NO PERMIT NUMBER APPLICANT TO FILL IN INFURMAIIUN WI ERIN RED LINES-U5E BALL POINT PEN ONLY 'l-J 0
CITY OF CUPERTINO BUU,DING-ELECTRICAL P
BUILDING DIVISION APPLICATIONIPERMIT PLUMBUIG-MECHANICAL
BUILON'G PROIEGT,IDENTIFICATION-,
BUILDINGADDRESS: SANITARY NO. APPLICATION SUB MAL DATE
I GT e/s/5'9
OWNERS NAM , ser , PHONE: ' CO CfOR'S N M �� LIC NO: s-a
I r /!LJ N/C CONTROL It
"1 I NGINEER: LI NO: -7 ADDRESS: ul�!` / ❑
145S "72190-
ONTACT: PHONE:- 5 .bZ] [/ til p .ry47..'�.`'re.:.BUILDWG'PERMIT
idr�sxc�- � so
��3�yi8 `( ❑ Consultant Fees Paid by Applicant(Initial) LDG ELECT PLU(�M�B METH
WCEN D QTYI 'tl+F >M ELECTRIC PERM1Tpg ' z'P-j,,S�P ��yFEE-
1 hereby affirm Nes 1 em licensed untl p o mot M1epar 9(commene g d.pint .kl+''e' t4y-•m,.5I-un a- m.tea+� 'L'9 a.nf !t ±5i JOB DESCRIP'T'ION
WOOwith Sut art]00o)of Dtms on Sa/NeBmincss end Yrofeasiam Ccdeandmylicanset PERMIT ISSUANCE RESIDENTIAL:
F ty in full foac and effut l s ❑SFDWL 0 KITCHEN REMODEL
C U U<aae ` Lic.p
6 APPLIANCES-RESIDENTIAL ❑ADDR70N C1 PLUMBING RE-PIPE
Z W Dau Co(=tor
6a -Do,iARCHTRLTSDECL O ❑MULTI-UNIT []STRUCTURAL
'p Z 1 understand my plans shall be used ss public records PANELS MODIFICATION
)Z�—'� UP T0200 AMPS OINTERIOR El CHIMNEY REPAIR
C�2 LW Licensed Profcssirand 301-Rh)OAMPS IMPROVEMENT ❑SWIMMING POOLS
OW.NER-BUILDER DECLARATION OVER IOOOAMPS ❑BATH REMODEI/REPAIR ❑DEMOLITipN
6 I hereby etTrm thus 1 em aempt from the Convenor's License Law for the ��,Hp� 1,
'3 a UF following reaan,(Section 70313,Business and Professions Code Any city or county SIGNS ELECTRICAL C� Ll]L��h
1 W O NQ which salmon,a permit m wrt
cons .alter.Improve,demolish,or repair any swcwre
.] pmormi.issecme,Wo tests.he applimed for such Permit m File a signed natement SPECIAL CIRCUIT/MISC.Mthaheislicens pumumtto@ Mviilonsoflhe CommnoesLicen UNr (Owpter9 COMMFRCIAI:
` Q (commencing withSusion]o00)ofDiviaionJof th<eusineasand Ptvfasiom Code)or TEMP.METER OR POLE INST.
.a caq that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDMON 0 DEMOLITION
k_^4 Section 7031.5 by any applicant for a,even subjects the applicant to a civil penalty of POWER DEVICES []TENANT 0 FOOD SERVICE
I. not more than five hundred sollua(15W). IMPROVEMENT
�SQp 01,a want of the propury,ormyemployces with wages as hebsme compensation. SWIMMING POOL ELECTRIC
F willdo the work and the structure is intended oroffered for sale(Sec.]B14,Business OTHER
Wm and Pretensions Code:The Conrcacmr'a License Lew deal nos apply a an owner n( OUTLETS-$WRGHES-FlXTURES
property who builds or improves hereon,and who does such work himself or through
his own employers,provided then such improvements we not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the building mintpmvensent is sold within one yew ofcompledan,the SQ.FT. OORAREA LSQ.
owner-Wilder will have the burden of proving that he did nos Wild or improve for put- / a/1 5'-2,1 cw4
c droll.). l/(')7(�
❑s 1,as owna of the property,am exclusively contracting with licensed contractors to TOTAL:
m arm,r the project(See ]Bra,Business and Professim s Code)The Contractor's L m tsps t � iy
cense law does not apply to a owner of property who builds or improves thereon,wasQTy' ik T.s;;,a PLUMBING PERMIT
whoomreeafor such pmjecawih stimulations)licensed Farmers an he Contractors A•" "`"e'm""'lJg:t
License Law. PERMIT ISSUANCE
I ant exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dae
WORKER'SCOMPENSATION DE the fRATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under paalsy of seperjury one of the following Wwow's Co.,..
