S 0725 APPLICI•NT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUu,DING-EI.EC'I RICA], PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUM,PROD CT IDENTIFICATION
O 0725 7 2 5
IIUILDIN(:PROJECT IDEYI'IF'ICATIUN O 1
SANI'T'ARY NO. APPLICATION SUBM1II'1'I'IALAh DAl
iIIIALDING ADDRESS:
Imo- 2-0 — lie Ott D� .��N 22L 2234 If 2Zy LzLICNO,J1 2 2) act qr
NER'S NAM.: PHONE: NTBACTOR'S#AMG /� LIC NO�/ 2 N/C CONTROL#
Wo . f �yAisoh SS
CII1'1'FCA/ENGINEER: I LICNU: ) L•✓'lf` K 0`r ❑
CONTACT': PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT, PLUMB MICA
❑ ❑ ei( ❑
LICENSED CONTRACTOR:S DF,CLARA11o1 QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(comrmming
Q9z whir 5cetion]fXM])ofpivision3ofthe Bminesswnd PsfirOmas Cock,and my license i.a RESIDENTIAL:
,00 m PERMIT ISSUANCE
F1_ lull fiuceand cRcc}. G ❑SFUWL C3 KITCHEN REMODE
a Urj License Cla.s APPLIANCES-RESIDENT'IAL El ADDITION E]PLUMBING RIi-PII'F:
yah
Dam Conovaor ��] ❑MULTTUNIT ❑STRUCTURAL
kCHITECI';S U Y:LA A'ITON PANELS MODIFICATION
FNy Ino
nl- a to . . IFa nsa t colorZZ- UP'10200 AM I'S El INTERIOR
❑CHIMNf;V RIEI'All<
OZ-�
F- sed l'n essinnul 2111-Itxx1AMPS IMPROVEMENTSWIMMING POOLS
OWNER-BUILDER DECLARA OVER IIXXIAMI'S ❑BATH REMOTEUREPAIR ❑DEMOLI'I]ON
6 I herchy afGmt lhul 1 ten exempt front the Co ,mars License Law hu the ❑OTHER
if O6 U following mann.(Section]0113,B.,mrss and Professions Cade:Any city or county SIGNS ELECTRICAI,
a,3 CW N which requires o permit m nm
cowsu ,alter,improve.demolish.or¢pair any stmcurre
F'I='�� prior to ns ill uanef.also¢quifex theapplicvm far such permit m Glca.igned smtanem SPECIAL CIRCUIT/M1115C.
fly mat he is licensed pma...l otheprovisinns urine Comracnsrs License Law(Chapter4 COMMERCIAL
Iwsmnencing with Section 7000)Of Division 3 of the Business and Professions Codclnr TEMP.METIER OR MILE INST.
cc a cC that he i..exempt therefrom and the basis for the alleged exemption.Any violmian of ❑NEW BLDG/ADDITION C)DEMOLITION
W^NSection 7031.3 by any applicant for a permit subjects the applicant ao a civil Penalty nl POWER DIEV ICES ❑TF,NANT ❑FOOD SIERVICIi
.n1 none Than live numbed dallva($100). IMPROVEME:ND
5SQ � I.asownernitheprnpony,ofnrymoployceswi,hwage,asmeirsolecomprnsaioo, SWIMMING POOL ELEC'I'RIC
W.. wJl An me work,vndthe ctrumul'e is nut lmundedornRvfN fnrsalclScu.76,14,Business 1!k
cc 3 and Pndcasions Code.The Comnmmr's License Law dons not apply ,,an owner of OUTLETS-SW'I'ICIIFS-FIX'I UR17S
0. properly who builds or improve,memon.and who does such work himsell Or through
his own employees,peoideol that such improvenenn are not intended or offered for NEW RESIDENTIAL CLIECIR SQ FI'.
sale.IL hsnvcvcr.tire.fuilJin6 ur intpmvatwm i.edd within be yearoff nplcuom he SQ.PI'.pl, RAREA $/SQ.FIE
nerbuilder will have the burden of proving that he did not build of improve for for, r M I D
pore of sale.). TOTAL:
1,as owner of the propen%am exclusively contracting with licensed comnetnn to /1
construct the project(Sec.lOtL Business and Profesm ioCode:)The C9nlmclor'.Li- O[awf �1
cense law does not apply to an owner of property who builds Err improves thereon, ad QTYZR .
PLUMBING PERMIT FEET oT1
whornlloraw for.ueh projects with vconaanor(s)licensed pursuant Connector's Clip.V
Liccnac law. ,I3 Nr I'C for thin reasoUANCE I r
I nm exempt under Sec.
