S 0563APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
C.W OF CUPERTINO BUILDING - RLEC'I'RSCAL
BUILDING DIVISION AP PLICATION/PERMIT TING PRNO -MECHANICAL
BUILDING'PHOJF:CI'IDKNTIF'ICATION
PERMIT NO.
S 0563
BUILDINGADDRESS:
p gad —`Fr. -.0e- Fps
SANITARY No.
APPLICATION SUBMITTAL DATE
OW ERSNAMjI C- P�� t90CONTNACI'O�RrS
`. u
NgMI�� LIC NO, li`�
1st` rr�
NIC
❑
CONIHO
LIC-g6�4 NO:
CHITECT/ENGIN ER: S
LE
aes CS. I -404o
ADDRESS: p�N
fie Sr�_6"� A 1
CON'TACI': PHONE:
BUILDING PERMI'I'INFO
R�.I �� GGS-649-1�7
❑ Consultant Fees Paid by Applicant (Initial)
BLDG .P PLUMB
LICENSED CON RAC'I'OR'S DECLARATION
I herehy alarm that l am licensed under provisions of Chapter 9 )commencing
QTY. ELECTRICPERMIT FEE'
JOB DESCRIPTION
PERMTTISSEIANCC
with Sectinn7000)of Division3oflhe Boniness and ProfR....us Crde,and my license is
'nfullforceamlenee. -rv�6CS-
RESIDENTIAL
Elsirm. 0 KITCHEN REMODEL
APPLIANCES - RESIDENTSAL
Livens 1a, Lie. p
Dote Contra• .. Vis._ a �` V
CADDI'1'ION ❑ PLUMB ING ISH -PIPE
❑MULTI-UNI"r ❑SIRUC'EURA1.
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
ARCIiI'TECTS Dount 'PION r
lam mndm��^ IlhuwA ¢s public records
1.in�
I'ANEIS
R�
UPT02MAMPS i� •
Licensed) ss"ilil
201-1100AMPS
WNER.BUILDISR DECLARATION
1 herehy air,. Wm I am exempt from the Cnnuarler's Licenw Law dim he
Inllnwingmasom(Section]03L5, Business anJ Professions Cale: Any city nr amn,Y
0 BA"I'II REMODEIIREPAIR L)UFMOLIT10N
0(yfllliR
OVER I(IIXIAMPS -
SIGNS ELECTRICAL.
which requires a permit to construct, aher, impr(ve, dunollsh, or mpair any nweture
SPECIALCIRCUI'IIMISC.
prior to its issuance, also requires the applicant for such Permit file a signed smmtmnt
that he is licensed pursuant to the provisions of the Contractors License law, (Chapter 9
(commencing with Section]tg0)ol' D....inn Sof the Bu,fra, r top rol's,i,aw Codc)rr
TEM P MF,TSR OR POLE I 'T
COMMERCIAL:
,but he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031,5 by any applicant for a permit subjects the applicant to a evil Penalty of
0 NEW BLDG/ADDITION 0 D1IM01.1'fION
ANT[I FOOD SERVICE
POWER DEVICESN
n more than Bre hundred dollars (S500).MPROVEMENT
1, as owner ofthe pmpcny,rr my employees with wages a% their sole enmpen.satam,
will do,he work, and the mm,no a is not intended oreflered Cor. sale (Seo. ](44, Husin¢sx
and Professions Code:'I he Contractor'. License Law does not a
❑OTHER
SWIMMING POOL IC
I OUI I.I?TS -SWIT IES -F T HES
property who builds or improves thereon, and who does such work himself or tI mug
his awn employees, provided Ron such improvements ere not ictendcd or oll'ecd for
sale. If, however . the building or improvement in sold within one year ofcourpletioo, the
owner,loudder will have the burden of proving that he did not build or improve for pur-
pum of amoe ).1AL
❑ 1, as owner of the popery, am exclusively contracting with licensed contractors to,
NEW RESIDENTS 1!co SQ Fr
SQ. FI'. FLOOR AREA
s1SQ. FI'.
-
instruct the project See. 7044, Broincos and Professions Gdca Thr Coun-olr's Li-
censeLaw does not apply to an owner of propcny who builds or improves thereon,and
QTY. PLUMBING PP,R FEE
who convects for such projects with a emtmostons) licenced paoomn allose Contractors
FERMI'r ISSUANCE
Lkonse Low.
I am exempt under S[r. ,B&PCmallisreawn
Owner Orae
ASTER - DRAIN & VENT -WATER (EAI
VALUATION
O
WORKER'S COMPENSATION DGCLARA'Tate
BACK FLOW PNOI'IiCf. DEVICE
I hereby front under penalty of,s t,lury one of the following dreluronone
I have and will maintain a Certificate of Consent to self-inwe ler Worker's Cooper-
smion, c provided for by Section 3](yl of the labor Code, for the performance of the
DRAINS- 171.0011, NOOK AREA, CONS).
S'I'OR119S"Y 'CONSTRUCTION
con r which this permit is issued
FIXTURES - PER TRAP
I have and will maintain Workers Compensation Insurance, as required by Section
37M rfthe Labor Codi, for the performance ofthe work for which this permit is issued.