- .have and will for by S Certificate of Consent s,Coda.fart far Worker'sce ofthe
DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
on, r provided for mi Ss inns 3)00 of the Leber Cede,for the perfonnance of the
work for which this Dermis is iswed. FlXTURES-PER TRAP
I have and will..lama Workers Can prowb n Insurance,u aspired by Session
of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM)INC.4 OUTLETS OCC.GROUP APN
Ny Worke�r's Comppccnsasia Insurance canis and Policy nJ'y 6s�'
Carncr,e' Ir GIAI(1 Policy No.:h1 GAS-EA.SYSTEM-OVER 4lEA) 3�2,-11-Qa/,
IR A OFIiXEMPTION FROM-1W IS0. GREASF/INDUSfRL WASTE INTERCEPTOR
r COMPENSATION INSURANCE evr-'-' "BUB;DN`G OIVIS[ON,FEES.'4s%' ?
(This susion aced tors be completed if the penult is formal hundred dollan(S 100) CK s �C.sS '��
or less.) GREASE TRAP PLANCHECK FEE
I certify that in the perfatmanceofthe work for which this permit is issued,l shall' SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any==r so as a become subject the Workers Compan- ENERGY FEE
0 Z radon Laws of California.Daa WATER HEATER WNENT/ELECTR GRADING FEE
O Applicant
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYST IsITREATING
became subject so the Worker's Compensation provisiam of the Labof Coda you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
7Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
m
UO Ihereby afirthe[there is coordination lending agency for the performance of Dm 0.uri
F he work for which this prmut is issued(Sec.3097,Civ.C.) TOTAL:
Lenders Name
U TOTAL:
Lemont.Address
yI ratify hat I Na read ha application and Stan hat the above .Tama.. s ,v. - {111. a q;; N,,v_- BULLDIN E r
H cotrtcs.I agree m comply with all city and county nMtnatts end sea¢laws relating t LQTY �y'`�1�pM MECHAMCAL PERMP,'� 6'FEE is�
U Z building canstrucson,and hereby authorize representatives of this city to enter upon the ws_,!_ar[`Ml ,Ir x. n euvaN t.� k rex'21• SEISMIC FEE
abovenantioned property for inspection puryous, PERMITISSUANCE
(We)agree to ave.indemnify and keep harmth
less e City of Cupertino against ELECTRIC FEE
Iiabllimajudgmenu,ewseM<z,6?,which they in any way aecmea,mistaici City ALTER OR ADD TO MECH. PLUMBING FEE
in calwa ace of the granting of f Dennis.
APPLICA 1eDERST D LL MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FE
SOUR REGULATION
AIR HANDLING UNIT(OVER 10.(00 CFM) CONSTRUCTION TAX
SigmuteofAppl¢enbCom sus ere EXHAUST HOOD(W/DUCI')
HOUSING MITIGATION FEE
HAZAR U.MATERIALS DISCLOSURE
Willilux,sican.or t u IlJing eacupnm store err hanJle M1azardaus material HEATING UNIT(TO IW,WO BTU)
as defined by an Cupertino is W Code.Chapter 9d2 and the Health and Safety
Cade,See ion 25532lay! I HEATING UNIT(OVER IOL"BTU)
Is VENTILATION FAN(SINGLE RESID) PAID
Date Raei H
Will he applicant or future Wilding occupant use equipment or devices which BOILER-COMP(3HP OR 1(10,000 BTU)
hazardoan
us ab contaminants as defined by the Bay Area Air Quality em
Maagent TO L:
R BOILER-COMP(OVER BID."BTU)
i wOYes �m
AIR CONDITIONER
L have read the hozeedous mdals requirement under Chapter 6.95 of the Cub- p ISSUANCED�ApT
forme Heal cry Code,Su s 35505,2553 onJ 25534.I undersand ban if the NEW RESIDENTIAL MECH. SQ.FT. �I
Wilds, as nate rely ha rent, itis mpospaslirym df the cupat kl
,fled aawhich ort an to ttofa Cabfi f
Owner or ouhonzedug n are TOTAL: ISSUED BY:
OFFICE