S 4373 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING F,I,ECTRICAI. PHRMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLU\III NG-MECHANICAL S 4373
BUILDING PROJECT IDENTIF'IC'ATION
BUILDING ADDRESS: 777T &h/Ae[e_1/ 606 y all Cc+ I SANITARY NO, APPLICATION SUBMITTAL DAT
OWNER'S NAMI/i��J�� PHONE. r� (. CO CT :S NAME: ' LIC NO:
ffNbIc H&I 2SJ ,IgG1_ NIC CGNTRDLN
RCHITECUENGINEER: LIC NO'. ADDR 'S: ❑
nrur�Fc /3, TR-G6,01V1N&- 6-z6203
CONTACT: D
PHONE: // BUILDING PERMIT INFO
2S 3 5_'105_'10b Z ❑ Consul aIrma ttg Paid by Applianl(Initial) BLDG , ELECT PLUMB FH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE `mlf'/ rIE 311- II-Gl /C-1✓
I hereby affirm thin I mn licensed under prnvfxlmu of Chapter 9 fnnanendtn
u100 ith S7013 DESCRIPTION
OxZ weaton7000)af Divkion 3 ofthe Business and I'micx.unn.Gala,media,lissom is PERMIT ISSUANCE RESIDENTIAL:
in full fora and e0cct. ❑SFDWL C1 KITCHEN REMODEL
QUU License Class Lien APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPF,
IIn Z a Data Can 11
FOy ARCHITECTS DECLARATION PANELS C1 MULTI-UNIT ❑STRUCTURAL
Z C) z l render aced my plans,hall he a,ed as public accord, MODIFICATION
OZp UP TO 200 [D INTERIOR ❑CHIMNEY REPAIR
Letroad Prnfos"onul 2(1 XI 1'S IMPROVF,MHN'ILjSWIMMING POOLS
OWNf:R-IfUILDER DECLARA'1'1ON O AMPS ❑BATH REMODEIJRFPAIR ❑DEMOLIT]ON
p.x x 6 I hereby affirm that I amt exmnpl from the Conalnor's License Low far the
x 3 a U fallowing reason.(Section 70315,Btemer,s and Pntfc,xfom Cafe:Any city or county SIG L AL [:]OTHER
111 a r~ which requires a permit it)construct,alter,improve,demolish,or repair any%"nure
�1=•0g prior in its issuance.also requires me applicant for mch cannot o file a signed,tmement SPECI IR U
f y that he i,licensed pursuant to the previsions of the Conwcmrs License Law(Chapter 9
11x.00 leommencing with Section"000)of Division Sof the Business and Prefesirns Cartel or TEM . RPOLEN COMMERCIAL
Z.a eC ohm he is exempt therefrom and the basis for the alleged csemption.Any viulmian of ElNEW BLDG/ADDITION C1 DEMOLITION
Man Section 7031.5 by any applicant for apermit subjects the applicant Inacivil penalty of POWER DEVI [I TENANT ❑FOOD SERVICE
0
rc than Eve hundred dollars(8510). IMPROVEMENT�Cd Vf,vs awneraf the prnpuny,unny employece with wngesnx theirsole coinpvnamion. SWIMMING Y(l(IL :LE RI
f$�SFD wdI it,,the work,vnd dmsvurmrc is mtmmnJCJoroNaread build,(Sce.7(s .0—ncss []OTHERLL13 m and Professions Carlo [he Contractor's License Law dears not apply to an owner of OUTLETS-SW ITCHF,S-FIXTURL.S
pmpcny who builds or improves thereon.and who does such work himself or through
his awn employees,provided that such impowemenu are not intended or offered far NEW RESIDENTIAL.ELECTR _SU FT.
sale.If.however,the building or improvement is sold within one year ofcompldion.the I •� SQ.FT.FLUOR AREA ESQ.FT.
owner-builder will have the burden of proving that he did not build ar improve for pati
p.eel I ). 9 2 'T(YI'A .
I f o P s,cf, 1 el, d t g rh licensed c d d Rs ( _3
t he Po,i t(Sou 7044B d 11 f s Co ),in,r-couriann,1 i- �l�
o,Law does are ,,Iy as amoor,ofpintern,who hold:mannorse,m d QTY. PLUMBING PERM I'1' FEE
he I' 1,farsach PeNco.infill amn.mtr(,)discover], soon,In the Contractor's A /F
Lsen. PERMIT ISSUANCE
❑Ire a rept underS PC far this u
ALTER-DRAIN&VENT-WATER RJO OOa VALUATION
Owns O
WORKER'S COMMN. TIO DEC,AKAT N BACK 171_0 PROTECT.DEVICE
hereby affirm under larnaldy of per sal lM1e fnlhre Imatbm; /
I have and will maintain a Certificate of Consenua olLlnwre for Worker's Compere DRAINS-I 1R.ROOF,AREA,COND. STORIES TYPECONST UCI'[ON
,union,as pmvlded or by Section 3700 of 0a Labor Cade,for the wrfamancc n1 the ///
work for wh'mh Ibis permit is issued FIXTURES-PI?
