30899 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY` -
CITYOPCUPERTINO ., BUILDING-F.LF.CTRICA1. -•I , PERMI'I'NO. QQ
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL , 3,0899
111111,DING PROJRCT IDENTIFICATION
RUIEDINGADDRESS: . .SANITARY NO. APPLICAPION SUBMITTAL DATE
12,Co-1 5-TEVeis Cc
rey 1 ti1�
'NIiR' AM �I J - PHONE: SVCS IJ V(,ql
NIC CONI'ROLX
RCHIT1X7UTNGINEER: a - LIC NO: ADPrdS :• X SLI,WN�w C�- 5 S� �� ❑ 2
CONTACT: _ - PHONE: 1IVV99 L _ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
"I ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that turn lleena¢d ueder.prnvlsinas fir chapter 9(rnmmencing •'C JOB DESCRIPTION
WOO with Section 7000)of Division 3 ofthe Business and Professions fode, fid my license is RESIDENTIAL
i. O in full farce and efl'ecl 1 // Y PERMIT ISSUANCB
K W r C' 3r'. �G L'I Z�/ O SFDWI. ❑KITCHEN REMODEI,
aVU Lic u,Ciyss�', - — Lic.X APPLIANCES-RESIDENTIAL OADpITION ❑PLUMBING RF:-PIPE "
N 6 amyl Cne DELL
y AhCHR[CTS DECLARATION OMULTI-UNIT ❑STRUCTURAL
Z O Z .y 1 andurswnd my plans shall he acted na public reandv , PANELS MODIFICATION
O Z--'a UPTO 21X1 AMPS
YW ❑
Licensed Professional I000AMPS IMPROVEMENT
" _ INTERIOR ❑CHIMNEY REPAIR
Lqq` 201-
OWNER-BUILDER DECLARATION OVERIgMIAMPS O BATH REMODEVREPAIR ❑DEMOLITION
K W G I hereby affirm mn1 l are exm en
exempt frothe Cmaracon'a Licse Law for the
ippx$,,O y U following reason.(Section 7031.5,Busineis and 11..lessions Code:Any city fir nwnty_ SIGNS ELECTRICAI. ) OOTHER
W 3 LL F' which acquires a permit to construct,411er,improve,demolish,mi repair any swcture moz
prior, 1 ': 1requirestM1 pplclntf hi - 'n N 'g Itt air( SPECIAL CIRCUIT/MISC. )'
}
thin he licensed prs a 11 Theppohicars ofthC mate ex LicariLa (Chapter 9
i 00 (cmince.cin,with Safti 07000)ofinv'siu 3afine Ba,massinod Pt1'essane Cadc)or TEM P.M ETER OR PILE INST. / . COMMERCIAL: a+a,
That he is exempt therefrom end the basis for the alleged exemption.Anyviolminn of BW BLDG/ADDITION O DEMOLITION .
i< ti Section 70315 byanyupplicnnt fore permit subjects the applicant to a civil penalty of POWER DEVICES '
v1 .. TFiNANT ❑FOOD SERVICE
trona than five hundred dollars(5510).Q IMPROVEMENT OLa.s comacrofihc properly,or my empinyces with wages as lheirsule compensation, SWIMMING POOL ELECTRIC
will dndte work,and flac,a uclure is..,arcaded aroffacd for sale(Sec.701.Business OTHER e'
W 3 and Professions Code:If.Commotion's License Law does ern apply m.n owner of OUTLETS-SWITCHES-FIXTURES, -
�' properly who malleo or improves thereon,and who does such work himself or through' .
his own employees,pmvidcd that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ PT. �jiJ
sale.if,however,the building or improvement is sold within one year m eontplclfmt.the - SQ. .F Or uA $/SQ.IT.
owner-builder will have the human of proving that he did not Build or improve for pur-
pose ol'p1c.)
ur-poseol'salc.) - /J IIsrX
O 1,ses owner of the pmpum exclusively ty,uexclusively contracting with licensed contractors to "-- TOTAL:' P��p/'j r
constrict ,
conset the project(See.7W4.Business and Profession,,Cale:)TCo
Hae na
cm.
