S 3202 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO • BUILDING-ELECTRICAL PER IT NO
BUILDING DIVISION APPLICATION/PERMIT. PLUMBING-MECHANICAL ` O
BUILDING PROJECT IDENTIFICATION l7
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DA
4 toy arPIP If) '
OWNER'S NAME 11P 0 8: COry/y A O NAMEIC NO:
S \Q or Ce-il' Q NIC COMI'ROL#
ARCHITECT/ENGINEER: LIC NO: DRF S:O Fx �� I}� ❑
CONTACT: PxorvE: BUILDING PERMIT INFO
- ❑ Consultant Fees Paid by Applicant(Initial) BIAG ELECT PLUMB MECIy
❑ ❑ ❑ �p
LICENSEDCONTBd TOR under
DECLARATION QTY ELECTRIC PERMIT FEE
I norms(form oat I am Blenmd under proWarona of chapter 9(commencingsis JOB DESCRIPTION
�WZO with Station 0000)of Division]ofthe Easiness and Profs imp Code,and my license is RESIDENTIAL
FW- in full force and a act. 7 PERMIT ISSUANCE
�UV Licence Clav Lie.# ❑SFDWL ❑KITCHEN REMODEL
yG4 Dam Camnstnr APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
I�J• Ipf ARCHITECT'S DECLARATION
yz oZ� 7 load erstand m,,imeshall bcteco spdsherecordw PANELS ❑MUhTI-UNIT ❑STRUCfURAI.
- MODIFICATION
b'I4 t:IQq Licensed Rnfesstonal UP T021N1AMP5 L1 INTERIOR
E2 CHIMNEY REPAIR
y 201-1 WII AMPS IMPROVEMENT
a' OWNS I.Teen OF,R DECLARATION CenteON [IDEMOLINGPOOLS
yy 1 hemby affirm that 1 tan exempt from the Cammcnu'.c License Law for the OVER loon AMPS ❑BATH REMOUEWREPAIR [I DEMOLITION
y(31 F following reuses(Sanson 1031.5,Businessland Pro&seions Code:Any city coastal, SIGNS ELECTRICAL ❑OTHER
WW 4 C,y which requires a Penni,to construct, he,improve,demolish,or repair any structure
prior o its issuance,uiso requires me applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
CEthat he is licensed pursuant to da provisions of the Contractor's License Law(Chapter 9
W AGO (commencing with Seen,,"of00)of Division 3 of the Business and Professions Call TEMP.METER OR POLE INST, A
F d c 2that he is exempt therefrom and the basis for,he alleged exemption.Any violation of y„ HW /ADDITION [-]DEMOLITION
W•^N Secfion 903156,any applimm Poraponnh,subjects the applievnuo aeivd pennl,y of POWER DEVICES
not more than five hundred dollars($500), .r� j` l� •NA ❑FOOD SERVICE
�,^!❑�'O i] I f th•property. y employers with wages a%their sole pe f n, SWIMMING POOL ELHCTRIC'I PROM 'NT
fr��4c
will d th k dde, t t muJJ R Jf I (S 9044 Business ER
0.3w
and Prom,sic.,Col The Conquerors License' Law does act apply, a of OUT 'CH -F � URE.�d
property who build. -.proves thereon and who dews such work h neelf or through
his own employers,provided,hat such intprovemehts are not intended or offered for N RHHOPING r ECT c S
setamptoncyarot
co nple0nn,the SQ.PT.FLOOR AREA $ISQ.PT.
er bawill
lder have the burden of proving that he cid not build or improve for put,
pin a m sale.).
❑ Las owner of the society,am exclusively contractors with hiceused contractors to `TOTAL.