OCC,G APN
GAS - EA. SYSTEM -1 INC. 4 OUT1.ETS
My WorketeL , fnruliaQMeuranck'arzier and Policy m aMur/t �c/��C
Carrico �7.gZ'e. r�1a->'Oi Policy No.: 7YO '4 1
GA: )
CER'rlFICATEOFEXF.MP'[ION FROM WORKERS'
COMPENSATION INSURANCE
GRI' STF.INTCRCCI'rOR
pUl LNG PIVS910N FEII.S
('Ihixsmirn need mullseompletNifthepenni, is foronehundreddnllars(SIgB
or If,,.)
GRIT SETRA PCVQ
sot,
A CHECK /#
I certify that in the performance ofthe work forwhich Otis period, is issued. l shall
not employ any Person in any mit are as to become subjecto the Wmaros' Compen-
SEW _SANITARY-S'IORMIIA.210 PT
kG :IS eq
WAST. WNEN'I LEI '
kADING FIT2.
corm. Laws of California. Dam
Applicant
NOTICU TO APPLICANT: If, after making this Ce tifcme rf Exemption, you should
become subject It, the Worker's Crmpennation pmvkina, of the Labor Code, you most
WAT1 /I'REAI'ING
SOILS FEE
WATER SERVICE:
forthwith comply with such provisions onhis pemtit shell be deemed rooked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction lending agency for perfommnce of
NEW RESIDENT IAL PLMB. SQ, dell
PASS)
Date Receipt#
the work lar which this peroull is Issued (Sec. 91197. Civ. C.)
Lenders Name
TOTAL:
TOTAL:
Lenders Address
BUILDING EEE
1 Certify that 1 have read this application and tire 'but the aMrve'mfrrmminn is
- -
correct.I agree to comply with all city and county ordinances and state laws ranting to
hullding consmatlon, and hereby authorize representatives of I4hcity m enter upon the
QTY MECHANICAL PERMIT 'FEE
SEISMIC FEE
PEHMir r ISSUANCE
ELECTRIC FEE
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of Cupertino against
PLUMBING PEE j
Iiabildies,judgmen¢, costs and expenses which may in any waynceare.,aren said City
in toof this permit.
ALI ER OR ADD1'0 MFCO
AIR HANDLING UNIT(1O 10,000 CFM)
MGCHANICAS. FEB
APPII NN) WILL COMPLY WITH ALL NON -POINT
grYd4'r
vy
AIR HANDLING UNIT (OVER 10," GIN)
CONSTRUCTION TAX
Signa ol'Applic t Confra[Irr Date
MATERIALS DISCLOSURE
EXHAUST HOOD(WIDUCO
HOUSING MITIGATION FEC
HEATING UNIT ('101(01,(00 BTI))
AZARDOUS
Will She applicant or farm building occupant.stom or handle hamrdoas material
as defined by a Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code "e"25532(d?
HIEAONG UNIT (OVER t00,0001DITH
PA 11
es ❑Na
LAW 1 ¢ Neceipta
Us
V, HIJTILMIONPAN(SINGLI? HISID)
BOILER - COMP (7HP Ok 100,1#10 BTU)
Will thcappllrmnor fn,urehuildingoccupanl useequipmmn ordeviceswhich
aous air contaminants defined by the Bay Area Air Quality Management
mit hvrdm
TQ pq1-;
BOILER- COM P(OVER I W.t#gI BTU)
Disuia? Yes CNo
LUr
AIR CONDITIONER
I vemad the hnmNnus mmerials myuirements under Chapter 6.95 rf,he Culi-
Ll CE I)ATF
NEW RE SI DEN I'IAL MECIL SQ. FT.
fund. ) al & Safety ate, S - ion., 25505, 25533 and 25534. 1 undersand that If the
building no not cum fly vc t at, that it is my mopsmaNhi, m notify he o[eapant
of Wore i nem, wh t a one ... aunccof' ' djk�1ty ) ncy.
�i
ISSUED BY:
TOTAL:
Owner or thorizedu e Date
OFFICE
FIRE DEPARTMENT
SANTA CLARA COUNTY
14700 Winchester Blvd., Los Gatos, CA 95030.1818
(408) 378-4010 (phone) • (408) 378-9342 (fax)
PLAN REVIEW COMMENTS
CONTROLNUMBER "
PERMIT NUMBER
PLAN CHECK No.
CODE/SEC.
SHEET
NO.
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JURIS
PLANS SPECS NEW REMODEL ASCONST.
DESCRIP.
BY
DATE
PAGE
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OCC
OCC. LOAD
AREA
ARCH/ENG/CONTRACTOR/OWNER
MAC-h350C1,4
ki7E
TQ;
NAME OF FACILITY
N Tr N i PPDN
LOCATION =
(?08Z-3 57cvEu5 ClLECK SLVb
A California Fire Protection District serving Santa Clara County and the communities of
Campbell, Cupertino, Los Altos, Los Altos Hills, Los Gatos, Monte Sereno, Morgan Hill, and Saratoga
t>.
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