S 3822 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C p r�n
BUILDING PROJECT IDENTIFICATION J O L L
BUILDING ADDRESS, SANITARY NO. APPLICATION SUHMITTAL DATE
1(:) 10 s Te4znA thevF_ c,u rlrJo G,", a5—a14 � 2 � Qt9
O ��L,1�I���$5(/��/A(NIH: I'UONE: �) p CO N'TRACTOR'S NAME: LIC NO:
l:� YDIr1E BIC CONTROL#
ftARCHIIECf/HN NEHR: LIC NO, ADDRESS: ❑
CONTACT: PHONE: ,-1 I' BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB /RIGH
LICENSED C(JNTIiACTUR'S DECLARATION QTY ELECTRIC PERMIT FEE' e/
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing _ • ° JOB DESCRIPTION
DaZ with Section7000)ofnivision 3 ofthe Business and Professions Code,and my license is RF.SIDENTfAL �s
WOp in full Et«e and effect. PERMIT ISSUANCE ft,a,e/"��
FLL� ❑SIT)WL LKKIICHIiN REMODEL
aUU Licence Class Lica APPLIANC&S—RESIDENTIAL.
yzWDon Date Cnntracmr ❑ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MULTI-UNIT F1 STRUCTURAL
z O v Z I understand my plans shall W used as public records PANEL 4 MODIFICATION
OZ=q UP TO 200 AMPS El INTERIOR [I CHIMNEY REPAIR
r4tW Licensed frootoirnal 201-10NIAMPS „_/IM.PROVEMENT [3 SWIMMING POOLS
•,�P OWNER-BUILDER DECLARATION OVER EXA AMPS LJBATH REMODEUREPAIR El DEMOLITION
C�I I M1ereby ofirm that I am exempt form the Comment,License Law for the
O L U brown,meson.(Se,Ilon 7031.5.Business and I'rnfessinns Gale:Any city or musty SIGNS ELECTRICAL ❑OTHER
which requires a permit m commit,idea imp rmx,demolish,or«pair any nmcome
prior it)its issuance,also«quiess the applicant for such permit o file a signed statement SPECIAL CIRCUITNISC.
WN that he is liwnnW pursmtm to Om prnvlsinns of loo Cnntramnr's License Llw(Ch aple9
ly��� (commencing with Sution]0001 of Division3of the Business end Rnfession'Cnde)nr TEMP.METER OR POLH INST. COMMERCIAL:
ti q a that he is exempt Nerefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC 4.
Seen...170315 by anynppllcam for apennit moire¢the a,hennl loa Old penalty of POWER DEVICES
LL^v, ❑IMPEl FOOD SERVICE
not mom than❑vc hundred dooms(SSW)' IMPROVEMENT
IMPkOVEMENT
f-ZO ❑Iits owner oftM1e pmpeny,or my employees with wages as their sole compensation, SWIMMING POO BLE
7D44will drlhesims,nod the etmemm erc,Licens Law(.not apply town owner
�O
3la. and Professions Codeor The Commetors License w Law does not apply to if owner of D 011'1'LETs-5 t 1X'1'
propcny whooyees,or impedes thereon,and who does such work himself or through
his awn employees,pudding that such mentis old w are not intended or pletiod for NEW RESIDF.N'IAI.F;,F. FT
sale.If,ho der will have TTebaden of pemenm isat redid non ildorimrove fomthe Fr`FLOOR AY ABEA IS FT.
r
der will have the burden of proving that he did nm build or improve far par- 1I1III,,eell YY (.JI 8199
sent s-glad,
0 1,vs owner of the property,an exclusively contracting with licensed conlueloo,4, Ol
construct Oe project(Sec.1011,Business and Professions Code:)The Contractors Li
cease law does not apply to an owner of property who builds or improves thereon,and QTY, t'PLUMBING PERMIT FEE ' Sy
who contracts fur such projects with a cmoramnr(,)licensed orstiantIn the Cturriel.,
License Law. PERMIT ISSUANCE
❑ Ion,exemp der Se . n ^ ,B&PCf�this reason
0 / 1 n,
•^ 1 ALT13R—DRAIN&VENT—WA'1'F,R(PA) VALUATION
WOIIKF.N:S COMPENSATION UECLARATION TE L BACK FLOW PROTECT,DEVICE
11 _ the«byaffimtnnderpenvhyofPerjury one of theelf-'ome ng Jedmmino
(have and will lin by Se Cion 37 m of Comet..Code,for for Worker's,, Ith- DRAINS—FLOOR,BOOR ARRA.GOND.
