S 0375 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO HIM.)ING-ELF.CI'RICAL PERMIT No,
BUILDING DIVISION APPLICATION/PERMIT 1'I.IG PROJIINCECT IDENO IG51. S 0375 '
NU1I.DIYC PROJECT IDEN'1'IFiCA'i'IUN
BUILDING AD DRESS: ^ SANITARY No, I APPLICAI'IIIN SUBMITTAL DAD
0
f N .PHONE: • C RACt NA : Ac n SIC C091RO��LL#�/
•ARCHITEC'DiNGINEER: LICNO: ADD PS S, C'l/ ❑ �� O +w+/ 7
b. 1
CONTACT:
I'IIONE: BUILDING PERMIT INFO
f ✓C �73 lqq2, , ❑ Consultant Fees Paid by Applicant(Initial) BLDG PLUMB
MECII
yo 'l
❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DHSCRIPTION
1 hcrcby affimt Thal]..I Iicensd under provision of Chapter 9(commencing
nizZ with Satlnn RNHII nd Division] he Rosiness and l'ndc"mrs C:dr.and my license is - �Gl RESIDENTIAL;
1-ac- fullfameindclec 20 P[RMI'1'ISSUANCE ..J v ❑ShOWL El KITCHEN RF.MODF;I.
aUfFj
Lac. LicX L APPLIANCES-RESIDENT'IAL ❑ADDITION PLUMBING RE-I'll'li
H4W pair Cnnvacmr� ❑MULTI-UNIT ❑STRUCTURAL.
CHITECI'S DECLARATION PANELS MODIFICATION
Z O rNjs Z 1 uodermand my plans shill W used a,public record, UP TO 200 AMPS
OZ-0 El INTERIOR OGIIIMNIiY REPAIRF�F'u1 License]Pmfcssional 201-❑xNIAMpS IMPROVEMENT O SWIMMING POOLS
OWNER-BUIIMER DECLARATION OVER l0g)AMPS ONATfI REMUUI?URIiPAIR DEMOLITION
C Q I hereby affirm that 1 am exempt from the Contract License Law for the l 0 OTHER
uxj3 ya,U following mason.(Section 9031.5.Busin%l and Professions Cde:Any city or county SIGNS ELECTRICAL
Qwhich requires a Permit to ranwmc.ahce improve demolish,or repair any structureC, prionnital.ssuancmahorequire,theaPplirmutorsuch permit In file v signed,tmmneat SPECIAL CIRCUIUMISC.
flythat he is licensed Perlman mine Provisions oRhe Contractors license lae(CasPta9 COMMERCIAL'
�<rp0 (commencing with S«tion7000WDivision 3ofthe Bmmr,svndpmfessions CWc).r TEMP.AIEILR OR POLE INST
a y o eL ,Jim he is exempt therefrom and the basis for tM a.
alleged mic .Jon.Any vimula n of 0 NEW BLDG/ADDITION [IDEMOLITION
W-4N. Section 9(IJL56y any applicen Brrs pennl,ilrrosthe applicant mao,il penaltyof POW17R DEVICES O'1 FNANT El FOOD SERVICE
ZT not mase than five hundred dallors(SNO. OTHERIMPROEMIiNT
I,
SQp O l,avope
wserofthepronyormyempioyeeswitbwagesastheir,olee,hmpensation, SWIMMING PIR,L ELECTRIC OTHER
F. willda the work,unJ lhe.strueulrc iv notimm�dW or�ffered fn a,,,apply 91034.Busines OUTI.I'i IS-SWITCHES-FIXTURES
W 3 m and Proressions Gde:The Contmcmr's License Low dims n,n apply m an owner of
property who builds or improve,thereon,and who does Inch work himself or through
his own employees,provided that such improvememx arc not intended or offered for NEW RESIDENTIAL ELt:CTR SQ IT.
sale.If.lawgiver,the Wildinlar impowermnti„old within nnc ycm oRomplIdon.lhc SQ.IT FLOOR AREA EISA.Pt.
Is awner-boilder will have the burden of proving had he did not build or improve lir pur-
'o,nf.mlc.) TA L:
0 I,c owner el the property,um exclusively comforting with licensed contract,,In
canonic(the pn,joel(Sec 9044.Bovines.and Pit.cloanl Gale:)the Co.ancti r',I.i-
nsLaw does net apply manounce ofproperty who builds or improves Bummer.and QTY. PLUMBING PERMIT FEE
who contmnv for such projects with a contracmgs)licensed pursuant to the Cameroon's
Licen ,Law. PERMIT ISSUANCE
1 am exempt under Sec. .H&P C for this reason
ALTER-DRAIN&VEND'-WAT ) VALUATION
.Owner one
WORKER'S COMPENSATION DF.CLARAI FIN BACK FLOW PROTECl'.DEVICE
�Ihcrcbyilll ai under penaltyme perjury one orthe following r declarWorkerlions
oeThavc and will maintain aCeniOcam of Conum mself-insure for Workers Cimpcn- DRAINS-FLOOR.RIN]It ARG.COND. STORIES TYPE CONS'1RUC1'IUI
satier,as provided lir by Section 3901 of the Ism r Code,for the performance of the
work for which this peon;(is Iswcd. FI%'TUNES-I'[R'TRAI'
0 1 have and will maintain Worker's Compemation Insurawe.as malarial by Section
3900nftbe Labor Code,for the performance oldie work far which this Permit is iz,maL GAS-EA.SYSTEM-I INC.40UThITS OCC.GROUP AI'N
My Workr's up. ation Ira me l Policy a 11 bei rc:
Came': }�F—Policy No.: � GAS-I3A.SVS'fHM-OV ER4(IiA)
CLI, B'A LMPI'ION FROM Mt)RI GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE, BUILDING DIVISION FEES
(Tho,ctiomnced not he unnpleled if the fermi(icor one hundred dollars($IIX) GREASE TRAP
PLANCHECK Ila,
or ins.)