AIN&V IiN'I'-WATER(EA) VALUArlO
Owner Dre
WORKER'S COMPENSATION DECLARATION IRO]PT'.DIEVICEI hereby affirm under pcndtyal perjury oneof the following dcdamdon,
I have and will maintain a Cenifica,of Consent to self-aware for Worker's ContpcnLOOR,ROOF.ARIEA.COND. STORIES: TYPE CONSTRUCIIf
/ cation.as provided fnr by Section 3700 of the Labor Code,for the performance of thwml,for which this permit is issued. -PISR TRAY1 ham and will maintain Worker's Compemation Insurance,as required by Sectio3700ofthcLahrCode.Rethe peiimrneeofthc work for whicfti.permit isievardYFTIENFI INC.q OUTLETS;
I ETS OCC.GROUT' AI'N
My WnrA ('n �r�sat�n 7ur cc and pu bora ;�� a53� GAS-F.A.SYS'I EM-OVER J(EAI
Cartiee /7 amkr an Y �•
ER FICATfi OI'li%IiMPI'ION FROM WORKERS' GREASE/INDUS'IRL WAS TE INTERCEPTOR
COMPENSATION INSURANCE I1IJILDING DIVISION PEES
fDssectinn needoot lxx contpleled it bmaoil is saran,hwndrcd doll;...AIXB GREASE'I'RAP or Icvel I'LANCHECK Igili
I certify that in the perfornwnscol lfework foranch thispermit is issued l shall SEWER-SANITARY-STORM EA.211111-7,
oat employ any Person in any nalourso ass to hsconle subject,.the W..cis Compca- ENERGY THE
O Z cation laws of Califtrmia.Date WATER BEATER W/VENTMLIECfR GRADING FETE
Z O Applicant
y NOTICE TO APPLICANT:If, it,,making this Crnifcate of Exemption,you should WAI ER SYS'I lzmf1'REATI NO SOILS IEE
(~ neem a Inflect to file Workers Compensation provisions of the Labor Code,you must
0. forthwith comply with such pool Siaws Of permit shall be deemed revoked WATER S17RVICE
aPAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FT, pate kccetpt A
I hereby affirm that ahem is a eonswmian lending agency for the orhummoccof
U 0—
W F the work Pur which this pemtil is i..ued(Sec.3097,Civ.C.) TOTAL
O U Lcndcr'n Name
0 PJ benders Addmss BUILDWG FEE Izz
LIs I eerily that I have read Nis applicnif :rod,tate mal the abovo inl'onoallm is
,Esso lip erect.l agree to comply with all city and county ordinances and.state laws minting to QTY. MECHANICAL PERMIT FEE SEISMIC
U Z huildin6 cnnnwctian.and herchy amhnriz<repmsenmtivcs of this city menmr�le�thc
eMrve.nemloned pm,fy fnr lnnpebon purposes. PERMIT ISSUANCE ELECT CITH
(We)agree to nave,indemnify vad Lee,harnlan the City of Cupertino again•
liabilitics,judgments,costs and expenses which may in any way accrue ageinet said City ALTER OR ADD TO MECH. PLUMBIN(' 'EE
in mscquence oflhe gradin of this permit.
APPLICANT UND sRST Ii')S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT'(T'010.(XX)CFhU MECII ICAL FEF,
SOURCE REGI' TI
a Q AIR HANDLING UNIT LOVER 111,1X111 CFM) CONSTRUCI N'TAX
arc of AppllrnnlCounselor Oaf. / EXHAUST HOOD(W/DUCT) HOUSINGMI'IIGAI SPITE
IIAZARUOUS MAI HIGALS 1)&Z)s URI,
Will theapplicantor tams milAingnaeupzm xolm or handle hozmdomm:non.1 DEATIN .UNI I LTO 100,000 BTU)
as ddired by the Cupertino Municipal Code.,Chapter 9.12,and the Ilculth and ST 1, HEATING UNI I'10VIiN 11X1J00 BTU)
Code.Seclinn 25532(u)'!
❑Yes E]No VENTILATION FAN(SINGLE RMID) PAID
Date Receipt#
Win the applicant or furore budding meopunt use equipment or devices which BOILER-COMPOHPOR IWAX)BTU)
'mit hazardous air contaminants m defined by the Buy Arca Air Quality Management TOTAL:
District? BOILER-COMP(OVER 1(10.000 BTU)
❑Yes NO
I have reed the Core.Se mmcrink re, 5533 a under Chapter soul ol'the Cull-
AIR CONIB"I'H INER ISSUANCE DATE
li:mia Ilcallh&Safny Rdc.Sections 2$$115,255))unJ 25534.1 undcrwanA Ihuf it lire NEW HIESIDIEN'I'IAI.MIECII, SQ.Irll
building does not currently haven Icmm1,lhW II is my reslxmniM1llly m nullly the ixvvpnm
III lire requirements which must B+mm prions lsa:mce of a Cenificnm of(kcupancy.
Owner ar autMmted agent
Date TOTAL: ISSUED try.
OFFICE