,talon,as provided for by Section 3100 of the Lohnr Cele,far the performance of the ___rSTORATS TYPE CONSTRUCTION
work for which this pemtil is issuco[. TEXT GRES—ITER TRAP /
❑1 have and will maintain Workers Compensation Insurance,as required by Sm e__i
377 of the Lahor Code,for the performance ofmhe work for which this permit is issued GAS—EA.SYSTEM-I INC.4 OUTLET'S OCC.GROUP APN
My Workers Compensation Insurance canner and Policy number are: z//
Carrier: Policy No.: GAS—P.A.SYSTEM-OVER 4(IIA) //\
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(his seaimn ruednot w,ourpleted ifrhe permit is forms,bundrdddlars(Slgp i vs° '' <`tBIJILDING DIVISION IEP•S
ar lits”) GRGSE TRAP vPLANCHECK FEE
I easily that in the perf...mncemt'Ihe w,ak for,odd lhixp,nna is issued.lsball SEWER—SANI'T'ARY—STORM HA.2nO P..
not employ any person in any manner so as to become subject to the Workers'Comptes ENERGY FEE
z'z a tion Laws of Califomia.Dam WATER HEATER WNENT/ELECTR
Applicant GRADING PEE
h NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/REATING
a ; become subject to the Worker's Compensation pmvisimm of the Labor Calc,you must SOILS PEE
forthwith empty with such pmvrsdous or This pert nil shall he deemed revoked. WATER SERVICE
CONSTRUCTION ismn.TION LENDING AGENCY NEW RESIDENTIAL I'hMB, SQ.FT. PAID
U 0 (hereby ann tram Ohmni uvruutirn lending anmlim
gency for n( t Receipt ffl
LL. P: dt,wnrkfnr which thisl emit is issued(See3091.Civ.C.)
U Leader's Name TOTAL:
LS1 Irondct,Addm,s L:
1 certify that I have read this m,hemion and slam that do,those information is - BUILDING
CL
cancan.I agree to comply with all city and courtly ordinances and stem lass relming in QTY, MECHANICAL PERMIT FEE /
C-) building conammion,and hereby authorize represcmatives ofthis city to enter upon the SEISMIC FEE
abnvcmenttoeed property for inspection purposes, PERMIT ISSUANCE / O
(we)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE 'O
liabilities,j adgnmms,costs and ex Lich may a against said City
peas Per yinanyw yaccrue agains y ALTER OR A DUTO M EGL. O
in consequence of the griming of thin permit PLUMBING FEE
APPLICANT UN ERSTANDS AND WILL COMPLY WITH ALL NON,POINT AIR HANDLING UNIT CIO 10,00 CFAU MECHANICAL FEE
SOIIR);1(',RCGU TIO �' 'q
AIR HANDLING UNII'(OVHR 0.0WCFM) CONSTRUCTION TAX
Slgnamre Ap e6nt/Cantmmor I )a1 ne EXHAUSTHOOD(WIDUCP) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupantstom or handl donations mmeriul HEATING UNIT LUD 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
_ Code.Section 25.5320x71 HEATING UNI'I'(OVER 100,0191 BTU)
❑Yes FIN. VEN'IIATION FANS INGLE RES ID) PAID
Dame ReceiptN
Will the applicant or furore building use equipment or devices which BOILER—COMP(FHP OR I0d.INdd BTU) in
,mil hazardous air contaminants as definN by by the the Bay Area Air Quality Management
Dlsrlcl^
[I Yes ❑No BOIL(?R—COMP(OVER 100,000 BTU)
AIR CONDITIONER
I havercad the a dousmareriads requirements under Chapter 6.95 of the Cali- ISSUANCE DATE
fontin Health&Sefet Code,Senions 25 500.25 511 vnd 25514.I understand Thal lithe NEW RESIDENTIAL MUCH, SQ.PC
buildi a I urre II hav t ardnitni-vmyrespomibili In nymhe pain
Mnh «q ,c/a11Ftxd� t prior to issuance(if a Get pc 9
Owner or onuJ ugemr Dhe TOTAL: ISSUED BY:-^� `
OFFICE