S 1157 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
PLICATION/PERMIT PLUMBING-MECHANICAL Q
BUILDING DIVISION '.nUu.up'(:1'ROdF:(."P nID:N'ru4GayON V 115
HUILDI D S: SANITARY NO. APPLICATION SUBMITTAL DAl
OWNER'S NAMP: a PHONE: CONTRACTOR'S NAME: LIC NO:
�GM t \C(aaa 9Z3
I H NIC /g AONTROLp
L l RCHITECTdDJGINEER: LIC NO: ADDRESS: ❑ /j/• `/y
CONT CT.b,kanl AS\LPHONE: - BUILDING PERMIT INFO
AR 1 233-aa$4
❑ Consultant Fees Paid by Applicant(Initial) � L� PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION QTY ELECT RIC PIeRh11T' ,FEE
1 hereby affirm that I em licensed under provisions of Chapter (commencing JOB DESCRIPTION
wo,"Z with Section 7")of Division 3 ofthe Business and Profcseions Cade,and my license is RESIDENTIAL:
F in Poll fort<anct.
d effePERMIT ISSUANCE
Cul(:. WL [I KITCHEN REMODEL
aW Dem Cenmaor License Class LIC.N
Z LL` APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
p
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
p n Z I understand my plans shell to used az public records MODIFICATION
Z— UP TO 2W AMPS
1.-21 Licensed Profssionel ❑INTERIOR [I CHIMNEY REPAIR
201-IOWAMPS IMPROVEMENT []SWIMMING POOLS
C•F•D OWNER BUILDER DECLARATION OVER It1W Ah1P5 ❑BATH REMODF,L)REPAIR ❑DEMOLITION
C W a I hcrchy affirm cont Into avcmpl from the Cnnl Oemr's I.i....e law for the
=U Ialmwing pawn.(Section 7031.5,Business and Profcan..,Coda:Any city or counts SIGNS ELECTRICAL ❑OTHER
aLL y which requires a permit to construct,alter,improve,demolish,or repair any suuctum
0a prier to its issuance,also requires the applicant for seen permit to file a signed statement SPECIAL CIRCUITM ISC.
r�} that he is licensed puruam mthepmvrionsefthe Contractorslumns.lsw(Chapurci - ♦�I
CLOP (commencing with Section 7000)of Division 3ofthe B.Omessand Praft rium Code)., TEMP.METER OR POLE INST. COMMERCIAL:
d e C not hf is exempt therefrom and the basis for the alleged assumption.Any violation of ❑NEW BLY'ION ❑DEMOLITION
X^+u• Scctinn 7031.5 by any applicant fore permit mhjcna she applicant teacivil penalty of POWER DEVICES ❑TENANT el!-R J ��p ERVICE
�..N not more than five hundred dollars(5500).EEll
IMPpkk G ❑1,as Owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑ 14
will do the work,and the atrvcture is not imcndcd or offered for sale(Sec.7044,Business ER
W we and Professions Code:The Contractors License law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES • CCq I•t� k
property who builds or improves thereon,and who does such work himself or through �'
his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL ELEC R SQ Fr.
sale.If,however,the building or improvement is sold within one year ofcompletion,th, SQ.FE FLOOR AREA $1SQ.FT.
caner-builder will have the burden of proving that he did not build or improve for pure- /\
pox of sale.).
❑ 1,as owner of the propcny,am exclusively contracting with licensed contractors to
construct the proms(Sec.7(x4,Business and Professions Cade:)Th,Convectors Li-
came Law does not apply it,on owner of propeny who builds or improves thereon.and ,QTY, ,p' �,PLUMBING PERh11T b FEF„� ��I
whocontrzcts for such projects with a contractors)licensed pursuant to Contractor's
License Law., PERMIT ISSUANCE
❑1 em ancmpt under Sa. .B&P C for this reason
Owner • a Dam ALTER-DRAIN&VENT-WATER HEA) VALUATION
�a
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ,J �
'I 1 hereby affirm under penalty of perjury one of the following declarations:
4\ It
Ihaveandwill mainuine Canificemof Conenttoulf-inure fm Workers Compcn- DRAINS-FLOOR.ROOF AREA,GOND. STORIES TYPECONSTRUCTIOI
sation,as provided for by Section 37M of the Labor Code,for no performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as requirM by Section
3700of the Labor Code,births performance of the work for which this permits issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN I
My Workers Compensation Insurance carrierend Policy number at '
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSfRL WASTE INTERCEPTOR 4 - -
(Thissection neatl trot be rompined if th,pcmdt is for one hundred dollars ISI W) BUILDING DIVISION IjIiPS}.
