S 0204 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH.DING.ELECTRIC.AL , PITT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL XJ 0204
,; RUILDING PROJEC!'IDEN'1'IF'ICA'i'ION'.t."
ISANIIARYNEO, AI'PLICA'1'ION SUNMI"IT'AI.UA'1IiIhIIING AUURESS: -
Crcc.1L 61yd- db00 Cvpv'Frnv 9�1k-F �i 'Z-I-tWNER'S NAME: . PHONE: CON'TRAC'IOki NAME LIC NOCONTROI.k_HITEC'IAiNGINEER: LIC NQ ADURFSS:
CONTACT PHONE: -BUILDING PERMIT INFO
❑ Consultant Foes Paid by Applicant(Initial) B la,rn' PI3 MFCU
LICLNSFD CONTRACTOR S DECLARATION - QTy r I LECTRIC PI RMIT 1 III FEL ❑
I hereby affirm th t 1 uen I de p - dChupor 9(comm 'ng + _ r: JOB DBSCRII''1'ION
,,
M W Z, wish Section 7(NIID of U' i loo 7 of the Busmass and Pr f.:ons Cndc,and my he nw IY RESIDFNTIAI.
(App PLNMIT ISSl1ANCC
C,FU- no full forceond effect. ❑SFDWI. F3 KITCHEN REMODEh
F ZIil Oamnse Class Convemor APPLIANCES-RESIDENTIAL. ❑ADDITION [I PLUMBING RE-PIPE
'ARCHITECI'9 UEChARATION PANELS ❑MUINI-UNIT 0S9'RUCTURAL
F7sq ,
yz I understand my plans shallbe used as Public records
o°z c MODIFICATIONTION
::11 UP'1W
'02AMPS El INTERIOR ❑CHIMNEY REPAIR
Licetrsctl Prolessional 201.101X0AMPS IMPROVEMI:N'T' ❑SWIMMING POOLS
OWNER BUILDER DECLARATION ❑BATH RI?MODCUREPALR ❑DEMOLITION
�`4�,.I OVER I"AMPS
CCW 6 1 herchy atTrm That 1 nm exempt from the Contractor License Law for the Cl OTBE.R
d U 4s1}nwiag reason.(Section 7031.5,Business and Ihofea,aaa,Cmh,:Any city or county SIGNS F.LEC'FRICAL
F w O^ which requim,a Permit to camshaft,after,improve,dmnalish,m repair any someone _
1JJJ prior o its issuance,also requires the applicant for such permit to file a signed statement SPECI AL CI RCUITIMISC.
feat he is licensed Pursuant m(he provisions of the Convenors License Law(Chapter 9 COMMERCIAL;
SOC (co�sencing with Section 7000)of Division 3 of the Business and Professions Code)or TEA11'.MF,TT:It OR POLF.INS'I'..
'q y M a ohm he is exempt therefrom and the half,for the alleged exemption.Any violation of _ ICIEW ISI.DGIADDITION ❑DEMOLITION
YXI 4•
Section 7031.5 hymyn,plimeh far a pencil object,me allheinna a civil pcnahy 0 POWER DEVICES NAN'P ❑FOOD SI?RVICE
y m more than five hundred dollars(85X0.
FZ61,as owner of the ro rt.orm enlaces with woes as their sole mm ation, SWIMMING 1'001.Ii1.ECi'RIC PR(1VIT11;NT
❑ n Y 6 fens HER
F_ ll pi@swank,Craft:
su Cmtisnrn
intended nrowdo l'metaBee.7(94,Business
L 3 m and Professions Codc'Dte Commcvsrs License Ino Jas ooh apply m an owner of OU'T'LETS-SWITCHES-I'1%TURES
pros ry who builds or improves thereon,and who does such work himself or through
hos own employees,provided that such improvemm�ts are not mended or ot!d for NEW RBSIIIIiNTiAI.ELEC'I'N SQ PT.
sale.if.however,the building or improvement lssald within ane year of meopletion,the SQ.FI'.ITIOOR AREA $ISQ.Pf.
