S 0503 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-F.LF.CI'RICAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLl1MBING-MECIIANICAL Q O
BUILDING PROJECT IDENTIFICATION J
503
BUILDING ADDRESS: SANE I'ARY NO. APPLICATION SUBMI'ITAI.DATE
�2 f S-3 5 -Lda.y
OWNESV E: f PHONE: ppLICNNO
CONTROL. 1- -111-7 Cd 4 IC/ � NA`
ftCHITECI'/ENGINEER: LIC NO: ADDRESS: a ❑
7`5- CJo-c•�,.w��-� '- w,- ..8 `14 33
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDGLE PI. LH
B M
LICENSED CONTRACTOR'S DECLARATION TY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRI ION
O�Z with Section lUXMB of Division 3 of the Business and Professions Code,and mylicenseis RF-1
WOO / p c PERMIT ISSUANCE
t�1_ in full foreeanJ cRe . Z�/ CP /bJ� ❑SFDWI. ❑KITCHEN R17MOD17L
lU License las LiaNig APPLIANCES—RPSIDEM'IAL. ❑ADDITION [I PLUMBING RE-PIPE
Dvm TS DECLARATION
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
I.p y PANELS MODIFICATION
Z O Z I understand my plans shall be used ss public recnMs
OZ OLL UPT02IXIAh1P5 ❑INTERIOR [I CHIMNEY REPAIR
P:to, licensed Professional 201-I(XIU AMPS IMPROVEMENT E]SWIMMING POOLS
a�Q OWNER-BUILDER DECLARATION OVER IWOAMPS ❑HATH REMO]) REPAIR DEMO ]ON
1 hereby ummt that I am exempt from the Commctor's License Law for rbc
O 6 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
673 W which requires it penin to construct,alter.improve,demolish,or repair any x0ucmre As
O prior to its issuance.also rcquirea the applicant for such Femtin to file a signed statementIAUS
SPECIAL CIRCUITIMISC.
!!fy that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9
(commencing with Section 7000)of Division 3 of the Business and Professions Cade)orTEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt Netefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
Section 7(131.5 by any applicant for. caraut subjansthe applicant too civil penalty ofPOWER DEVICES ❑TENANT ❑FOODSERVICE
xGnot marc Nan Five hundred dollars($50% IMPROVEMENT
❑ 1,ss ownerofthe pmpcny,or my empinyeeswinh wages asnheirsnlewmpensntlnn, SWIMMING I'OOLELGCTRIC ❑OTHER
will Jo the work,and Incarnation,is ton intended ormfered for sale(See 0614.Business
L and Professions Code:The Contractor's License Law does not apply to an owner ofOUTLETS-SWITCHES-FI ij
Property who builds or improves thereon,and wha does such work himself Or through
his awn employees,provided that such improvements ort not intended or offered forNEW RESIDENTIAL El ECTR S FT
sale.If.however the building or improvement is sold within One year ofcompletion,the SQ.FT. L O REA $/SQ,FT.
owner-heilder will have the tollm of proving that he did not build or improve far pur- I�
poseofxwne HcyD[A�
I, owns of the pmm ex
peny,men controlling with licensed commerce, TOTAL:
C]1.
