B 0265 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /y��
CITY OF CUPERTINO BUILDING-ELEC THICAL PERMIT NO. O Zark
V V
BUI1d)ING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL SOOOI
BUILDING PROJECT IDF,NTIb'ICATION
1 • HUILDIN ADDRESS: SANITARY 40. AI'PLIG\I'IOY SUHMI'I'INL DAT L
So CAS I ESTATES S �12iVr CUPI`PTINO
1 OWNIi� SBIE: M (PHON � � CONTRACTOR'S NAME: LIC NO:
HH Y1J1 (Q7VP
N/C CONTROL-#
CWTECl/F,NGINLER: LIC ADDRESS: ❑
CONTACT: PHONE: BUILDING PERNIIT INFO
TEAr✓NI_ MO NAMM60 OR ❑ Consultant Fees Paid by Applicant(initial) 13LDG HLECI' PLUMB MEGA
5A+D MOHAMm15-D ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DL LARA' ON QTY ELECTRIC PERMIT IahG
1 herchy alarm Nal I am licensed under provisions oI Chapter 9(comose.6ng JOB DESCRIPTION
,cc, with Satin7WB.(Divi,mn 34the Businnsand l'mfession Code,and my license is RESIDENTIAL:
W O p PERMIT ISSUANCE,
F in Class deflect.
Iyl ❑$IUWh KITCHEN REMODEL.
QUV License Class Lic.p APPLIANCES-RESIDENTIAL. []ADDITION EI PLUMBING kI?-PIPE
vFiQL Dam Contractor
ARCHITECTS DECLARATION [IMULT[-UNH El STRUCTURAL
PANELS
ZOlinZ Iunderamid my,em—hall be useda,public mcards MODIFICATION
OZN- UP1'0200AMPS ❑INTERIOR ❑CHIMNEYREPAIR
Lacnad Pmf•somfol 201-10WAMPS IMPROVEMENT E]SWIMMING POLLS
OWNER-BUILDER DECLARATION 1
perp,, C 6 I hereby alliner that 1 am exempt from the Contranors License Law for the OVER IOOOAMPS CI BATH REMOUEVREPAI� UF.M01 TION r
pq R a O following rcunm.Stasis n]031.5.Hu.ciness and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W a F`Fi which".a.,a permit t.command.slot,imprme.demolish,or repair any snucmrc
^,-+�Q prior toisissuance.also requires me applicant for such pem+il to file.signed.statement SPFCIALCIRCUGDMISC.
% yi1 that he is licensed pursuant to the provisions of the Cnmmctors License Ww(Chapter9 1
W Cn0 (commencing with Section'l0MOd Division 3 ofthe Business and Professions Cade)or TEMP.METER OR POLE INST COMMERCIAL:
d X o mut he is exempt therefrom and the hams for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031,5 by any applicant for a pelma subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Wt more than Me hundred dollars(SSW).
F Z i IMPROVEMENT
'ZyQ OLo the work,the property,or myot intended withwagesas their sole ethn(teusinen.ss SWIMMING POOLELECTRIC
W C will dnlM1ewnfk,Codec he ConiCnstri,License Law,does rvlepply 7B fa,Business ss ❑OTHEk
d,E•o
YI m and Pmfe who
Code:The C. there s License law,does not apply to if owner of OUTLETS-SWITCHES-FI%TURF"_S
0'a.. n ugh
his
who builds or idedtimproves thelium,and who does such work intended
o f or offered
p+ 1
his own employees provided that such improvement
is sold within thin nal inter of m of@red for NF:W RESIULNTIAI.LIECTR
nh
sole.lf.M1oderw.11 haveldi burden fprovin ithat hidon build
cprovetfogthe SQ,17,FLOOR AREA s/sQ.FT
wn
tom-huilJer will have the burden.f proving that he did not huilJ nr intpnrvc I'nr par-
j JUL Q'� ro
IN 1.as owner of the propeny,am excluovely contracting with licensed contractors to 'TOTAL:
construct the project(Sec.7044.easiness and Professions Code:)the Contractors Li-
seLawdanotapplytoanownerofproperty who builds or improves thereon. QTY. PLUMBING PERMIT
rcFEE CIIY Ur uturenIailu
who contracts for such projects with a mmmctur(s)licensed pursuant to the Contractor
Licence Law. PERMIT ISSUANCE
❑Iam ea tondo Sec. ,B&PCfor tticreason
m
ALTRR-DRAIN&V ENT-WATER(EA) VALUATION
Da
wn u R:S OM1 VSAT,an )ECLARATION BACK F10W PROTECT.DEVICE
I hereby Ca
roon under penalty of Perjury one of the following
ikions
Ihaveand will 3ofCoserv. nmrcfor Worker's
DRAWS-FLOOR.ROOF,AREA.GOND
smion,as provided far by See ..J7W ofNe labor Codefmhe perfomanive.fdaw
STORIES TYPE CONSTRUCTION
work for which this formal is issued. FIXTURES-PER TRAP
F7 I have and will maintain Workers Compensation Insurance.as required by Section
3700of at labor Care.to,the paramouna of the work for which this permit is i...d, GAS-EA.SYSTEM-I INC.J OUTLETS DEC.GROUP APN
My Workers Compcnmion Inwmnce carrier and Policy fo m er aro.