or less) GREASE TRAP PLANCHECK FEE
I ccnify that in the performance ofthe work for which this permit is issued.)shell SEWER-SANITARY-STORM EA.2FT.
nm employ any person in any manner sons m become subject m the Workers Camper-
0
amper- 1X1 ENERGY FEE
OZ ..ation Laws of Caliomia.Data WATER HEATER WNENTIELECTR GRADING FEE
Z Q Applieant
r•+ y NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEMITREATING
f•” become subject to the Workals Compensation previsions of the Labor Cade,you must SOILS FEE
Wti forthwith comply with such provisions or this Permit shall be domed invoked. WATER SERVICE
a Q
CONSTRUCTION LENDWGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. 4TAX
L) p Thereby effinn that there isaconstructinn lending agency for Performance Of �m a pts3097.Ci¢C)Lenders Name t TOTAL:W LaroersAddress1 ccnify Nat I ham read this application end state that the above information is ,. .. . -- - ...correct.l agree to comply with all city and county ordinances and suite laws relating to Q'fl'L�' ' r• MIICHANICALI'ER MIT' .'} -t '•FEF.I ,V Z building co loonflon,and hcrchy authorize rcprcenadives ofthis city to enter upon the7.00
alcove-mentioned property for inspection purposes. PERMIT ISSUANCEr(We)agree m save.indemnify and keep handless the City of Cupcnido against E liabilities,judgments,costs and expenses which may in any way seems,against said City ALTERORADDTOMECH.in comealuence of the grendng of the permit. E APPLICANT UNDERSTANDS AND WILL COMPLY WITNALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) .FEE OURCE REGULATIIINS.\ AIR HANDLING UNIT(OVER 10,000 CFM) ONTAX
CS
SigmmrcofApptcan n ter am EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant same or handle foramens material HEATING UNIT(TO 100.00)BTU)
in defined by the Cupertino Municipal Code,Chapter 9.12,shall the Health and Safety
Cede,Section 25532(a)7 HEATING UNIT(OVER 1 XLMD BTU)
0 Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Data Rcccipl X
InWill the applicant or future building occupant use thimpmrnt or devices which BOILER-COMP(3HP OR I W.IXIp BTU)
,it haurdous air contaminator as defined by the Bay Area Air Quality Management TOTAL:
surer, BOILER-COMP(OVER 100.000 BTU)
❑Yes nNo
I have read the hsurdma materials requimtnenr miler Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET. 411008 I/�'
building does no currently have a tenant,Nat it is my responsibility to notify the occupam
of the rgaimmenr which must be met prior to issuance of a Cenificam of Occupancy.
Owner or authorized agent Data T/ ISSUED BY:
OFFICE
b ❑ r
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Input Permit Number `51157 - t(�Illil�l"ih�r�IiG
> PERMIT#: IRCHITECT: i.W.ARCH DESGN iALUATION: 369298 I Ir'If�l�I itIu1P1Y
.ICENSE#: 41r 71 I
qx �. APN: 32617885 ISSDATE: 8410 98 t f 111 C,
-US STREET: ORCHARD 3UBDATE:i81 28 98 SITUSNO#: 22189 LCHKDONE'. III�f+�r �IIti1(
p 1 JE.CT,ST,RD CT TYPE: SFDWL ATE CODE:
! �y 'r. N,S,E,W: ESCRIPTION: SNG.FAM.DVYEL 3LDGDEPT: iw F1'rl t'�ilr�a
NO#: L -NGDEPT:
CITY: CU PLANDEPT. 131 'f I ae
r n ZIP: 95014 'LCHKREO: CMA I�j
1 `Ep! O ;ATEGORY: 2 CTRFIRE:
,,w 2 -OT#: )ATEDUE: 02 83 98 SAIVDIST:
ID: ASAKI rmmercial -iLTHDEPT:
-TRCTENG:
OWNER: CAsgJHt 1 r1�1.
r4 OWNER CE-sq#1##:: TOTAL: c}I ori 1 f�r
INSPHOLD: S
F;!
J xy ADDRES CN-saltft#: i T
r' r, Y,STREET,ZIP: CUPERTINO CA Ix�rlilr 1`�fh117J
asidential � 1� r
dx 'HONE: F
� RN-sq#tt#: 3838 t- Idr' III'II'(I�
i,r!- R 7NTRACTOSAN,FEES DUE RE-sa#R#: I Senrch'Uy !1 gi lIII�IIIl '
t i LIC#: US-sa#ft#: G51
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