B 0416 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE B LL'POINT PEN ONLY
CITY OF CUPERTINO BUILDING-REECHA ICA I PERMIT NO. 0 416
BUILDING DIVISION APPLICATION/1'F.RMIT. PING BING-PROJECY IDENI I, 50001
-+BUILDINL'PROJECP EDF.\TIFICATION:" '
BUILDING ADDRHSS;..• SANITARY NO. APPLICA'1'I(IN SURMIrfAI,DATE
f WNER'S NAME: - PHONE: CONTRACTOR'S NAME: LIC NO:
C r _ NIC CONTROL ft
ARCHITECUENGINEER: IL LI h ADDRESS: ❑
CONTACO PHONE: ,%� . art' BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
"Oc
LIC VSFU CONTRACTORS DECLARATION QT>''f ,CLEC]kIC PLRM?ITy Vii, Ia IFG
I by n nmTl licensed d I 'Chapter 9 houniv g ,T : .. +- : 1 JOB DESCRIPTION
I app whits r ]anB nf-T 'm,naonlra n..a-. ndl roreaatnaendc vnd mrltu _ RESIDENTIAL '
P-?RMIT ISSUANCH
infull[orccande 2� R ❑SFDWL, ❑KITCHEN REMODEL
�UU License Clan. eb Lic.pAPPLIANCES-RESIDEll []ADDITION ❑PLUMBING RE-PIPE
F z W Ura Cnmmcu
vj6a ❑MULT[-UNIT' ❑S'TRUCT'URAL _
ARCHITECT'S DECIARATION
I..y z 1 understand my plain shall In used as public records PANELS MODIFICATION
O Z.r' UP TO 200 AMPS
❑INTERIOR ❑CHIMNCY REPAIR
�
4t, Licensed l'mfe+smoll - 201-1000AMPS - IMPROVEMENT E]SWIMMING POOLS
<.jf-� OWNER-BUILDER DECLARATION OVER TWO AMPS ❑PAT'It REMOD: PI'AIR ❑DEMOLII']ON
ip� Cy I nereby of ion that 1 am exempt from the Comracmrs License Law far the fyT�Tr��a'��� A A QT Q
O F U following ren.on,(Section]1131.5,Business and Professions Codd:Any city nr county SIGNS EITCTRICA-. M•/-?R�l,'l�c
to 3 W y which requires a permit to construes,aper,improve,demolish,or repair any structure a,1-L b _ l _ '
or priatit, lequremapplicant for such perniu file aBd.trement SPECIAL CIRCUIT/MISC. wEr;rAar.
or poor
w':liouslp a,,he p sof all Conamcda t e : Law(Ch:pter9
Wa'4 (commencng with Section](XXj. d,,,ion Sof the Ruatess and lr l'es,i roco )ot 'I CMP.MEI HR OR POLE.INS'(. COMMERCIAL:
a a e C that he is exempt thercfmm and the basis for she alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
>C.nW Section7031.5 by any applicant for a permit subjects the applicant up a civil Penalty of POWER DEVICES [ITENANT _. -•-❑F(TODSERVICE
m—w Im:na,d man Bve nawred Donors(sstxn. . ,
' =6Q ❑ loo,1. fr t of the progeny,or my510D). eea with wages ate their sole compensation, SWIMMING POD] RT:fiL9T
IMPROVEMENT
F ❑OTHER
waldothewark.and thestrarium isnot intended or offered for sale(Sex.]tWi,Business
and Professions Calc:The Contractor's LicensC Law docs not apply to an awmer of OUTLFI'S' SWITaHE3-FI 'ILRES
property In.builds or improves thereon,and who does such work himself or Ihmugh _
his own employees,provided that such improvements are not intended or offered forTPERMIT
RESIDENTIALELECfR 'SQ FT.
WO.If.however the building m improvement issold withinone yral.fcompistion,lire SQ.FT.FLOOR AREA USQ,FI'.
owner-builder will have the bunion of proving(hut acrid not build or Improvo far pur-
poseofxeleJ.
I,as owner of she progeny,am exclusively contracting with licensed contractors to TOTAL:
constructh project(Sea 744 Business ndProfessions Cade)no Contractors H1f1 - 1 ;! r- t•onset J T apply to an owner ofp pnY hhlds ormpnnca Thereo 1 ; j{ PLUMBING PFRMi'I" ( t •1 , FEE trI}who contract:( such projects with a comenarnr(s)licensed pursuantto the Conmcmree+ r +- I jLicense Law. ISSUANCE;
0'I Ins exempt mew,See. ,B&P C for this reason
ALATER-'DRAIN&VENT-WATER ETA) VALUATION
•owner _ nate ,
,WORKER'S COMPENSATION DECLARATION BACK PIAW PROTECT.DEVICE.
