S 1969 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
r
TY BUILDING-RLRCI RICA I, 1'Ii 1'1'X0
i QTY OF CUPERTINO ' 1969
n,DING DIVISION APPLICATION/PERMITPLuwlmr. w?<:unNICAL.
BUILDING I'RIIJRCI'EDF\'1'I4'IGTION
Hl11LUINGADDRF_SS: SANITARY NO. AI'I'LI ION SUBMITTAL DAH
1flQ8
UWNCR'S NAME' PHONE: )NI TORS NA E'. LIC NO:
V N/C CONTROL#
�•CH I HC'F/ENGINEL'R: LIC NO: UIIRESS: ❑
S- S
CON'1'ACr: PHONY:: RU ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB NISCH
LSED - 0-6�� El I/ EJ ❑
LICENCONT HACIOR:SD:CLARAI'[ON QTY. ELECTRIC PERMIT FEl3
1 hemby afar"and I run licensed under provision,"tChapmr 9(cantntemang JOB DESCRIPTION
Q 07 with Section 7000)of Uivdina 3 of the Insimmsond Pmk W..n,Cn In.mainly license is I'IIRMH ISSUANCE RESIDENTIAL:
F,WO Wfnll twee and u0nts ❑SFDWI, ❑KI'ICHfiN RIiMOUIiI,
QUV Liccn¢C Li `�� AI'PIJANCLS-RESIDEN'I'I AL ❑AUDITION ❑PLUMBING BEIIII'II
F z u] Dalr____s y CommGor
on6d ❑MULTIUNIT ❑STRUQ'UkAI.
AHCIII I'IiCI'S DECLARATION
~NZ IundcnlanJ mY plan„M1ull be uscl ac public recoNn I'ANIihS b10U119CA'H(IN
ZO-O N_ p TO 2W AMPS
❑INTERIOR ❑CHIh1NIiY REPAIR
F EQ!:W Llcahmd l'mfcs.ional 201-10NNIAMPS IMPROVEMENT 0SWIMMING POOLS
zY2; OWNIE-BUILDER DECLARATION OVER 1(XNIAMPS ElBATH REMOD17URFPAIR El DEMOLITION
C 6 I hereby affirm that I on exempt from the Contractor's License Law for the
IKy 3 tL U t'ollowing reason.(Section 7031.5.Husine%s and Professions Code Any city or county 1 SIGNS ELFC7fR1CAL � El OTHIik
v� y which"'Imre,n#,nail n.eunxtfine'6 alter,hmpmve,demolish,or repair any structure
LyNy th. ,l' all hl lI II l 1. amncm SPECIAL CIRCU FMISC.
>. thad 1 IJp , tt 1 p p' fth C t t I I (Chuptcr9 COMMF,BCIAL:
p o
W C, mmungwlh Sect ret 7NI0).J I i niofhv Im,nor. JI le'on,C'de)nr 'I'CMP METER OR PO B INS 1.
I he is excm t theretmnn uuJ the basis Inr the allcNal cxcmpmon.Any violation of ❑NFW BLDG/ADUI'1'[ON ❑DIiMDL'IJON
X-LL Sochum 703IS M any applit canline I,abec!,amlipplieanl In.civil#,malt 1 IOWER DEVICES
-y #cans j Yo ' El TENANT [I FOOD SERVICE
nal"urethan foe handled dollars
ye mpl IMPROVEMENT I�
=O ❑Lothas e c,k, dd the,no am,I, employees orc wugaa,Ih 1-1.competed-, SWIMMING POOL ..F IC
F will Jothcwmrk,Cwfr: stmcwrcraoLicense
actalSec.o an nolo 04
❑QTHER Grp
'L 3 m aril 1dy wbmm Calc inip Contractors cthe ' License Law d'he,not rply..It owner of OU'I LETS-SW'ITCHLS- DRF$
property whobuilds orvidedvuntsuch ,andwhod'v,re work himselfter through
bis awn rnghloycin,pmvlJal mal such improvements are urn Inlenu or ufferan far NEW RCSIDENTIA IiC! SQ PT.
,tdc.11;hnwcvcr.lhc bu'JJingor lnhprovmnnn h-old within oar ycan,f contpldioa the SQ.FI'.PIIfOOP�HIAD SISQ,Irl'.
