S 0492 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - /A' Q
CITY OF CUPRRTINO ' BUILDING-ELECTRICAL PEIjMIT NO
ArvICAI. S . OT VZ
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECH
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL])At
/O/S • s c-. 9`/S 97
�.� OWN!R'SNAME: PHONE: CONTRACTORS NAME: LIC NO: NIC CONTROL#
U
/� RCHIT LGN'INFER: LIC NO: ADU [55: ❑
J i 6��LxA 1U0�t
CONTACT: PHONE: BUILDING PERMIT INFO
�tfAPPLIANCHS
nt Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONELECTRIC PERMIT FEE I heresy affirm that I um licensed under provisions of Chapter 9(cJOB DESCRIPTION
of Z vcbSevdoa Vlk)0lmf Division 3onhe Basinassa.d Plofesxinn.Cude,and RESIDENTIAL:
WOO ISSUANCE
Fps. in full line and e0'ecl. ❑SFDWL ❑KITCHEN REMODEL
aUU Do,. Class LIcK NCES—kF,SIDENTIAL ❑ADDITION 11M11HING RF:-PIPITNU U'Jle Cpntmctnl /ARCHITECTS DECLARATION ❑MULTI-UNIT RUCTURAI.
ZO'erZ Iu.decaaWmypLsnsshall be used as publicrecords MODIFICATION
OZ`4'—Q 00 AMPS ❑INI PRIOR El CHIMNEY REPAIR
F11�u] Licemed Professional 201-10W)AMPS IMPROVEMENT SWIMMING POOLS
s1 OWNER-BUILDER DECLARATION OVER ll#klAMPS ❑BATE I REMODEURF,PAIR ❑DEMOLITION
C C Q' 1 hereby affirm that I am exempt from the Contractor',s License Law for the
atO c.U following reason.(Section 7031 5,Business and Professions Code Any city or county SIGNS ELECTRICAL ❑at HER
W 3!L h which requires a permit.)construct,altar,improve,demolish,or repair any structure
prions its issuance.also requires the applicant for such permit to file a signed statement SPECIALCIRCUITIMISC.
J oey that he is licensed pursuant to the provisiunsofthe Conbactoes License law(Chepler9
(commencing with Section 7000)of Division 3 ofthe Business and Professions Gads)or TEMP METER OR POLE INST. COMMERCIAL:
A.c.c C that he Ls exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW RLDG/ADDITION ❑DEMOLITION
x ac Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑l'ENANT ❑FOOD SERVICE
not morethan five hundred dollars($500). IMPROVIiMCNT
F.
1.as owas banner of the pro,my,or my employees with wages their sole compensation, SWIMMING POOL ELECTRIC
0
FFO willdmha work.and the swcmm isnot intended moBered forsale(Sec.JOli.Bminers ❑OT"ER
W 3 e' and Professions Code:The Contractors License Use does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves Ther .ar,and who does such work himself or through
his own employees.provided that such improvements are sat intended or offered for NEW RESIDENTIAL ELECTS FT
sale.If.however,the huildingorimprovement is sold within one year of completion,the .IT.FLOORAREAstsQ.FT.
ser-huilder will have the burden of proving that he did not build or improve Int par- y{ ' D
rya ca".1c.).I] 1 f the property. t t % Ih licensed contractors in TOTAL; - ww
run moat @ l 1 t(S 704T Business J Prof Cod J lT —a an :L: - SEP 15 ��
c 1 J tapply t an ofp pony h bill p :th J QTY. PLUMBING PERMIT FEF: ``y' y�f. eD
whcontactsl such p , t itha contractor(s)lcensedp ant to the Contractors • �'CI11 (J(- .
License Law. PERMIT ISSUANCE
❑ I nm axcmpl ander see. ,B&P C fonhiare.xor l.UrtNJIItiU
Owner Date ALTER—DRAIN&V ENT—WATER LEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK[LOW PR(H'ECI'.DEVICE.
