B 20325 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO
BUILDING DIVISION APPLICATIONMERMIT PLUMBING 50001 _%0325
BUILDIbi PROJECT IDENTIFICATION
BDINOG AI)I)NI?SS�/��0� ��bef/110 O/� SANI'ITRY NO, APPLICATION SUBMITTAL DATI
O N 'S N ME: r E: �. 2 02
RACTOR'S NA :: LIC NO.
NIC CONTROLp
IT 1ENGINE N: , I ICNO ADDRESS: ❑ �?
�/ �� BUILDING-JPER LU INFO
(1` Consultant Fees Paid by Applicant(Initial) DLDG ELECT PLUMB MEcx
Ll r Efr' e� rr
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
%2 D'Z
I hert .ffi
hyrm der that 1 am licensed unprovisions of Chapter 9(commencing JOB DESCRIPTION
with Section nxlo) .
olDi 'sion 3 of the to..n.sa and Prof xmn.code,and type case is PERMIT ISSUANCE
�C)O in full force and effect. O /'CJ 3
Liesuce Class Lic.p C V ❑SFUWI. El KITCHEN REMODEL
H Dam Convactnr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Fpy ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
Z p tt2 Z I understand my plans shall be,used as public retools MODIFICATION
OIZ,., UlIT02MAMPS [:1 INTERIOR El CHIMNEY REPAIR
1-•��j t�i Licensed Professional 2(II-11100 AMPS IMPkOVRMENT C]SWIMMING POOLS
020,,te�t1 R OWNEBUILDER DECLARATION OVER["AMPS C1 HATH REMODEUREPAIR DEMOLITION
Q 1 hereby affirm that 1 am exempt from the Commences License Law for the
3 a V fallowing mrs rm.(Section 7031.5.Bmines and Pmfecvinna Code:Any voy or county SIGNS ELECTRICAL ❑OTHER ^'''O
as which requires a permit to c...tmc,,alter,improve,demolish,or mi nit any mmcwrt L
'+
prior,.its inuance,nlso anx,iresdarpplaud for such pertain.file.signed statamem SPECIAL CIRCUIT/MISC.
y"1G� thatbeisllcensed pursuam to he provisionsof,he Conuacmrs License Law(Chapter 9
W p0 (commend,,,with Section 7")of Division 3 ofthe Business snit Profession,Code)., TEMP.METER OR POLE.INST. COMMERCIAL:
Its a e' that he is exempt therefrom and the hasis for the alleged exemption Any vinlinion of ❑NEW BLDG/ADDITION ❑DEMOLITION
W
Section by any applicant for a permit sobjmts the upplietimm a civil penalty of POWER DEVICES
=y []TENANT ❑FOOD SERVICE
F Z} not more than five hundred Jolla,,(E$(D). IMPROVEMENT
Oa ❑Lothewrof the propeny, rmyemntendedwithwngesasthei(Sec.rompensmion, SWIMMING L F. IC
will do the work,and the swnom is nm intended oroRcred for sale(Sec.]011,Business ❑OTHER
and Professions Cade:The Combanor's License law does not apply to so ca, of OUTLETS-SWI RES 3 r J
3 propeny who builds or improves there,,.,and who dons such work himself nr through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDF.NTIA.ELE Q FT.
sale.If,however.the building or improvement is sold within one yearofcompletioathe SQ.FT.FLOOR AREA E/SQ.f4.
mer-builder will have the burden of proving that he did not build or improve for pur- G-O
pose of sule.) ``g
❑1,as owner of Ne propeny,am exclusively contracting with licensed contractors to T L' ego
construct,he project(Sea 71144,Business and Professions Code:)The Commons Li-
come Law does notapplytoannw r ofpaiwho builds or improves thereon.and QTY. PLUMBING PER FEE
whn contracts limsuch pmjoclyA , cit, (v)licensed pursuant to the Contractors '
License Law. T f
I an exempt under Sec. L� ,B&P C for this recon PERMIT ISS NCC S�J�
Owner Date ALTER- &VENT-WATER(EA) VALUATION
6
WORKEPRR'S COMPENSATION DECLARATION BACK FLOWICE /
Ihereny.rbrm ameer pann),y tap i.ry.ne anha fnlmwing den...fir.: U ' Q7(9J U
❑ Iloveird villumirdiir.Celiticumnfeverent to self-inmrc for Worker'0 C m,pen- DRAINS-FLUOR,HI 'AREA.COND. STORIES TYPE Cf1NS1'RUCDON
as provided for by Section 3700 of the Labor Code,house performance of the
ark fm which this permit is issued. FIXTURES-PER TR 0•�(� `r a�n
1 have and tam W ins Compensation Insumnee,as required by Sation
""at rC gforN rfmmence of the work for which Nis permit is issued. GAS-FA.SYSTEM.I INC.4 OWL E. OCC.GROUP APN
My Wor r r e d Policy number are:
Catrlcr: Policy No.: GAS-FA.SYSTEM OVER 4(PA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
fH,is section need not becomplemd if Ne permit is forme hundreddollars(5100) GREASE TRAP f
or less,) PLANCHFCK FEE Q 7J`
Ioys,that
.a the performance oma.beemfor ewhich tw porithe iinke",Comssued,I hall SEWER-SANITARY-STORM EA.XXI FT. "�
not employ any person in say manner so us to buame subject,o Ne Workers'C.mPen- ENERGY FEE 32 , /y
� z smiou Laws of California.Date WATER HEATER W/VENT/ELECTR
Applicata 1 GRADING FEE
.Nr NOTICE TO APPLICANT.If,aper making this Certificate of Exemption,you should WATER SYSTEMaREATING
a, SOILS PEE
becomesubject suhjeco the Workers Compensation provisions of the Lahr Cale,you most
forthwith comply with such provisions or this permit sha11Ise deemed revoked. WATER SERVICE
0
n' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FT. PAID ���4• LS
I herth ffinwhrodum is a construction lendin Some rformunce of Date Hec
VQ yu .agency pe 12?.05-
�. the work for which this permit is issnoil(Sec.1097,Co.C.) -
O f" Lenduea Name TOTAL
V Lenders Address TOTAL:
y I agree that 1 have and this application and stem that the share information
ng is BUILDING FEE
h
correct, egrectacomply wcabyacity add county ntaiivex afnnd site lawsrefusingupon
QTY MECHANICAL PERMIT FEE
building construction.and hereby amharim reprenemativea of this city meter upon,be SEISMIC FEF:
shove-me.tinned Property for inspection purposes. PERMIT ISSUANCE v
(We)agree to save,Indemnify and keep harmless the City of Cupertino against ELECTRIC FEE 30•
Iiahllities,judgtnems,costs and expenses which may in any way accroe against said City ALTERORADDTOMECH. PLUMBING FEE G
in consequence o[ gra ting of this peon,,. p s60
APP I' DER ANDS AND W L OMP. WITH ALL NO POIN p1µHANDLING UNIT(TO 10,1X10 CFM)
SOU l )I ATI NS. X MECHANICALFF.E
1r�Jv C- �y9 AIRHANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Appl'm..UConwnor O/ IJat EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE.HAZARDOUS MATERIALS DISCLOSURE
Will flu,applicant or future building occupant store or handle hazardous material HEATING UNIT(DO 110.14)0 B9'U)
as definN by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 2553200? BEATING UNIT(OVER 100,000 BTU) CC�qp
❑Yes XNu VENTILATION FAN(SINGLE RESID) PAID S-1ti-r / Z5�7P
/ Dem Receipt of
Will the applicants future building occupant use equipment or devices which µOILER-COMP(JI{POR 100,(KKI I1'IV
mit hoaudom air contaminarnttss as defined by the Bay Are.Air Quality Management TOTAL: t Q
isuict]❑Yes Nu BOILER-COMP(OVER 100,000 BTU)!.T�AAIR CONDITIONER
I harc read the hvaolous material Ir.mems under Chapmr 6.95 of,he Cali- ISSUANCE DAT
fomia Heult Safn Code,Sunio.. Sa.,25533 C5it 25514.1 toitoomi tom if a NEW RESIDENTIAL.MF.CH. SQ.PT.
hu d not cu ntly havcatannn fiustny Immsihilirymno,if , um
hich must he tan Hca
/ - Owner or authonmd agent D e TOTAL: ISSUED BY. A~7
OFFICE