construct the prnjar(Sec.](44,Business and Professimts Code:)The Cnmmemr's Li-
wave Law does not apply to an owner of property who builds or improves thereand.add QTY PLUMBING PERMIT FEE YTY Uh GUr
ho contracts for such projects with a contmemns)licensed pursuant ns the Commanrs tH I ENO
License Law. PERMIT ISSUANCE
❑ I am exempt under Sea .B @ P C fonhis reason
ALTER-DRAIN @ VENT-WATER(HA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK PLOW PROI'EGT.DEVICE
I hereby ulBrm under penalty of perjury one o(the following deciaatinns:
I havevnd will maintains Caudillo,OfConam to self-iumn,for Worker's Compen- DRAINS-MOOR.ROOF,AREA,COND. S'TORIS TYPE CONSTRUCTION
cation,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issuul. FIXTURES-PER TRAP
1 have and will maintain Workers Comperaid i insurance,as required by Section
37M.fthe labor Code,(a,theperfonnanc,of Ne work for which nhispetmit isissuW. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
MY
Wo
Mrker's Cnmpef�'ti�n lnsuryu •Tani and Policy nu Mr Bey
Cuter ^ Policy No.: �C ��lo4 GAS-EA.SYSTEM-OVER ERTIF ATEOF EXEMPTION FROM WORKER$' GREASIVINDUSTRI,WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION ITF_S
(This section need rot h completed Bill permit is formhundred dollars'(s l flan) GREASETRAP
or IcssJ PLANCHECK FEE
I certify that in the performance of the work(in which this Permit is issued,l shall SEWER-SANITARY-STORM EA.MXI FT.
not employ any perater in any manner an as m become subject or rhe Worked Compen- ENERGY HE
OZ smion laws of California.Data WATER HEATER WNENTMLECTR GRADING FEE
7 Applicam
F7 VI NOTICE TO APPLICANT:IL ager making this Ccnificat<of Exemption,you should WATER SYSTEM'HEATING
a become subject to the Workers Compemmion provisions of the Labor Code,you must SOILS FEE
forthwith comply with such Provisions or this permit shall he deemed mvokeA. WATER SERVICE.
CONSTR LENDING AGENCY NEW RESIDIiNTIAI.PLMB. SQ.IT. PA
fOID
V O thereby vrtn that Here isis.colconswdion lending agency Tonle perfomtance of Date pip
W t•s. the work for which Nis permit is issued(Sea 3091,Civ.C.)
O V LenJels Name TOTAL:
{>a TOTAL
Lenders Address
Qs 1 certify that I have red this application end sum that the above infoalmlion o BUILDING Il '
rA correct.I agree to comply with all city and county radiance,and sate laws tnlmiag In QTY. MECHANICAL PERMIT FEE
(� hnildingconsuuction,and hereby authorial represenladvexofrhi.s city toentenipon the SEISMIC FPI]
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree mauve,indemnify and keep hannlesa the City of Cupertino against ELECENIC ITE
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH.
PLUMBING FT
inconsequence of the granting of this permit.
APPLICANT UNDERSTANDS�9ND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL HE
SOURC�QN(A'IY)NS. ,
AIR HANDLING UNIT(OVER 1(1,000 CPM) CONSTRUCTION TAX
Signawrc nfAp wDale EXHAUST HOOD(W/DUC'ry HOUSING MITIGATION FEE
HAZARDOUS
US MATERIALS DISCLOSURE
Will duarippliciatnfurorepmr handle allousal
HEATING UNIT[IO 100,000 BTU)
as derided bythe CupertinoMunicipal Code,Chapter 9.12,and the Health slid Safety
Gill,Section
25532(e)9 HEATING UNIT(OVER 100.000 BTU)
E]Yet 7 N VENTILATION FAN(SINGLE RISID) PAID
Dae Raeipt X
Will Ne it co um or future building by the B use equipment sr devices which
mit hamrJous air comaminamsmJcOneJ by the Bay Arca Air Quality Mawgemcns BOILER-COMP(31{p OR 100.000 BTU)
TOTAL.:
Owneff BOILER-COMP(OVER 100,000 BTU)
❑Yes C]No
I hove mail the hmmdousmaterials mquirentems under Chapter 695 Orme Cal i- IAIR CONDITIONER ISSUANCE DATE
foods HwIN @Safety Code,Sections 255115,25511 and 25534.I tutdersaM Net if
the NEW RESIDENTIAL MECH. SQ.FT.
foobuildingdw mcnrrc havcation Whntit is my and mbility tonorstadthat if,
ofthe ansa hill must be Puerto{ssuancesfa Cerif¢aeof c
L
Owner or auNori am TOTAL: ISSUED BY:
OFFICE.