FI I have and will maintain Worker's Compensation homicams a reported by Section 1 L/
P(O nRhe Labor Cale,lire the pr6mance of dbe workmrwhichth,,ractini,ismeJ, GAS-FA.SYS'Hibl-II TUTS pC ROUP APN
My Worker%Compensation Insurance canner and Policy number are: (IQ\/)
Cancer: Policy Na: GAS-FA.SYSTEM-OVE ( )
CERTHICATE OF EXEMPTION FROM WORKERS' GRFASUINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This,catinnnenl not bemmpldcd if the lw,air is for one hundred dollars IS 100) GREASE IRAP
of le".) PLANCHEC
I mnlfy dial in tM1e perlornuumcofthe wnrkf rwhich this pvrntit lx issncA.l shall SEWER-SANITARY-STORM I7A.200['P.
not employ any person in any le ner so as m beeame.wbject to the Wmkecl Compo ENERGY E
O Z ,.Iran Lows of California.Date n WATER BEATER W/VENT/ELECTR
Z 2 Applicant GRAD,
NOTICE TO APPLICAN'D If,after making tin,Certificate of Exemption.you should WATER SYSTEMOREATING y'1
become subject m subjecthe Worker's ComlKnsstion provisions of the Labor Coh.you must SOI
fanhwllh comply with such ponskions or this permit shall h deemed cooked. WATER SERVICE
CONS'I'RUCION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
herehy nffinn dial can,is a cnulliarinn leneLng agency litethe perfemm�ce of // .-•/ L Oma Rtteipp
UO I
1"t t ha work Ger which this meant is fsaed(See 31X)7,Civ.C.)
QU Lenders Name
} W Iw ndcr's Address TOTAL: Pop
M 1 certify that 1 have real Iii,application aad vote that the above information i, BUILDING PEE
F' tq correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE / /
UZ building construction.and hereby authoriu representatives of this city to enter upon the ELECTRISEISMIC C C/. 40
aMtve-mentioned pnrpny for inspection parpsses. PERMIT ISSUANCE 5. ELECTRIC FEE �7, 7J
(We)agree lir wvc,indemnify and keep harmless the City of Cep rt m agairnlIce
Iiuhihnievjudgmcols.costs and expcmcs oh ich miry a any way accrue against said City ALTER OR ADD TO MECH, o
nechunee til car griming tit this Pnrndt. PhUMBING PEI: D
"'RCI,ICF RANT UNM-h{STANDS ND WILL JO PLY WITH ALL NO POINT AIR HANDLING UNIT(TO 10,M)CFM) ••�3
u0 EGUfI\T(1N5. X7
/t AI R HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signommof AppllaanVConlramr u t
)f ✓e W
EXHAUSTHDOVIDUC) HOUSING MITIGATION FEE
.
HAZARDOUSIAL S DISCLOS
Will the applicant or future building occupanTaare or handle Intonations macrial HGTING UNIT(TO 100.000 BTU)
as armed by the Cupertino Municipal Calc Chapter 9.12,and the Health and Safety
Ca laficnicn 2553200 `' HEATING ON]T'(OVER 1110,1X10 BTU)
El Yel IANn VF;MCILArION PAN(SINGLE RESID) PAIU
Dale Receipt#
Will the ap,llcanl or future building occupant live equipment or device,which BOILER-COMP(JHP OR I W,(XX)BTU)
n heandou,air commitments as defined by the[lay Area Air Quality Management TOTAL:
Ii crieR \' BOILER-COMP(OVER 110.x0 HIM)
❑ ^O�
Ye, WNo
.�.- 3a.'
1 have rend the hamnloucentered,,centered,reyuitenuhapmr 6.95
ms under Cof die Cali- AIR Comm HONER ISSUANCE DATE
f r health&Su&t Calc.Sectinm25505.25533 card 25534.1 understand chat if die NEW RESIDEM1'IAL MECH. SQ.FT
ail, n,dor,ndu iIybme beam.thm it, ralarmt 'b caollly dn.mcup tit
tai en t rant g
Owner or aithodeedagent ' Da TOTAL: ISSUEDBY: ;& 2
sisi 'J 3 OFFICE r/(r