er-budder will have the bunter of pnrving that he did mol hnIIII or improve forper-
posaofaal,dL - TOTAL: ��(�
I,a,owner of the property,am exclusively contmeling wild hcen.ed conlmdol,to • AUG 0 6 ANSI
congmcl the project(Sec.7144.Bu,incs.,and Pmfessiom Cwle:)The Cnno-anor'I Li-
redo,Lw does not appy uh an owner of property who builds or inlprne,thereon.and QTY. PLUMBING PI7RNIIT 9 FEE
who contracts for such Pmjce,with a commands)licensed prammand to the Conlrannh CttY Ur curertilN
License Law. PFRML'I'ISSUANCE
O 1 ata exempt under Sec. .11&P C far this mason
ALT i?R-DRAIN&VENT-WNI ER IFA) VALUATION
Owner Dam
WORKERS C(IMPENSATION DIICLARAI'ION BACK FLOW PROI'I:C'T Up ICE
1 herchy effort undop nail,of pc l'nY ono of ton toBmving dcclurmion,u
J I Oveondwillmainwin a Certowaneof Conxenl lomlf-in,nne I,,,Worker's Compere- DRAINS-FLOOR.ROOF,n R HA,CON U. S_OR IIS TVP13 CUNS'IHI1C'TI(lD
,"lion,as provided for by Section 3700 of the Labor Code,Bane pcK ounce of the
work for which this Fermi,is issued. 12I X'I URES-PER TRAP
El 1 have mad will maimmis Worker's Coal...in.Insurance,as required by Second
3700ofthc labor Cala far the perfotmunee ofthe work fofwhichbis permit is i....J. GAS-HA.SYSTEMd INC.40UFILIGS FICC.GROUT'My AI'N
Crier p pep Onn hJyl Jae Pnlcy No.:Policy d� `��, �Z GAS-EA.SYS'rEM-OVIiH 4(P.A)
•MCE,RTTHICA'I H OP EXEMPT ION FROM WORKERS' GRI!ASEaNDUSTRL WAS 11:IyHERCEPfOR
COMPENSATION INSURANCE BUILDING DIVISION
(Tb'wsuctio inccd not be complemahl he Isonal:,l:norm hundred dour,IS 100) GREASE'rRAP
nr In,,.) PI ANCI IFCK THE
Ieerlfy Ne iMac ork for permit:ke, C l,ha- SHIVER-SANITARY-S'I ORM ITA.41X11'1'.
mol mnploY anY p”--'^^' n any m��'nnv+nm a,m M:eome.,ubjecuu the WarkrP Cominn- ENERGY FEL:
Z cation Laws of Califorom Unto WATER DEALER W/VEN'VELECTR
zO Applicam GRADING FEE
NOTICE 10 APPLICANT If.aftar nuking this Certhmme of Exemption,you should WNIER SYSTE- %REATING SOILS FEE
^ Nwome subject to the Workers Compcncmon pooWm a of the labor Code.you all
a ? forthwith comply with such provisions re this permit shall be deemed revoked. WATER SERVICE
0
CONS'INUCOGN LENDING AGENCY
NIiW HE1IDE1TIAI.1'LMB. IQ FT PAID
hereby a hi mi mm IImm is a oic,meIimn lending agcnuy In,the INrformmon of Date Huciptp
LAH 'he work fn which phis'cruet i,Issue(Sec.3097,Ctv.C.)
O Lrudl Name Torn L:
ndcd Addm,, 'TOTAL:
V Lw
r G 1 eerily mall have mad his mpideatiao.m l elate mal the ul.we information is BUILDING PCE
F' N c meet.l agree to comply with all city and county oNinance,and stare laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U building a.....t......d hereby midionu mileveadamesofthis rity In enter upon the
aMwementioned#"party for in,peclion purposes. PERMIT ISSUANCE ELECTRIC ITT
(we)agree to save,inJammfy sand keep hanmles,the City of Cupertino again%t
Iiabildie,.judgmenn.costs mail expen,es which may in any way acerae aging said Cry AI,TERORADDTOMECH. PLUMBING FEE
consryucncc of the gmalm,of this pormil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IIAN DUNG ON[r TO 11.000 CFM) MECHANICAL.PER
S( EC
RF UL AIR HANDLING UNI'I'(OVER 0JS0CFM) IONS'I'RUCI ON INS
4 G
Sigh amrc ufAppl' at/Crum actor Date EXHAUST HOOD(W/DUCI) HOUSINGMITIGATION FEE
AZAHU(lUS hL\'TERIALS DISCLOSURE
lltheii,beam nrforum MhilAing'eeupam,tare or handle hneadou,material HHATING UNIT OR)I ORION)BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Ilodth and Safety
Code.Seelimn 25532(«)7 HEATING UNIT(OVER Ipfi,000 BTU)
[:j Y" [:I Nin VENTILATION FAIN(SINGLE RLSID) PAID pale Rttreiptp
Will the upplinml or Emme building occupant use vYpdpnmnt()I devicl )ILF -COMP(3HP OR 100,INNI BTU),which If
nil M1aeaJnus air cun,I in I,u,shined by the Bay Area Air Quality Mumogenanl TOTAL. S
hi,tnct7
Ye., ❑Nn BOILER-COMP(OVER II(I,i XX)11'TU)
❑
I have read the hal mdcrial,requiremcnu under Chapter fi YS of the Cali- AIR CONDITIONER ISSUANCE DATE° /J
fomite Health It Safety Calc Sections 25505.3533 and 25534.1 unoktsmnd that lithe NEW RESIDENTIAL MUCH.
building does not currently have a hand.that it is my re,p'msihiloy rah mtify the accupum
aft� 'hicb roid to iszhuncc sail"tile of Occupatwy.
Otoor"'inth rime agent Dote TOTAL: ISSUED BY:
OFFICE