B 0108 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLRCTRICAL t PERMIT NO. .^5II �yf
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAI, SOOO1 OlOv
BUILDING PROJECT IDENfIF'ICAI'ION
i, BUILDING
AUDItGSS. ,�� ����� D �6361q 63 SANITARY NO. AI'I'LICAI'IUN SUBMITTAL DATE
OWNER NAME: D/LUS PHUNIi: COSTS f0 Ap10/. � '. LIC NO:
[� /A E: CN NIC CUNfROLp
CHIT ECT?NGINF.ER: IC ADDR ` ❑
E. u�/Cocu r/E.
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUMB ME>
LICENSED CONT RAC'I OR'S DECLARATION Q'ry ELECTRIC PERMIT FEE
1 thereby affirm tem 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Ox's wiN Section7q%B of Divisinn3of the Business and RnfessionsCMe,and mylicen
f+lOp PERMIT ISSIIANCIi SO RESIDENTIAL: Y /'
F+� in full force and cffmt. O �Sf ❑SFDWL ITCHEN REMODEL.
QUU Lieensc Cls Curno 0 M6 APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING BE PIPE
NQ d Hme Conlmctor
on<= ARCHBFM.Cr'S DECLARATION PANELS El MULTI-UNIT ❑SIRUC'I'URAI,
Z O o,Z I understand my plans shall he used as public records MODIFICATION
UPT0200AMP5
OZ—O ❑INTERIOR
F� ❑ ❑ IM
sLicensed Profesaionul 20I-10M1AMPS IMPROVEMENT ElSWIMMING
POOLS
.'9 OWNER-BUILDER DECLARATION BATH kEMODFIRFPAIR El DEMOLITION UKODAMPS
C W Q 1 hereby affirm Nat 1 am clean,from the Contracum,License Law for the
I U following reason.(Section 7031.5.Badness odd Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHI7R
3 a.ym
wcb termites a permit est construe,tame b o,owe.dcmnlixh,nr ,pan any structureO¢
He,to it,i...anee.al.....imsthe upplicam forsuch permit to file a signed stamment SPECIAL CI RCUITIM ISC. 7
f 1`Zt,T that the is licensed Pursuant to the prnvi.anns of the Contractors License Law(Chapter 9
�a (armamncng wflo Sermon 7000nol'Division 3of the limmel,mid Prute,eions CUJc)or TEMP.MET'IlR Ok YOLEINSI'. COMMERCIAL:
e.E o C that be Is exempt therefrom and the basis for are alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ec=i Second 703L5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES ❑TEIANT ❑FOOD SERVICE
not more than five hundred dollar%($500). IMPROVEMENT
Sp ❑ Las owner f the property,or my employees with wages as theiremle compensation. SWIMMING POOLELECTRIC
F
will do the work,and the swcma is nut intended oroRcied for sale(Sec.7611.Business OTHER
w and Professions Cotle The C es thereon,
License Law Jces mot apply m on r through
of OUTLETS-SWITCHES-FIX'TUBES
�'3 pmpmy who builds or improves thereon,upr who Jces such work intended
or or through
his own employees.e building Nm sock improvements are on iyeso0f or offered for NEW RESIDENTIAL ELECfR SQ FT.
talc.If.M1owevcr,the building or intpnwmncm is sold within one year of rnmPletion.lhe .IT.Ft OOR AREA $/SQ.IT. .
n hili will ethcb d provingfthth did not land P f,Par Y
pose f' )
C]1 f thep pcnY exclusively contracting with licensed o ntrr hors to TOTA
tmor" he project S70W B and Pod CJ )'ITC I- nrILi
cence Law does not applyt f property who builds incentives th n.and QTY. PLUMBING PERMIT FEF,
who amtmeo[nr mcM1 pngssts with o conuamoKs)licensed punv.mor the Commnors
License Law. PERMIT ISSUANCE
1 am exempt under Site .B&P C for an,reason
Owner Uule
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMP ENSAHONDECLARAHON BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty ofperjury one ofthe followingdealatations:
J lbavcard will maintain a CearacmeofConsennoself-insumfor Worker's Corfen- DkAINS-PhOOR.ROUP,ARGA,COND' S'T'ORIES 1118 CONSTRUCTION
cation,uc provided for by Section 3700 or Ibe Labor Cure,for the parfomtwcs of the -
workfmwblcbthispermitisissued FIXTURES-PER TRAP ❑ r
❑I have and will maintain Workers Compensation Insurance,an required by Section
3700otNo lahot ,ale.fnnhe twr mumecolthe work for which Eis permit--mi GAS-EA.SYSTEM-1 INC.40UTLE'15 OCC.GROUP AI'N
My WnrkcreC - ss .cL,Ga_ Poliit cy
No:numbr/Sf)301.R GAS' EA.SYSTEM"OVER)(-A) A
Carrier. ,+YY �L.`7 CG7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This scctimm�cedna bectumplotedifhe permit is fortune hundred dollars($IIX) vus BUILDING UIVISIO, 'EES
nr las.) GREASETRAP ) Vt v
PLANCHECK FEE
Loy any Natiothein ficarany mananceofare
In bee for which this perthe W rker,'Cmssued.I shall SEWER-SANITARY-STORM EA.200 FT.
