B 0120 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PER NO O n 2 O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MBECHANICAI. pqe� Il
1. BUILDING PROJECT IOlrNTIFI.._rION c7�OT
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL.DATE
Y � v 2 �v 7vo -�9-
OW ERS NAME: PIIUNE: CONTRACTOR'S NAME: LIC NO:
' N/C CONTNUI.p
'VCHITECf/I?N NEER. LIC NO: ADDRESS: ❑
NTACT: PHONE BUILDING PERMIT INFO
Z ❑ Consultant Fees Paid by Applicant(Initial) BLD ELEC PE.UMy 7LICENSEDCONfRACTOR'S DECLARATION' QTY ELECTRIC PERMIT FEE ®/ •Lod(
1 herehy vflirm that I am licensed under pmvition of Chapter 9(commenting JOB DESCRIPTION
OCZO with Section 7lXXp of Divivinn 3olNe Business and ProfcssionsCmle.and mylicense is PERMIT ISSUANCE RESIDENTIAL'
F , in full lbrceamdollect /QgQ�3 ❑SFDWL KITCHEN REMODEL
aUV License Ess .d N APPLIANCES-RESIDENTIAL ADDITION C3 PLUMBING RE-PIPE
FZW Data ummaor
Q ta• MULTI-UNIT ❑STRUCTURAL
AN HRIiLTS DECLARATION
TOy PANELS CHIMNCATION
F2Z I undernnnd my plum shall be used es public recnrJx ,,,,...�...,,,,���/
CZ=f� UPT02WAMPS gDNTERIOR ❑S IMMINGP OL
F4Fu1 Licensed Professional 201.1"AMPS ' IMPROVFiMENT E]SWIMMING POOLS
Y .�44 DWNF.R BIJILDF.R DIiCLARATION
ROVER 10DOAMPS p('13ATH RFMODEIJRPPALR El DEMOLITION
6 I hereby affirm that I am exempt front the Contractor's License Law for the /p
kd V m
fallowing rcon.Second 9031.5.Rusimexs and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 U4 II- which requires a Permit m construct,tire,,improve,demolish,or repair any stmaure
t e70a prior in issuance,also rcsryires the nppliwnt for such pvnnino Elcnsigned statementSPECIAL CIRCUIT/MISC.
E!7y that he is beemed pursuan e llCh
to the provisions of the Contractor's Licensaw Chapter 9
y'd�OO (commencing with Section 9fXp)of Division3of the BusinasanJ Pm(dssions GNe)o, TEMP.MEEMORPOLEINSLr�r�EE
COMMERCIAL
A.a c a' Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW RhDG/ADDITION El DEMOLITION
^,y Semina 9113 L5 by any npplieam for a perosis euhjeds the npPllcam eta civil penullY of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZMnot more than live hundred dollars($500). IMPROVEMENT
❑I,Is owner of the property,or my employees with wages is dia' ole compematiom, SWIMMING POOL ELECTRIC
° will do thework,trndthastmnowisnotintendedorofferedforsale(Sm.7{W4,Business ❑OTHER
W
oo vad 1'mfessiona Code:the Contractors License Law does not apply to an owner of OIffLETSr SWITCHES-PI%TURKS
property who builds or improves Nctetn,and who does such work himself or through
ZD—
his own employees,provided Nat such improvements me and intended or offered for NEW RESIDENTIAL ELECTS SQ FI
sale.If however,the huddingor improvement is sold withmone yearnf completion,he
SQ,FT.BOOR AREA 5/SQ.IT.
mer-builder will have the burden of proving that he did not build or improve far put.
1
,some of sale.). TOMn 1,is owner su the property,vat exclusively contracting with licensed contmemrs 1. / 7 }� 001nnstruct Ne project(Sec 9094,Business and I'ndestions Code:)tire Contmetrn's LI-sc law does not applym un owner ofpropeny who huilds or improves tbemon,and QTY. PLUMBING PERMIT
twho contracts for such projects with a martin d licensed pursuant o the Connectors
License law. PERMIT ISSUANCE
{r7I, ❑I am exempt under Sec. .B k i'C fur this reason
AI TER-DRAIN&VENT-W'AT17R(EA) VALUATION
Ow er Data
WORKERmade,penalty
COMPENSATION mj. n DECLARATION BACK FLOW I'ROTECI'.DEVICE
Iherehyumrm under Penalty of of Coneneo the self-mrm,for Jerker's a
have and will maintan eCenificam of Consent to selGinsvrt for Workers Compcn- DRAINS-FLOOR,ROOF.AREA.GOND. STORIV 'TYPE CONSTRUCTION
as provided for by Section 37M of the Labor Code,for the performance of the -
wotrk for which this permit is issued FI X ORES-]'Ell TRAP
E have and will maintain Worker's Compensation Insurance,as required by Section
3900 of the labra Cale.for the pmornmesee of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLET'S OCC.GROUP APN
My Worker' Conrpt I lnsumncekyner and Policy mm�Mr arc: /e
Carrier: —'Qr folic For, nV�_�/ GAS-P.A.SYSTF.M-OVIiR 41EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEoNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES _
fThisseameal al not he completed ifthelremtit is forme hundraddollam(5100) GREASE TRAP
or les") PLANCHECK PIiF:
I certify that in no performance ofthe work forwhich this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT. or
not employ any pdtsom in any mender so as m become student to the W..tons'Crops.- ENERGY FEE
Q Z Nation Laws of California.Da¢ WATER HEATER W/VENT/ E 'R D GRADING FF.'
