICAL
SP :'IAL CIHCU IT/MISC.
'I'li stTRk oR POLE INST,
COMMERCIAL:
El NJW BLDGIADDITION ❑ DI!MOLITION
ANT El FOOD SERVICE
pROVEMF.NT
[IO ..R
POWER DNCUs
'SWIMMING PO LELIiC'rkIC
OU'1 H -Ls - SIN S -FIXTURES
is SQ FI'.
SQ. fT'Af>k AREA
PA 1 /A
D
S/SQ. FC
tO
ns Dant rimtheproperty,umaaewstselyand conoaeting,- .Teems-wmrrnarsm
i
amsnct the projwl (5ea 7044, liuninccs nnJ Profexeinnx Code:)'fhe Conunaor's Li-
a
sense Law does not apply to an owner ofpmPmcnYwhobuilt.orimprovesthcrton,and
,
'i' 1 gad iGonsr
AR 17
who contracts for such projects with a contcton s) licensed pursuanto the Cantr.currs
Licence Law.
l am cstmptimer Sec ,B& P C fart his reason
trVl"
Ur
nd=revisions o /
r�ER IEA)
µ
I t1i d
Owne
WORKER'S COMPENSATION DI!ChARA'fl N
ALUATION
1 herehy affin t under penalty of perJury one of Iha I'ollowine declvrmin I,
❑ I have and will maintain a Cenifute cdConsenuoself-insure for Workers Camper-
cation, as provided for by Section 37W of the Inman Cole, for the performance of the
DRAINS- .()OR, ) \Rk
STORIES
TYPECONSTRUC1'ION
work for w[ban This pernil is issued.
X" -
❑ 1 have and will nnintaln Worker. Congmaation Insurance, as required by Stenon
3708 of the Labor GJe.for the Permanence ofthe work for which thispermit is issued.
GAS-EA.SYST -11 C.40UTLIi'S
OCC. GROUP
APN
My Worker's Compensation Insurance carrier and Policy number arc:
Cannier. Policy Na:
S
CEk'I'1 FICATE OF EXEMPT ION FROM WORK17RS'
COMPENSATION INSURANCE
GREASE/ .TRL WAST' f!R i It
Bf111.U1NG DIVISION HIS
(This section Dict not he completed iOhc permit ix forone hundreddollms (5100)
I,, less.)
a
PLANCIII?CK PF.E
SEWER -SANITARY- S'IORM RA. 200 FP.
I certify that in the,flommucaoflhe work for which this permit is issared, Ishell
nod employ any pecan in any manner m e, m t wore hubject ur the Workers Ca open-
-11—RGY FEE
WATER tlfiA'IER WNENIIELF,CENAlml
I z
0
0
H
ULanders
fy
h
,771-
cntion Lows of Califnrme, Date
GRA NO FEE
NOTICE
Name 0j APPLICANT: If, rarer making This Cion uta of Exemption, you should
become whlect to the Worker's Compensation armit Tal of the Wbm Cotle, gnu must
forthwith comply with each provisions or permit shell be decmnl revoked.
CONS '1'RULTION LENDING AGENCY
I hemby affirm lhenhem is a redemption lending agency for the performance of
the work far which this permit is issued (Sec. 3097. Civ. C.)
Lender', Nine
WA'T'ER SYS 'T'EM?RI!AI'ING
WA'I'I!R SERVICE.
SOUS P v
PAID
U:n Receipt
NEW RESIDIiN'TIAL I'LMN, SQ, PL
'1'O'I'AL'
TOTAL:
Address
BUILDING FEE
I certify Thal I have read this appliation and state the the aMrve information is
correct I agree to canmply wish all city and county ordinances and state laws relating to
building cnnstmednn, and hemby uulhorize mpresenmtivcs ofthix city menwntpnn the
-
QTY. MECHANICAL. PERMIT FEE
SEISMIC FEE.
PERMIT ISSUANCE
ELECTRIC FRE
move-narmiumil proper for superman pwpnses.
(We) agree to save, indemnify and keep harmlex the City of Cupertino,mrs,
Iiabilines.judgnenls, costsmad eepenses which may in any way acemesgeinstsaid City
in saryencc on the granting nl this retain.PLUMBING
ALTER OR ADD TO MECH.
FEE
AIB HANDLING UNI'I'(rO 10,0(10 CPM)
MECHANICALfTl3
APPLICANT UNDERSTANDS AND WILL COMPLY WITH A- S
SOURCI'
AIR HANDLINGUNI'1LOVER I0,000CFM)
CONS'FRUCTION'1'AX
EXHAUSTHOOD(W/DUCT)
Sig aur plicae onm.eror }•ly9g.
HAZARDOUS MATERIALS DISCLOSURE & �J /•
HOUSING MITIGATION FEE
HEATING UNIT( TO 10NI.W0 B' 1' UI
Will the applicant or future building occupant store or handle hazardous maer
as defined by the Cupertino Municipal Cala, Chapter 9.12, unit the Health ant Safety
Cale. Section 2553207
HHA'I'ING UNIT (OVER IIXI,IXXI PLO)
'
pYe. 0 N
Will thou lion or l'aou buicho• occn mace Tor dcvicus which
PP b pram Area
emit im'? s cif ammminuma as defined by the Bay Area Air Quality Management
Oisdct7
❑Yes 7 N
PAID '-
Dam Rweipt#
VENTILATION PAN (SINGLE RESID)
BOILER-COMP(311P OR Iffy,W JUL)
TOIA1
BOILER -COMP (OVER 100,000 13 Rd
AIR CONLA IIONER
lave tend the awriouamaterials parameters under Chapter, 6.95 of the Call-
ISSUANCE DATE.
NEW RES IDENI'IA I. MSCI I. SQ. 14.
barna Health & Safety Cale, Sections 25505.25533 and 25531. 1 nndenand that if the
building docs not currently have a tenant, that It is my responsibility am notify the occupant
-
of the tuluirements which must be tact prior to issuance of Cer ificmu of Occupancy.
qFF
ISSUED NY:
Owner or euthodmd .gent Dam
TOTAL:
OFFICE ?•