no employ any person in any manner m as to become suhjecnn the Wmkcn.'Compen- ENERGY PEG
O z cation laws of California.Date WATER HEATER W/VENT/ELHCTR
Z Q ApplicantGRADING PEE
t NOTICH TO APPLICANT:If,after making Nis Certificate of Exemption.you should WATER SYSFEM/IREATING
abecome vubjeel to the Worker's ComPensatinn provisions of the Labor Cale,you mux SOILS FEE
Ourovidt comply withmch pmvisin c,ar this permit shall be decmedrevoked. WgT'ER SERVICE
:D z CONSTRUCTION LENDING AGENCY NEW RESIDENTIM,PLM9 SQ FL
PAIIJ
U O 1 hereby kforwhicht this Permit
isit sued((Sec.
3097. agency les,Nc Performance tar Da RccciPt#
j the work Na which Nis permit is issued(see.J097.Co.civ.e.)
O U I cnder'.v Name TOTAL
hcndcr.I AJJrchh TOT
I nify the 1 have read this nPPlicmion and tame that the above information is BUILDING FEE
p) enrea.1. res as cumPly with all city and county ordinances and.state laws relating m QTY. MECHANICAL PERMIT FEE
U z builJingE I ", suronJh cby aulhorne npremntnlivcx of Chia city to soler upon the SEISMIC PIAT
id—c-ment red pmpe+t tr inspection barque.. PERMIT ISSUANCE
I W) res los ,indemnify odd keep hornless Ne Ciry of Cupctino against ELF.CfRIC FEE
liabilities, d ems, a.sre and expenses which may in anyway accrue against said City ALTERORADDTOMF.CH.
rmryue a 1'Ih Standing of this permit. PLUMBING FEE
APPLICAN' L ' :RSTANDS AND WILL COMPLY WITH ALL ON DINT AIR HANDLING UNIT(TO Iyouo CFsU
SOURCERE U NS. / MECHANICAL FEE
I AIR HANDLING UNI"I(OVER 10.000 CUM) CONSTRUCTION TAX
Signature ofA r ancon D: a EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
A ARDOUSMATERIALS DISCLOSURE
Will Neapplic rrfumrebuilding«cupantsloreorhandlehar ousmmerial HEATING UNIT(TO I IIg0o0 BTU7
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Calc,Section 25532(x)1 HEATING UNIT(OVER I(a)lan BTU)
❑yes ❑No VENTILATION FAN(SINGLE RESID) PAID -.
Will the upplicam or dove building occupant use equipment m devices which Dare Receipt#
omit LuraMnm air murrainants m relined bythe Bay Area Air Quality Mmmaturent BOILER-COMP(311POR RXy0I0BTU)
Dittnct7 TOTAL:
❑Yes ❑Nn BOILER-COMP(OVER 100,0(0 BTI)
Ihaveresdlhehazvduus rteorials,equirements-under Chapter 6.95 ofIM Coli- AIR CONDITIONER
ISSUANCE DATF,
mold.Health&Safety Code,here,sacrou ,fted i 25533 and 25531.I understand rho if Nc NEW RESIDENTIAL MECFI. SQ.1T.
formr HJueh ma afety Coe,S u tenant,(hat it ie my rand 255 4.1 m naifY thehat if tot (P
of the requirements which must be met poor to issuance of a Certificate of occupony.
Uwneror nuNnrirsJ
to, Dole TOTA (CoSSUED B
OFFICE ( o