I hereby affirm under penally of perjury one of the following declarations:
❑ Ihuvc and vAll 3700of he"brself-immrctor Wmketsr,of h- BRAINS—PLOOk.ROOF.AREA.COND. STORIES TYPE CONS'TRUCI'10
( smion,as hick thi fpr mi$calci dp of tM1e Labor CMe,for the pednrmance of the
work have and
this Leann is orker Iq%TUkliS—PER TRAP
❑I haves,La will maintain he Workers Compensation work
hi h required by Satian
MyW.the laM.Gads.,(,ache perharmancer and work for number am: permit is iuucJ, GAS—EA.SYS'fEM-I INC.q OUTLETS OCC.GROUP ANN
My Wpr�kJey�r�,�.f/}�',s�tuY�pe jinn In mm s�� try Na:numtzr em:
Cartim. r Y � nlicy No. GAS—F.A.SYSTEM.OVER Y(L))
I 'CF:RTIFICA Ii OENSATI FN INS FROM WORKERS'
COMPENSATIONINSURANCE GREASP/INUUSTHLWASTE INTERCEPTOR
BUILDING DIVISION PEES
(This section need not be completed if the permit>for one hundred dollars lEl(XI) GRf:ASETRAP
or less.) I PLANCIIIiCK ItiE
lesdif,flon intheperformsnceofthe wnrkfmwhich thislerunnOst,viad.Ishall SEWER—SANITARY—STORM EA.200 FT.
not couldany peon.in any... ....tras to become sobjecua the Workers'Compete ENERGY FEM
ZZ sails laws of C.1ifomia.Date WATER BEAT WNEN"DELECTR
Applicant s GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exempnor,you should WATER SYSTENVTREATING
a ' become xubjccuo the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
LkI ti forthwith comply with such provkme,or this Lemont shall be,deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RF:SIDF,NTIAI.PCMB. SQ,FT PAID
I hereby affirm that there on
isocsmaion lending agency for the perfma
ornce nT Date Rvccipt#
CUL H the work for which this Mnnit is issued(Sec 3097,Civ,CJ
0U Lender's TOTAL:
Wlenders Address TOTAL:
1 really thin I have rend this.,owation and state that the chose information is BUILDING FEF.
r'�. correct.I agree to cpmpl,with.11 city and county armarmccs and state Iaw.relating Io QTY. MFCHANICAL PERMIT FEE
L) Z building construction.and hereby nufhnrim representatives of this city to tuner upon the SEISMIC FEE
above-mentioned property for inspection purposes PERMIT ISSUANCE
(woo)agree to save,indemnify and keep harmless the City of Cupertino against IiI.Ecl RIC FEE te
Iiabiliticx.judgmenu,costs and expenses which may in any way seems,against said City ALI ITR OR ADD IONIECIL
on scra c of the graining of his permit. PLUMBING EEE
in n
APPLICANT ON DERSTAN US AND W COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFMH
SOURCE REGULATIONS MECHANICAL.FEE
q /7 // 517 AIR HANDLING UNIT LOVER 10.000 CFM) CONSTRUCTION TAX
Sigmnmrc Bean ontmcmr ( Date EXHAUST HOOD(WNUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will rhe.,licanor future building occupantsme,m handle hmardoua material HEATING UNIT(TO 101000 BTU)
as defined by the Calandra Municipal Code.Chapter 9.12,and the Health and Safety
Cade.Section 25532(x)^ HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Will thea Ikea nr future adding t use t or devices which Date Receipt#
1p dbythen ea Air n BOILER—COMP Offs OR I W."BTU)
:mit havardnus air contaminants as defined by the gay Arca Air Quality Management TOTAL
(' L
BOILER—COMP(OVER IW.00(i
t
El ❑No
tJ th h l I AIR CONDI'1'IONF,R
q I: is Ch'Pt 6.95 I rh Cal' ISSUANCE DATE
S ly Cat l t s 25505 25539 a d 25534.1 d .t JII n I t the NEW RE [DICNTIAl.MECH. SQI tlyh I t th t t y sWii bllyt I'fylh .pmtuns wh Jin m ....neco!.CenTeamofOccupancy,
nrir<J ngcm Dole TOTAL: IS iD IiY:
OFFICE