.z Applicant
NOTICE TO APPLICANT IL doer makingthis Certificate of Exemption,you should WATER SYSTIiM/TREATING
a > SOILS FEEbecome subject ,the Workers Compensation provisions of the Labor Code,you must
nrker -
forhotihcomplywithsuchprovisions or this Permit shal l he deemed revoked. WATER SERVICE
a �
�
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PL SQ.FT, PAID
.�] ate Rece tN
U0 Ihertby affirm that Nem isacnna,uctionlrnding uyency fonhe perfnnnunce of FVU
F Nd work for which this permh is issued(See.3097,Cis,C.) �I 1 V
0" ULender's Name TO L:
Lenders Address 'TOTAL: I
BVI.D G rpH e O o
[r 1 certify that 1 ply read this application trod sine tutu the above laws
relining is
Z building agree it)tio.and with all ynothadd boumyordinances
tiothiand state lawstdmingm QTY. MECHANICAL PERMIT FF.E
UZ building conatmnion.and hereby amhoriu mpresematives of this city toenmr upon the SETS IC FEE
above-mentioned property for inspcetion purposes. PERMITISSUANCE 3 �rb
(We).gree m save,indemnify and keep harmless the City of Chipman.ugninxt EL RIC FEE?
liabilities,judgments,costs and expenses which may in any way accme against said City ALTERORADDTOMECH. PL'MBING FEE
incomequenecofthegrantingof Nisp it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10,000C Ill MEC ANICALPEE 00
SOU .FRz LAT
S ! /G
AIR HANDLING UNIT(012R 11,000 CFM) CONSAUCTION TAX
Stgnauno of Applicvyd' tmcmr // me EXHAUST HOOD(W/DUCT)
AZARDOUS MATERIALS DISC PSURE HOUSING MITIGATION bili
W II Nc applicant ail furore building aeupant store nil handle haeallous material HEATING UNIT(TO 100,000BTU)
as Jefinal by the C.Nninm Mmdcipel Code.Chapter 9.12,and the Hari end Safety
Codd,Section 25532(a)l HEATING UNIT(OVER 100,000 It I'U)
❑yes ❑NoVENTILATION PAN(SINGLE RESID) s 2� PAID Q
Date Receipt as
Will the npprcam or future building occmMm use ttrvipmem it devices which
titImmoou,air amtamirem,mdefined by the Bay Are.Air Quality Management BOILER-COME'(3HP OR I W,00(1 B1 U)
s\dc\9 ❑Nn BOILER-COMP(OVER I W,WO BTU)❑Yes
1 have renal the haallous materials requirements under Chapter 6,95AIR CONDITIONER5 of the Cali- /p ISSUANCE DATE
''1
fomia Heald,k Safety Code,Sectimms 25585.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. y 7
buildingdoe nn rrently haves redact tit is responsibility to antify Ne cecuyyyI���yti/o�n��n/lll// s.9 / f f
aft yall • :which ustlo to to i' achicerdficteof pas _
mhnved age Date T ISSUED BY:
D
OFFICE
CUPERTINO SANITARY DISTRICT
20065 Stevens Creek Blvd., Bldg. C
Cupertino, California 95014
(408) 235-7071
Date:
File: CuSD - MOP
Building Dept-Cupertino
Community Development Department- Building
City of Cupertino
10300 Torre Ave. //�� / / ,//
Cupertino, CA 95014-3202 Re: Subject: q�e3r J�>4af*dd/ l7oh/�¢.vm41
Name: 111711le-r-
Address: /D q{ o / ' 7 e v /11 E Tv e_
APN: 3&1 -
Control/Plan Ck No:
Permit No: 5S 2—
Gentlemen:Gentlemen:
The Cupertino Sanitary District has reviewed the plans for the subject project:
❑ No additional conditions/requirements by the District.
Sanitary sewer is available and the existing building is connected to sanitary sewer, see
conditions/requirements listed below.
❑ Sanitary sewer is (not) available, see conditions/requirements listed below. (Refer plans
to County Health Department.)
The following Conditions/Requirements are made:
❑ Cupertino Sanitary District Fees or Permits are required for the subject improvements,
please do not issue any building/grading permits.
❑ Plans and enclosed Restaurant Wastewater Discharge Questionnaire shall be reviewed
by the Industrial Waste Division of the San Jose/Santa Clara Water Pollution Control
Plant, Phone 945-3000 for questions and to schedule an plan appointment. Please Do
Not Issue permits until pretreatment recommendations have been forwarded to you by
the District.
pl- Locate and raise to grade a property line cleanout.
❑ Install a backflow protective device (verify serviceability if existing.)
❑ Break areas- authorized minor electrical appliances only.
❑ No disposal or commercial dishwasher installations.
❑ No added lab/office equipment which results in additional waste water discharge.
• ❑ Other: .............................................................................................................................
Storm water from surface or roof drains, other general surface runoff water or condensate from any
residential C equipments all not a Iischarged to the sanitary sewer.