cenifythat hcra the performance k(ofwhijrct the W isissued. ,n-shall SEWIiR-SANITARY-STORM EA.200 FT' ENERGY FEI;
sol employ any craman:Illy manner so:hl m bccinhe wbiem u,the workers cimhpen-
O,Z .cation law,of Crldirnis.Date WAIER HEALER WIVENTIELECI'R GRADING TEE
Applicant
LZ-i rj) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER— SYS'IEM/1'REAI'ING SOILS FEE
f-' be,mom xabjmuo the Worker's Compensation provisions of the Labor Code.you must
W > forthwith comply with such providon,or(ho peribut hall be deemed revoked. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM. SQ.fT. PAID
U,z Da e<eipt x
L) OIherehy alarm that lhcrc isumnsimction landing mgcncy far the penbmmnm of
he work for which this Permit is issued(Sec.3099.Civ.C.) 'ICTAL
C) I'- Lender's Name TOTAL:
r U Lcndcr's Address BUILDING F'.
Q. I certify the(I have read this.,plicmian and,tum that the above iminuahon iI
,F. N coned.l agreem comply with all city and county ordinances and state lows mlatinga QTY. MECHANICAL PERMIT FEE S171SN11C IS,
V Z building r.moretion,and hereby audience representatives of this city to enter upon the
above-rationed property firimpection purposes. PERMIT ISSUANCE ELECTRIC T
(We)ugrce m save,indemnify and keep hmmless the City of Cupertino against qq�
liebili(ies.judgmenR toxo and eapenses which may in any wayaceme againnmid CityALTER OR ADDTO MECIL 047 IDNIBING IS
in conscyuence of the gmn(ing of this permit.
APPLICANT U NDERSTANDS AND WILL COM PLY W LTH ALL NON-POINT AI R I I ANDLI NO UNIT(TO I q(Nx)CFM) MECIIANICA.ITE
SOURCERE ULA'VONS.
AIR HANDLING UNIT(OVER 10,0 YJ CFM) UCI'ION TAX
sign r phrium/Contrarmr ' Dae EXHAUST HOOD(W/DUCT) �/ V HOUSING MITIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE Lf”
N'i 11 the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.000 RTU) U
s Ilan by the Cupertino MunlclPlll Code.Chigncr 9.12,and the Health and Safety HEATING UNIT OVER I(NI.(xx)BTU)
Code.Section 25532(a)'!
0 Ycs E]No VEINTULATION PAN(SINGLE RESID) PAID
Dam .Receipt x
Will(Ire applicant or Insure building occupant enc equipment or devicox which BOILER-COMP(31 IF OR 100,0 NI BTU)
coal Weardous air contaminant as defined by the Bay Arca Air Quality Management ' I:
District? BOILER-COMP(OVER 180.001 BTU)
❑Yes EJ No
AIR CONDI'IIONER ISSUANCE LATE
1 M1ave read the Wormous materials requncmenel under Chapter 6 95 of the Cmi- ^
n
mmiv Ileallh&Surety Cnle,Sections 25585.25533 and 25534.1 understand that if am N17 W RESIDENTIAL N1ECH. SQ.FT.
building docs nnl curmndy hove a¢nuns,that n iv my m,prnxiailuy m nmify the hccupont fJ 7
of the tout ireaent,whab man ba met Prior In issuance Ora Cenilia(o of Ocsvprncy.
Owner o,autharizcdagent Dam TOTAL: ISSUED BY:��rC--/�
OFFICE
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lirnbonu •bued. ALL RIGHT RESERVED.••
.. .. ' All above sign deaigto A m[va,lo ae beloatg b SIGNS EXPRESS MF(l.CO., Any dt,pproh�
:N1 Lk
Scale ; Noted Drawn by :
'N1_M —"p:qEn MM.
Co Date :Date : 5 21-97 I Drawing
s/re Basan AWL,SoM a MOKm cel 91 fl17
rr 811 r 3347 • 816443-1615CFAtq APPROVED BY :
STATE YC.*554097 LLL APPW W*6.119586
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