Cat Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRI,WAS I'17 INTERCEPTOR
(This section need not he cample al ifthe Penait is future hundred dollars S I W) BUILDING DIVISION FEES
or less) GREASE TRAP PLANCHECK FEE
I canal,that time p.dimmence.fthe work for which this perm isissuad.Island SEWER-SANITARY-STORM EA.2W FT.
not employ any amun in any manner so as m become wbject m me Workers'Compton- ENERGY HE
ZZ satins Law,of California.Date WATER HEAFER W/VENT/ELECTR
O Applicant I GRADING FEE
NOTICE TO APPLICANT If,after making this Cenif+cam of Exemption,you should WATER SYSTEM/TREATING
a , hcco ne suhjaet to the Worker',Compensation provisions of the Labor Code,you most SOILS FEE
fnnhwirh comply with such m0000r,mr this permn,hull 6th dImant revoked WATER SERVICE
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMe. SQ.F3'. PAID
I hereby affirm that them is a conreclion lending agency for the pedrroance of Uare Receipts
fJy F the work for which this Permit is issued Set 3097.Civ.C,)
Q Lenders Name 'IU1'AL:
r Lender's Address TOTAL: 0
("+ G 1 easily eat I have read this applaidion and,rate tha the above information is - BUILDING FEE
Y) correct.I arra m curnply with all tory and crnmty ordimmces and state laws relating Ira QTY MECHANICAL PERMIT FEE
U building commerical.and hereby auforim representatives of this city In enter upon the SEISMIC FF.E
aMrvomenti.ned portion,for inspection par sev,. PERM I ISSUANCE
(we)ave,indemnily and keep hantdcav the City Cupertino againrt ELECT
gree w save, RIC ITH
liabilities.judgments,costs and expenses which may in any way acme against said City ALTER OR ADDTO MECH.
in amecyuence of the graming.f this pcnnit. PLUMBING FEE
APPLICANTUNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNI'1'(TO 10.000 CFM)
SOl'/\�E♦�REGULADONNSN1� L MECHANICAL FEE
1A� 1 hl I AA.M�.II �// IIflC1� AIR HANDLING UNI IO,gN1 CFM) CONSTRUCI[ON TAX
Signature of Pplc. .manor O 1�-�)a1f EXHAUST IIIX)U(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
HOUSING MI'I'ICAFION FEE
Will the applicant.rfuture building occupant sore or handle hazardous material HEATING UNIT(TO 100.1100 BTU)
us deeneJ byline Cuperimn Municipal Q+de.Chapter 9.12,ani the Health and Safer,
Cods,Seri o.25532('.)'! ���� HEA'I'INC,UNI'F(OVER 101,0000TU)
❑Yee ®N. VENT LATION FAN(SINGLE RESID) PAID
Wilt Ne a heath or limn,building t use a Dam Recclpt a
pp dby the
of Air Quality
Management
BOILER-COMP(3HPOR IW,000B'1'U)
.h bmbloos air contaminants as Jeered b the Bay Area Air Qualit Mane ement TOTAL
District? / a
�Ya BOILER-COMP[OVL'R II111,nIN1 P'TU)
I have mad the hazardous materialsrcuimmeno undo Chapter 6.95 of the Cali- AIR CONDITIONER
9 ISSUANCE DATE
lumia Health&Safely fly It Sections Z5505,25533 and 25534.1 undustwd thvt if Ne NEW RESIDENTIAL MECH. Sp,PI'.
Wild,. does not currently have u¢ t,that it is my mcponsibiliym ratify the oe,taxas
.f the vy ircntem fell a v�d lei pro m i,�uanw o Ccn +f keu1p�a]nJcy.
wnc�`a'utI u cn"1 '��r�l +AA —I—Ttc TOTAL:
SSUBD BY
OFFICE
ADDITIONAL PERMIT FEES
BUILDING PROJECT IDENTIFICATION VALUATION
AUILoIxc r�� � r!
AODAEss ti.J
C c 2 nivL2 5-gi
GwNER5 /-Q ' FEE SUMMARY
s�kj M /I N. 4�od'zss-6�Iz
coMrR.croR s
BUILDING
xA E
Llc.xo. PLAN CHECK
gxrflACTOR 5
AoOREse FEE 1
PxOxE SEISMIC FEE -
OTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES
PLUMBING
PPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS
SIGNS TRANS. TOTAL Ji'�d
SPECIAL CIRCUIT
EMP.METER OR POLE INS. PERMIT VALIDATION
MOTORS SEE FEE SCH.
O SERVICE CHANGE
17_ o TOTAL
ISSUANCE DATE
LLJ > CITY. PLUMBING PERMIT FEE RLDD, ELECT, PLc. MECH,
CL 0
Z) Z ALTER DRAIN&VENT-WATER(EA.) [El
CJ O BACKFLOW PROTECT.DEVICE
w ORAINS-FLOOR,ROOF,AREA,COND.
} a FIXTURES-PER TRAP
N
F— z
GAS.EA.SVSTEM-i INC.40UTLETS �
(„) GAS-EA.SYSTEM-OVER4IEA.)
INDUSTRIAL WASTE INTER.
• LAWN SPRINKLERS 1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.2001t/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP. 1 B
TOTAL
O
CITY. MECHANICAL PERMIT Cl tFEE -"r170
lr ,
ALTER OR ADD TO MECH. UI_Co/14
APPLIANCE V
AIR HANDLING UNIT(TO ID,000QF R)
AIR HANDLING UNIT(OVER 10=C.FM.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.1
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOILER COW 13 H.P.or 100,000 B.T.U.)
BOILER COMP MVPI 100,D00 BTU)SEE FEE SCH.
TOTAL