S 0321 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY,DF CUPERTINO BUILDING-I'LECTRICAL PERMIT NO.
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL S 0321
BUILDING.PROJECT IDENTIFICATION
BUILDING )!)SS: Al. � R` SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NA3EZJ3 PHONE: Cj`J CO CIDRS NAMEI:. 1 r/fir./w L ,N�Ors: t
,_/ �(IV LCr` / �/6, I NlC CON'IRCL#
4RCHITECDENGI LIC NO: - ADD FSS: N. 4 ❑
V
CONTACT. PHONE: BUILDING PERMIT INFO
&p� PCa�s)9�s ❑ Consultant Fees Paid by Applicant(Initial) BLDG PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT F
1 hereby affirm that I am licenced under provisions cf Chapter 9l commencing JO DESCRIPTION
W pan with Section]IAMpof Division 3 ofthe Buxinessind PrnfescionsCde.anJ my licenseis ' PERMIT ISSUANCE RESIDENTIAL:
in full force and effect. OSFDWL ❑KITCHEN REMODEL
tut License Class Lie,# APp1.lANCIS-RESIDENTIAL ❑ADDITION L1 PLUMBING RE-PIPIT
Pzw Dam Conamemr
Fly ARCHITECTS DECLARATION PANELS [I MULTI-UNIT El STRUCTURAL
vn Z I understand my plans shall od used a public records MODIFICATION
Oz—, UP TO MIO AMPS [I INTERIOR [I CHIMNEY REPAIR
a,`�„�41 Licensed Professional 201-0100AMPS IMPROVEMENT SWIMMING POOLS
C C Q 1 hereby union OWN that Iam exempt f a tCLARnTreONrs License Law for the OVER 10WAMPS ❑BATH BE
BE OF!REPAIR �D. 0 TION.�y-'�
K�M V following reason.(Section 703 1.5,Business and Profession.,Code:Any city or county SIGNS ELECTRICAL. �L+l}�R � �0 N
Yl LL O which requires a permit m conswn,alcor,improve,demolish,or repair any swaure K�-C
F' prior to its issuance,also requires the applicant for such Parmino file a signed statement SPECI AL Cl RCUI"1'/MISC. ii Mail,inp.
�} that he is licensed pursuant the provision,dilaw Conuncmr'e License Law(Chapter 9
�yp0 (commencing with Section of Division J offs,Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL,
a 6 o that h,is exempt therefrom and the boas for Ne alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DIiMOLITION
❑N
Section 7031.5 by any upplicam for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not more than five hundred dollars($500).
F Z} IMPROVEMENT
6 �hosowner k,the tropeuctur myemployees with wages astheir(Sea 704,LBsiiess SWIMMING POOL ELECTRIC
wall Jo the work,and thestructure is not intended nntlicred focor apply 71414,Business []OTHER
tail and Professions Cade:The Ccmmnors Liauxi.aw does nm apply m an owner of OVfLETS-SwITCHFS-FIXTURES �0
prrryeny who builds or im moves thereon,and who docs such work himmif ser through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL 1?I.130 SQ Fr.
sale.If,however,the building or improvement is sold within one yearofcompletinn,rhe SQ.FE FLOOR AREA E/SQ.FI'.
mer-(wilder will wave the burden of proving thm he did not(wild or improve for pur-
pose of sale.). ,0O
❑I,as owner of the property,ten exclusively convening with licensed crmrwemrs to TOI'A
comma x tae poojat(Sol.IlW4.Business send Profeaaime,Con,The Contreclor's Li-
censeWwdoesnotapplymanownerofpmpens whored pursuant to
thereon and QTY. PLUMBING PERMIT FEE
who umaacu fur such project,whhaeommnor(s)licensed pursmm terse Conaoemis pp�g pp
License Law. PERMIT ISSUANCE P A e D
❑I om exempt under Sa. .B&P C fm Nis re esm
ALTER-DRAIN&VIiNT-WATER(EA) 9 VALUATION
'Owner Oise JUL NII
WORKERS COMPENSAT ser DECLARATION BACK FLOW PROTECT.DEVICE (y u
I hand willlmai under penalty oe pe Jury one of the followingleor edket's Conover-
TSO �Tp101FR�J u
❑Ihave end will maintain ation 37M of Cort senor Cod.for tPor Workersce of du- DRAINS-FLOOR,ROOF AREA,COND. CITY VI EfJFLH�I TYPL CONSTRUCTION
safiof a provided for by Section 3]00 of Nc Labor Cade,for the Performance of the
k for which this permit is issued. FIXTURES-PER TNAP
1 have and will maintain Worker's Compensation Insurance,for wh .s'ms Per by Station
]
cause Mbar Cade,for the performance of the work for which this permit is issued. GAS-FA.SYSTEM-1 INC.4OUTLETS OCC.GROUP AI'N
CrWor)Yc�nm_ pcpsa1Ingereanicrand Policy nury3A N52AL OAS-EA.SYSTEM-OVER 4(EA)
,f. I Policy Na.: [.`7fR 1,
UibeJ114CVRnFICATE OF EXEMPTION FROM WORKERS' GRFASF/INDUSTNI.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVE FIiES
(Thissectinnneeul not Wman,leled iftr,corit is foronehandreddollars($100) GREASETRAP
or leas.) PLANCHECK FEE
I certify that in the performance ofthe work forwhich Nis permit is issued.I shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as m beton a subjectto the Workers'Compen. ENERGY THE
.OZ .cation LawsrfCmifimrw Date WATER HEATER WNENTALECTR GRADING ITE
Z O Applicant '-
NOTICE TO APPLICANT.IL after making this Cmificam of Esemptian,you should WAFER SYSTEM/TREATING
become suhject to the Workers Compensation previsions ofthe Labor Code,you must 5011.5 FEE
RI.. forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
p" CONSTRUCTION ENDINGAGENCY NEW RESIUIiNT1Al.I'LMB. SQ.Pr pAIU
r� .�7. Date Rec�eIplN
VQ . I hereby.,it
Rodthemi iea .construction0 lending agency for the performance of
LL Pthe work for which this pernif is issued(Sec.309],Civ.C.)
Lender's Name TOTAL:
O V Lender's Address TOTAL:
cg's 4 I certify that 1 have read this application and slam Nat the uMv<information is BUILDING PEE
iFi h coraco.iogrecto comply with all city and county nrdinanca and slam laws relating to QTY. MECHANICAL PERMIT FEE
V building construction,and hereby uahoriec representatives or this city to enter upon the SEISMIC FEIi
above-mentioned property for inspection protocol. PERMIT ISSUANCE
(We),gra m save,indemnify and keep hemtlecs the City of Cupertimo against ELECTRIC LLE
liebilitics,judgments,costs and expenses which may in any wayve bueri,mnst mid City ALTERORADDTOMECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT ERST NDS N ILLCOMPL WE IALLN!]!- NIT AIR HANDLING UNIT(TO 111,000 CFM) MECHANICAL FEE
S c UI T
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sig tam of pplicautiContmdor\_Of JDatf EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEB.
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building uccupanutow or handle hazardous material HEATING UNIT(TO I t1BWB BTU)
as defined by the Cupertino Municipal Cede.Chapter 9.12,and the Health and Safety
Coda Section 25532(a)? HEATING UNIT(OVER IU),INN)BTU) a'
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID Dam Receipt
Will the applicant or future building occupant use equipment ar devices which
emit haznrdouc air contmninants as defined by the Ray Area Air Quality Management BOILER-CUMP pHP OR IW.uEgo B'rut
TOTAL,:
Distrin? BOILER-COMP(OVER 100,001 BTU)
❑Yes ❑No
I have rend de hazardous nationals regrimmcmx under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
firman Health ae Safety Cade,Sections 2.55115,25533 and 25534.1 understand Not H the NEW RESIDHWIAL MECH. SQ.IT.
building does not curemly have.tense.,this it is my re.,11asibility m artily the cwcupant
of the requirements which most be met prior ser is,muce of a Certificate of Occupaay.
Owner or
an
agent Date TOTAL: ISSUED BY:
OFFICE