I •1
cm.Law dean.,apply to an owner of pmpeny who builds fir improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects withacuitmctor(s)licensed pursua0
no the Contractor's I ut-���� -
Licenselaw. - PERMIT ISSUANCE
❑lton exempt underSO . ,B&P C fm,hBpm, n - Q
ALI ER-DRAIN&VENT-WAI'IADIA) VALUATION
Owner Dare
WORKIiR:SCOMPENSN'IONDECLARATION BACK FLOW PROTECT DEVICE ' • - -
1 hemby affirm under penalty of perjury one of the following declarations:
I lmYamd will maimurt.Cenifcat¢of Consent,nsd6iravine fir W..ker'.v Gnapen. DRAINS-FLOOR,ROOF,AREA,COND, STORIES TY IH CONSTIt UCION
salon,is provided for by Section 3710 of the Labor Coale,for the performance of the - ,.
work for which in,minor,is i.vsucd. FIXTURES-PER TRAP s
O 1 have and will maintain Worker's Compensation Insurance,us,required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40UTLCrS OCC GROUP APN
M Wer�"�rc'�Gpp��eensalio asumnc5.�artier and folic a , eC - `
yncr.Jlh n_ �V iQV Policy NOY '-�� 10 GAS-EA.SYSTEM-OVER 4(EA) '
CERTIFICATE OF EXEMPTION FROM WOR KHRS'
COMPENSATION INSURANCE _ GREAS_IYINDUSTRL WASTE INTERCEPTOR
(This xenlon Deal not hecompleted if thepermi,is fnnmc BUILDING DIVISION FEES
hundod dollars(SIM)
ar less) GREASE TRAP" - PLANCHECK FEB
Iceadfythwimthepafarma..O.Nhav, kforwhichthiapumit ixlnwcd,lsholl SEWER=SANITARY-S'IORM I?A.2110 PC
an
not employ my pxrmn in y manner so as to becanc¢subject m the Workers'Co.,.- s ENERGY FEE
,Z cation Law.wtd California.Dam WATER HEAT ER WNRIS VELICTR
0�7 O Applicator GRADING FEE r
,,i,, NOTICE TO APPLICANT If,after making this Certificate if Exemption,you.should WATER SYST fisiffREATING
become subject to,he Worker's Compensation provisions of the Labor Cale,you must t SOILS PER -
LaL1Q fnrlhwilh comply withstich provisions or this Permit shall be deemed revoked.• WATER SERVICE
QONS98ULTIONLENUINGAGENCY NEW RESIDENTIAL PLMB. SQ,FT, PAID
d y..
UO I hereby affvattbhtmereis u construction lending agency l'anhe perllmnance.1 Dave ReceiptX
Lks F ,he work far which this Permit is issued(Sec.3097,Civ,C.)
O U Icoder's Name TOTAL: -
W Lender's Address T(
I ecoil'y elan l havo rend man applicmlon and mala the the above information is - - BUILDING FEIi J,
f�/f correct l agree to comply with all city and county ordinances and state laws relatting In QTy,, MECHANICAL PERMIT FET:
U7
F7 building construct on,and hereby anbnrize representatives of this city to enter upon the SEISMIC FEE
abovcmentianed properly for inspection purposes.
(We)pgree 1a save,indemnify n.J keep hnnnlcse the City at ISSUANCB y al Capertin,.,.in,, OLIiCTRIC FEIi
liabilities,judgmemts,costs and expenses which may in any way inameaminst said City ALTER OR ADD TO MECIL
in comequcnce ofine,ran ting of this mem'. - PWMBING PEE
APPI CANTO ST AND LL COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO 10,MX)CFM)' '
SDURI +REG ATI 1 M17CHANICAL FEE
AIR HANDLING UNIT(OVER 10,M)CPM) CONSTRUCTION TAX
Sarea ef Cmmave
nracr - - DEXHAUST HOOD(wmuCr) HOUSING MI'TIOATION FEE¢HAZARDOUS MATERIAI S DISCLOSURE -
Will theapplanot or nature huildingawcupunlsore erhandle bazunhos raecniii BEATING UNITGif)100.009FITI7) ,
as definaJ by she Cupertino_Municipal Cade,Chapter 9.12,and are Bastin,and Safety
Code,Section 25532(al'! HEATING UNIT(OVER 100. 10 BTU) -
OYes F1No PAID
/ VENOIATION BAN(SINGLE RESIDE Data Receipt
Will the applicant or future building occupant use equipment or devices which BOILER (3HP OR 100,000 BTU)
•mit haaanlous air contaminants as defined by the Bay A.Air Quality Management TOTAL:
L
iBOILER-COMP(OVER 110,0(X1 BE U)
El ON.
read the hazaroms mamriils requirements under Chapter 6.95 of the Cali Alit CONDITIONER ISSUANCE FIAT]--
pectin
AT]-
Health&Sore, Cede, ns 2551]] 5533 wd 25534,1 mtdwswnd that if(0et NEW RIiS1DENT1A1,MECH. -9Q.PI'.
I le ail, F Its my fC.tpamsibi ily le nnlify lh¢eetupail
here mat v,locate nuance tufa Certificam of Decals cy. '
hon uo � —""Oce 'TOTAL: ISSUED BY
OFFICE'