mer-ladder will have the h nden of proving that he did not build on improve far par. Pf p ' D
porve nl sale.L TUI'AL 1— A
❑1,as r of the pre a ny,am exclusively contracting with licensed contractors o
construct theproject(See 7044 Huanee:and Pr fe..i n Cod:1 Ibe C t t f.I- ,•rs c - C^ 'r
cruse La I not apply to un owner of p p ty h hddimprovesthere fail QTY. s', i PLEI.MBING PERMIT' ( 1 {, r" 'FEF. .,r N 24 prps9
who comment for.such grocers with u cont odq licensed pursuant the Comnclorx r ' IIC41D
I'ccose La PERMIT ISSUANCE �r
'c"ase
emp under Sec. ,B&P C far this rent I' r Ur
ALTER-DRAIN&VENT-WATER IEA) A'UON
Own Un¢
- WORKERti ENSATION DECI.ARATION BACK FLOW PROD ECT.DEVICE
I and
w affirm maintain
a pennhy of pe Consent
on ens of the fnatia,for
dedua0are. -
Jihave and will maintains Cenifcate of Conannoself-insum far Workers Compen- DRAINS-FLOOR.RODE AREA.CONE. STORIES TYPO CONSTRUCTION
,moan,as provided for by Section 3!1x1 of the Lahr Gxlc,far the pedenneace of the
work for which this permit it issue. FIX'T'URES-PERT RAP F
❑1 have and will maintain Warkerx Compensation ho,mmue,os required by Section
3700 of the Ldmr Code,mica,pe,finrtanceel the work for whicbthis permit I,issued. GAS-EA.SYSTEM-1 INC.J OUTLHffr OCG OU APN
My Worker's Compensation lnwounce carrier and Policy number arc:
Caniee Policy No.: GAS-EA.SYSTEM OVER 4(RA) _
CERTI FICAggi OF EXEMPTION FROM WOR KERS' GRI!ASNIINUUSTRI.WASTE INTERCEPTOR COMPENSATION INSURANCE I N i DIVISION PEES -
pfiisnedionncednotbecompinedifthepermitisforoachundteddollars($11X) GREASE TRAY
- nr lessJ. - 1'LANCIII
I ceniOr that in the performance of work for which this Permit is issued,l shallSEWER-SANITARY-SEE ORM F.A.2W FI'
not employ tray person in any manners as to become subject ho the Workers'Con,sm I!NEH 'EE
Oz nation Luws of Cali forms,Dmc WATER HEATER WIVENIELECI'R
z Applicant
CRAM IEE:
0 A
y NOTICE TO APPLICANT:If,afar caking this Cmificme of lixempton;you should WATER SYSTEMn REATING -
(~ [' nomns
forfeiture object the Workers Compensation provisions of the i"ma,CIA.,You must SOILS IgiE
ao G hwim comply with such provisions or this permit shall he deemed revoked WR'I'ER SIII<VICE
fon
Eli p a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH, SQ,FD PAID
s7 z Iherehy affam that tberel,a canaaatin I lending agency air(he pedualawn of Date Receiphp
{U0 the work(car which this permit is issued(See 3197,Civ.C.)
O Lcndcrs Name ' 'IVTAL:
V� P�der',Addrery FTOTAL:" C < 1 amity that 1 have read this,application sad into that the Acle informminn is ,-- _ , BUILDING F Plili
TA corect.l agree to comply with all city and county ordinances and ante laws relating ho QTY. MECHANICAL PERMIT" 1 'Flili
ttiy r I SIi1SMIC FEE
i...( 0. bulJingmnarvclnn,and herchy nuthnrizc represemotivex of thio dty'ummer upon the -
alrove-mentioned papa nY for inspection ampooss. PERMIT ISSUANCE FLEC9'RIC FEE
- (We)agree to for indcmnify and keep harmless the City of Cupenino Samo t
Iluhllhiea.jndgmemac slxandmxpensx wh et may In any way u¢meuguin,t saiJCity ACTERORADD'IOMP,CII. PLUMBING FPI:
in consequence of the granting of this permit. -
AI'PLICAN" .RSTANDS AND WILL CO 'LY WITH ALL NON-POINT AIR HANDLING ONIT(T(l HI,000 CFM) MECHANICAL FEE
sd RC iIsn "IONS.
AIR HANDLING UNIT(OVBR 10,000 CPM) CONST RUCTION TAX
Signuwre nlA cunUCanfacm' nese E%IIAUS'1'I100DIWIDULTI HOUSING MITIGATION PEE,
HAZARDOUSM AIS DISCLOSURE
Will applicant or future built
gmcupam Blore or handkhaznrdaus material IIGTING UNIT(IY)I(XI,IMXI BTU)
as defined by the Cupedioo Municipal Gdc,Chapter 9,12,and the Health unit Safety
Code,Section 25532m)^ - III:ATINO UNIT(OVER I(IgfX)(111'IV)
❑Yct r7 No VI!NTIIATION FAN(SINGLE BESIDE ('AID
Dmc Necdpt N
Will the applicant or future building reception me equipment or deviccs which BOILER-COMP OHP OR 100,00f1Id1U)
sit hazardous air confirmations m defined by the Bay Arca Air Quality Management TOTAL:
- sianctP HOILER-COMP(OVER 100,000 If I'IT
Cl Yes ❑No
I have rend the hazardous m:nerms retptiremems under Chapter 6.95 of the Cafi- AIR CONUI'HONER ISSUANC17 DATE
humin Health&Surety Code,Sections 25505,8533 and 25534.1 uademand that if the IN 11W RESIDENTIAL MSCIL SQ.FT.
building does not currently have a tenant,that it is my resrymsihilin to notify the occupant
of the nr-{uiromwnt which nmv be met poor m issuanec of it Cenilicme of Occupancy.
Owner or authonJ motor Date TOTAL ISSUED BY.OFFICE
�PCyARq . . . .
°0 FIRE DEPARTMENT
FIRE '�° SANTA CLARA COUNTY CONTROL NUMBER
• 14700 Winchester Blvd., Los Gatos, CA 95030.1818 PERMIT NUMBER ks
(408) 378-4010 (phone) • (408) 378.9342 (fax)
PLAN CHECK No.
PLAN REVIEW COMMENTS
CODE/SEC. SHEET NO.
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JURIS PLANS SPECS NEW REMODEL AS CONST.DESCRIP BY fi DATE PAGE
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SEC./FLOOR OCC OCC.LOAD AREA ARCWENGiCONTRACTOR/OWNER
0 Z200 3hAJ& 4 3 !M 64qlCk
NAME OF FACILITY LOCATION 6 c44 7 C 600
l l��►c /� cA� El� �t
1-151f2 � 210�1 5%e✓E�5ek / r
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
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