Iherebyill mai under penaltyof perjuryone finefollowingng ..ker'',Co �7
0Ihave and will for by eCion ofConwnt he LabrCod,fortfor Wmkdscempem DRAINS-FLOOR,RUDER,AREA,GOND. gpORU:q 'TYPE CONS'fRUC'1'ION
walkI as provided for by Section 3]W of me Labor Code,for the performancc of the
work hart which this pennn it issued. IIXTURIi$-PER TRAP
�ypyh 1 have L will maintain w'orker's ante Oftte w rkfor hi h required by Section
JIBII of me lsMrr Code.for perfnmsancc of me work for which mit permit is issued. GAS-EA.SYSTEM-I LNC.;0UT1-F'rS OCC.GROUT' APN
My Wadeyy's��CppmmJy�g IIarLIns}I( .ya..,'er nnA Polioy (
Carrier; `u'�• � (/._�•_Pnlicy Nn.; -�IC I��A/JD/k. GPS-❑A.SYSTEMOVERafEA)
CERTIFlC OMPEN ATIONIONFRAN WORKIiRS' GREASI]INDUSTRI,WAS 1'I;INTERCEPTOR
COMPENSA[ION INSURANCIi BUILDING DIVISION Pii)S
(I hlssdc(ion neednot forma Imedifthclwnnit is livnnchundred dollars 181(Kq
p GREASE TRAP
or less.) PLANCI ILCK 171171717I?
I certify that in the performance ofthe work forwhich this permit is issued.I shall SEWER-SANITARY-STORM EA.200 ET.
not mnp-oy any person in any manner xo ns ro become subject m the Workers'Cmnpen- ENERGYFEE
Z .nation Laws of California.Date WATER HEATER WIVENDIBLECTR -1
Z� Applicant t O GRADING 1"1,
.j N NOTICE TO APPLICAM':If,after making this Cvmfiane of Exemption,you should WATER SYSTEMR BEATING
f•'1 bacon..subject to the Wndcr's Cmt-ensetio,providers of the Whar Code,yon must SOILS Fl:N.
Wfanhwith comply with such pmvisinns art this permit shallh Deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDEM'[AL PLMB. SQ,FLl PAID
U0 Thereby affirm that there is a construction lending agency liar(lie performance of Dora Receiptp
H the work for which this permit is issued(See.3119],Co.C.)
U Lender's Name
F G / TOTAL:
Lenders Address TO1'AI
1 certify That I have read this application and state that the above information is - 1 1 ,t r .- BUILDING THEkillcorrect.l agreaur Comply withal)city and county ordinances and State laws totaling To Qjy; MECHANICAL'PERMIT'" ' PEE '
tit SEISMIC FEfi
r) ,Z huildingcnnamumlon,anAhercby awhnrize repmmnmtivexarthlsci(ytoemerupanthu ' '
above-mentioned property for inspection purposes.
(We)agree m save,indemnify and keep hamdess me City of Cupertino against ELI?C'I RIC Fiil?
Iiabilitic.n,judgmemx, stsnnd expcnses which may in any way accrue against said CityJ122MECH. '
1. nxcgaencd of grunt n of this permit PLUMBING FEIi
APPLICANT IVDERI S AND .CON LY WITH ALL NON-POINTIT(TO 10.000CFM) MECHANICAL FEE
$ORC' F
IT(OVER 10.BgICFM) CONYI'INC'fION TAX
Sign mo Applica Contracto Dare EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WIIlmceppirmt ort(mmre bai-dingo,raTemt storcor handle le,nodnue marerW I]EATING UNIT(1010(1,0x0 BTU)
as dcfrned by The Cupenino Municipal Code.Chapter 9.12,and the Health end Satiety
Code.Section 25532(a)'t HEATING UNIT(OVER Buddhist BTI) I//nI�hll+ � Ifn1I
Vcs �Nn 1�> � flit Ed
VENTILATION FAN(SIN01.1?REGIO) LL����� 2 ffiaiitt za+ II p(II
Will the applicant or future building occupant use equipment or del res which BOILER-COME'CHP OR 100,000 ETU)
emit hazardous air communints ns defined by the Buy Area Air Quality Management `
District? 1 BOILER-CONIP(OVER I b,jXr HE'D)
MAY 22
C]yes Who
I have read a b.adins materials requircutraw, de,Chapter 6.95 Of me Cali AIR CONDITIONER ISSUANCE DAT.
farm.Health& my Cfav
tions 25505,25533 and 25531 I understand m.,if(ho NEW RE; IDI TIAL MEGA. SQ.FF.
builJing does c( tlmount, tis •sptmsibility to modify the occupant
of(he- rams e copy; nfu Cenifa'm n[Oecupane.
O aumodz aBcm Uate TOTAL: ISSUE
OFFICE