onstra a the major,(Sec.9044,Business and Profeiaimn Code)The Contractors Li-
cence,Law does not apply to an owner of property who builds or improves thereon,and QTY LUMBING PERMIT FEE
who contracts for such projects with a oontramor(.c)licensed pursuantto the Contramnr's
License Law, PERMIT ISSUANCE
El I am exempt under Scc. .B&P C fm this,,anon
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACKPROTECT.DEVICE
I hereby affirm under penalty of portray one of,he rallowing declarations: !L
W '
El I have and will maintain aCertlfrcaa of C-1c-t oself-trare for Workers Compen- DRAINS OR,ROO. EA-MM
moon,as provided for by Section 3100 of the Labor Cade,for the Performance of the STORIES TYPE CONSTRUC'NON
work for which this permit is ficat FIXTUR -RTR
Vhave and will maintain Workers Compensation Insurance,as required by Section
7141)ofthe Lahr Code,forthe performanceoftle,work forwhich this permit is issued. GAS- STE -IINC.4OUTLETS
My We, 'sC a etion�nsuranceoarriernnd Pulicy$a�be am OCC. APN
Cartier: ' Pmi,yNo.ay�,rr{G1y9C GAS- SYST. `0"ER dkA) 7901, .
CERTIFICAT OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREA EINDUS']'RE WASTE INTERCEPTOR
Ohis.cec0an need not he completed ifthepermit is forme,hundred dollars($I W) BUILDIN(J DIVISION FEES
or loss) GREA t
I lcerif that In the PLANCHP,CK FEE '
y any manner
to
ewubje this the Wisiseuedlser-
nm in Law any person in any manna.co ax to become subject to the Workers'Compen- SEWER-SANITARY-STORM t ENERGY FIE
,2 cation Laws of California.Dam WATER HEATER W/VENT/ELEC'I'R
Applicata GRADING FEE
NOTICE TO APPLICANT:If,after making this provisions
n s of of Exemption,yoo should WATER SYSTEMOREATING
f~
forthwith
subject the Worker's Compensation Provsinal of the de Labor Core,you must
forthwith comply with such provisions or this pemtit shall Its,deemed revoked. SOILS FEE
W� Q WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L)� IM1ereby etBrm than there 1.acmnmmction lanJing agency Tor tha perfonnaoca of Date R eipt#
w ma work for which this scroll is issued(Scc.]091.Civ.C.) -
Q ULenders Name
Lender's AdJrr_vs TOTAL:
a1 eerily that 1 have head this application and state tire,'he above information is T(yfAL. BUILDING F
rn stare,.1 agree m comply wim all city Into ammy monaracce and state laws relating m QTY MECHANICAL PERMIT
U
buildingorientation.property
inspectby ion purpose,
.fives of this dtytocorer upon the FEE SEISMICF
obovo-menfi agree
rindan dee,ee_ PERMIT ISSUANCE
(We)ngreo..cave,indemnifyexpn and keep hay in an they ay accrue
udCity ELECTRIC
no rsectanc of the
granosts ting
expenses which may in any way acerae n&ains,.said City ALTER OR ADD TO MECH.
vnAPPLICANT of the graFANDfRhie it. - PLUMBING E
SOURCANT UND S'PANOS iUW LY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(VU CPM)
//r/9 MECHANICAL EE
9'/ ? AIR HANDLING UNIT(OVER IO,OVU CPM) T
!! CONSrRUCTI TAX
Slgnawre of ApplmenbCARDOr —�atc EXHAUS'P HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE: HOUSING Ism riG ION FEE
( Will the applicant or future building occupied stmemistndle hazardous mmerlul HEATING UNIT(TO 1010,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Same,I� Calc,Segiso 25532(m)p t• HEATING UNIT(OVER I(IQoIgI BTU)
%Elycs
VENTILAHON FAN(SINGLE RESID) PAID
Will thm applicant or furore building occupant use equipntetn or devices which Date Receipt#
` eon hazardous air contaminants h,, Fmed by he Bay An.Air Quality Management BOILER-COMP(3HP OR If fifflO BTU)
District
❑Yes - BOILER-COMP(OVER 100,000 BTU) L. O
I have read the 4h}' 'In ulfic undo Chapar 695 of the Cali- AIR CONDITIONER
fomin Health&SaretyJ� a Scc}}}}}} ns 2. U5,25533 and 255]4.1 andersmnd that if the ISSUANCE DATE
builiingeoesnotwurfenl hn5e hero, h them bilis to notify me neer NEW RESIDENTIAL.MECH. SQ.IT. / �—
yresponai y y pan,
of me regoirem m t me t rte iss..cents nif'ateo ey.
Owner tar out sed age.
Dille It TOT
'Ul-FICE
ISSUED BY: