00020088 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI.TV OF CUPERTINO BUILDING-ELEC'TRICAL I'Ia<nn'I'NO,
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDEN'1'IF'ICATIl1N
BUILDING ADDRESS: SANHARYNO. APPLICAIUN SU llhtl'TI'Al.DAP I;
1 -79 E8
TIN\) Z^ z,, Da
WNER'S NAME: PHONE: C NTRAC'I'Ok:SN E: LIC NO.
rC'-�_f�� � NIC CUN'I'ItOl.p
RCIII'1'ECI'/ENC CER: LIC NO: JA DD ?59: ❑
18�w e- AVC'- olu J t��
CONTACT: PHONE: BIJ ILDING PERMITINFO
❑ Consultant Fees Paid By Applicant(Initial) BLDG IP.1iCr PLUMB
EJ ID ❑ note
LICIiNSF.D CONTRAC'f(1R:S DECLARATION QTY. ELECTRIC PERMIT FE17
1 hereby a�nu dorm I on Eemtsrd ander pmeititnx niChapter 9 PxPronendng JOR DESCRIPTION
aZ wiih Smtitn2(XXEPt vlsfnn 3nfthe Business and Prule,u oCode.undmy lirence is RESIDENTIAL:
RIO c p PERMIT ISSUANCE:
F-� in full!re rid e0at / J �� 1 CSIq)WI, CKI'TGIl1iN RIiMODIH.
aVU Livens hic.N P� APPLIANCES-RESIDEN'I'I Al. El At)[)] ION C1 PLUMBING RE-PIPE
_ Z
Comms sx
ARCHITECTS DECLARATIONCMUA]-ON(I CS'TRUCTURAL
y p Z 1 understand my Plans shall or used as public records PANCIS MUDIIICA'1lUN
OZ-+O UP TO 2N)AMPS CIN'TERIOR CCH I M NEY REPA IR
1=..'4t Ed Licensed Professional 201-INX)AMPS IMPROVEMENT E]SWIMMING POOLS
Ck ; OWNER-BUILDER DECLARATION OVER HXX)AMPS CBA'TH REMODFUREPAR [IDEMOI.IT]ON
C I1 Q 1 hereby affmn that I am exempt Prem the Cnnnu ma's License Law far the
r_1
L O following reason.(Section"!031,5,Business and Professions Calc Any city or county SIGNS 1LIXCI'RICAL (yI'HI?k
TALL Roy which y px lI chrism, Imc p d dish p; any structure L 6 pS
Qprorl t I: 0 th pylic tl such mill 11 bncJ.mlanl SI'IiC1A1.CIRCUIT/MISC.
�1VA'y'd )but he islcensed pursuant to thep ns of the C t mr'sL 1 (Chapter9
aap0 Eurearncing with Section 2100)of Division 3 ofthe Business and Pmfessinm Cdc)or TEMP.METER OR POLE INST. COMM.RCIAL1
R.d c C that he is exempt Iherefmm and the hasin for the alleged exemp0nn.Any vinlmiun of ❑NEW BLDG/ADIJII}ON ❑DIiM(Ih1'1'ION
X^_+� Section 2031,5 by any applicant for a permit wbjects the applicant at a civil Penalty of POWER DEVICES 0TENAN' CPOOD SERVICE
m not more than five hundred dollars($500).
FSG Les owner oOne n IMPROVIiMIiN'1'
Propey,or my employees with wages as their side eonswusutinn. SWIMMING POOL ELE"Ji CO'D HER
p. will do the work,and the structure,is not intended or offered forsme(Sce 2144,Business
Www and Profexdoos Code The Ci n amon',Licence Law docs Dol apply m an owner of OUTLETS-SWITCHES-i fi
3 r propeny who,builds or improves thereon,and who does such work himself or through
his own employees,provided that.such improvements
am not intended m offered for NEW RESIDENTIAL ELEC'I'R ef.
sale.IL howevea Ne building m improvement is sold widaus oneycarnf rompdctinn.the SQ.PI'.FLOOR AREA $/SQ.IT,
owner-builder will have the hutdcn of proving that he did not Wild or improve for pur-
pose of
❑1,as owner of the properly,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044.Business and Pmlcssiom Gde:)The Contractors Li-
ceaseLawdoesnotapplytoanownerofthornywmobuildsorimprovcslhemon,and QTY. PLUMBING PERMIT FEE
who c nsommis for such projects with a cSPwmcwNs)licensed pursuant set the Comranm'x
License Law. PERMHISSUANCE
❑1 am exempt under Sec. .B&P C for this Italia
ALTER-DRAIN.@ VENT-WATER IPA) VALUATION
wncr Date,
:1 WORKER'S COMPENSATION DECLARATION BACK R(1W Pk(TI'ECT.DEVICE
1 hereby affirm under penally of perjury one of the following declarations
I have and will maintain a Cenifcata of Cousen toulf-mom for Workers Crimper- DRAINS-FLOOR,ROOF,AREA.CONE). STORIES TYPE CONST RUCTION
cation,as provided for by Section 3700 of the Wfsa Code,for the performance of the .� /� 7 Q
work for uM1ichthis permitkno ed. FIXTURES-PERTRAP (p G.
C 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofthe Lahr Code.for the performance tithe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40UTLFUS OCCGR(1GP AI'.
My WmT pensatioQlnsurance artier anJ Policy1nu
Carrier:lr a-r110 1 Policy Nn:yy�-"'V�,n�n� GAS-FLA.SYSTIiM-OVER4(IiA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRHASFJINDUSI'RI.WASTE IWERCEITOR
COMPENSATION INSURANCE BUILDING DIVISIO THEN
flhissectionneed not he cmd,cmd ifthe perinn is Ensure hundred dollars Dl(0) GREASE TRAP or less.) PLANCIIIiCK hili
I cenifyt in mea ormance of the work fu M1ich�his emit is issucJ,lsball $13WER-SANITARY-STONM FA.2(N11T.
not employ any ria ymanner.xoae® o n Ie V li,w ompen- 1!01: riE
Z tritium laws aro VAT ER HEATER W/VENT/ELECIB
z — Applicant a to GRADING IB21i
NOTICE T( APP AN':If,afier necking pis Cc ' null WATER SYSTEM/TREATING
hecome subj I .Workers Compensation Provisions of the labor Code,you must Solus Igs1s
IZ ^ funhwith comply with such provisiotnof this pvmtit>half be deemed rcvoked. WATER SERVICE
a �
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
D Z I hereby affinnthmtnere is a emsuuction lendmgagenry for the pen rromiebf Dam kacipla
W� IM1e word for which at .it is illy (Sec. ].Civ.C.) TOTAL:
0 U Lenders Name,
W Lenders Addresses TOTAL'
1 certify that I have mad pth
is application and state at the above information it BUILDING ILC
correct.I agree to comply with all city and county ordinances and state laws relating set QTY. MECHANICAL PERMIT FEE SEISMIC IT:E
U Z buildingeonsttuctinn,and hereby authorire representatives ofthiscity in enterupon Ne
abnre-mentioned property for inspection parallel PERMIT ISSUANCE ELECTRIC 1:111?
(W I save,indemnify and keep harmless the City of Cupertino against
liabilities Iudgmen .sPus and expenses which may in anyway accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in con. enceof egramingmflhispermil.
APPLIC T U ERSTANDS AND WILL COMPLY ITHALL ON-P I AIR HANDLING UNIT(TO 10.0(0CFM) MECHANICAL ILII
SOURC EGUI ATIONS,
AIR HANDLING UNI'F(OVER 10.000 CFM) CONST RUCTION TAX
igmature r'ApplicanUComracmr Da EXHAUSTHOOD(WB)UC) HOUSING MITIGATION FEB
HAZARWUS ATEUP, DISCLOSURE
theapplica loffutu Iddng ac panumermhanllehe�outmamrial HEATING UNIT(TO IW.OfkI BTU)
as defined by the Cupertino Mu mipal Code.Chapter 9.12,and the Healon and Safely
Code.Section 25532(a)' HEATING UNIT(OVER 1110.000 BTU)
YesVENTILATION FAN($INGLERESID) )'AID
Dam Rtceiptx
Will the applicant an fulude building occupant use equipment or devices which BOILER-COMP(3HP OR 1(40,00X)BTU)
.it h aardous air contaminants as/definN by the Bay Area Air Quality Management T(11'AL: f
District? rC BOILER-COMP(OVER 100,000 BTU)
11 Yes
have read are hadadver,..Hall requirements under Chapter 6.95 oflhe Cali AIR CONDITIONER ISSUANCE DATE
tannin ahh& afety Calc Satinet 2551)5.25533 and 25514.1 undersm Nat if the NEW RESIDENTIAL MEC1L SQ.FT. �Te
Wild' glwsn cunentlytermatendnLNaitismyaspunsibifinyl nmK
if) mpaal ' 1 r z0��
of Ib ire cots which must be mel prior Io iss o a Cenifi f uey.
Own ra Norimd agent Dam TOTAL: LSSUIip HY:
OFFICE