S 0227 (2) APPLICANITTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, _ PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0227 227
BUILDING PROJECT IDENTIFICATION �J
BUILDING ADDRESS: .SANITARY NO. APPLICATION SUBMU7AL DATI
/6-3142- 61 k `
OWNER'S 11 NeMIf:� z
� -P IONE.�32� CON]' CTOR'S NAMI:e v C LIC T���Z
\V<<JJ ,,5 .l. NIC
CONTROL 0
�ARCHRECT/13NGINT:T:R: LIC NO; ADDR e VI/I^ S ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) HI.DG `LL lief PLUMB MEC H
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEL ❑ '�.'1E
1 hereby affirm that 1 am licensed under provisions of Chapter 4 pmmmencing JOB DESCRIPTION
wo,QWZ With Section 7000)of Division Softhe Nuainasand PmEssions Code.wd my license is RESIDENTIAL:
FiW full force and eRecL. PERMIT ISSUANCE
W F, '" CZJ J 54G Z"L ❑SPDWL ❑KITCHIiN kF.MODEh
Liccnsc Clan. Lic.M
N � Doc Cnmmc TL V//_ APPLIANCES-RESIDIiN'1'IAI. ❑gDDITIDN ❑PLUMNING RC-PINI:
ARCHITECTS DECLARATION ElMULTI-UNIT ❑STRHC'1'1JRAL
,z;. TPANELS
Z O n
yq 1 undersand my pl Lathe yy}j put/�m recoNs MODIIICA'TION
OZta ,_�+-.-IF\aQiC.f-p I1PT02nn AMRS ❑INTERIOR ❑CHIMNEY REPAIR
F�FBI Licensed Professional 2014fi00AMPS IMPROVEMENT E]SWIMMING POOLS
�YX; OWNER-BUILDER DECLARATION OVER IWAMPS ❑BATH REMOD'1lRIPAR ❑DEMO[ "TION
C Q 1 hereby afhmm that I am exempt than the Communes License Law for LM1e
xtxi O i U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a proud to construct,alter,improve,demolish.or repair any structure _
F rR,O priono its ion...e,ul.a0 requires tbcapplletm lir such perming f lc aeignednammenL SPECIAL CI RCU IT/M ISC.
tbal he is licensed pnommo,,the prnvi.io.is Of The ConLmemr's Lieensh Loo,(Chaplm9
C� METER OR POLE INS
(commencing with Section]000)of Uivicionlnl'the Business and Pndasions P. ]'. CDMMFRG-LAI;
d 6 O Chde)or TEM
that he is exempt therefrom and The basic lir the alleged exemption,Any viaticum of
cq p g ❑TNEW BLUG/ADDITION ❑FOODSERVI
LL Senion]OJLS by any applicant for apermil mbjmsthe applicant macivil pcnnlry of POWER DEVICES OLITION
W=r/r []TENANT El FOOD SERVICE
HZY not more Nan five hundred dol[arsyepl
O ]has owner nfthe pmpeny,or my employees with wages as their solecompensation, SWIMMING POOL ELECTRIC 01 HER Ch18NT
Sia will dnth,,i.a,amt,The
is ami Li,mdnrnvodoesor sale,pl,t an Business ❑Ol'HER
a 3 andPro Professions Cadc:The CO s there's Lieensc Low does not apply w an owner of (IDTLETS-SWITCIIliS-FIXTURES d ��
his cam who builds or improves thmch i anal who Oma such walk himself or through _
his own employees,pnrvideA that such impravcmentx aro not imlmalaa or nl7cred for NEW RESIDENT[AI.ELHC'I'R SQ PI'.
aide.If,hhweven the building or improvement is sold within one year ofcompletian the1' AIREE.A E/SQ.PT
owner-huskier will have the burden of proving that he did not build hr improve for par- N
pose of sale,. TOTALerr raL�!
❑h as owner of the property,am¢.elusively cntnreom,with licensed op otcmrs to :
mstrvct the project(See.70J4,Business and Professions Code:)JIM Conlactues Li- - - - Uf t,ut r�NO
cense Lawdoes not apply to an ownernf property who builds or improves thereon,and QTY. PLUMBING PERMIT F E
who contracts for such projects with m umhncun(s)Iicersed pursuant m I Int Comtacmr's
license Law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. .B&P C lir this reason
ALTER-DRAIN&VIiN'I'-WATER(EA) is. VALUATION
Owner Doe
WORKERS COMPENSATION rj., he
RACK FLOW PROTECT.DEVICE
I hereby ulBrm under penalty of perjury one of the following Jedaatirns:
Q l have and willmainmin a Certificate of Chosen,to self inure for Wnrkc,,Compen- DRAINS-FLOOR,ROOT,AREA,CO NU' STORIES TYPECI1NS5'11UCTION
amino,as provided lir by Section 3900 of the Latur Code,for the perfam arce of the
work for which this Iwhon,is issued. 171XI ORES-PER TRAP
1 have and will maintain Worker's Cmrlx:rsutlmm Insurance,as rcQuired by Section
3700 ofrhe Labor Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's C`rat f m Insurance cooler and Policy yp]��pcyare �// Q
Cartier: FN su Policy NO.:rI/_C..!O.& /IL GAS-EA,SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INUUSTRL WASTE INTERCF.PTDR
BUILDING DIVISION THUS
(This section recd not M completed H ire permit is throne hundred dallam(810(1 GBRAS E TRAP
or less.) PLANCHECK FEE
I cmifymhal in lhcperfmmanecnfthe workforwhlch thispenolL le issued,[,hall SEWER-SANITARY-S'rORM EA.2(k)F'I'.
not employ any person in any manner set as um became sabjua m the Workers Compe
n- ENERGY FEE
zZ smihn Laws of C.Hform..Dam WATER TIES[ER W/VENT/ELECfR
Applicant ` ORADING PER
Tie,
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEMO`REATING
a , bane subject to the Workers Compensation provisions of the"for Cmle,you mail SOILS PEE.
forthwith comply with such provisions or this permit shall he deemed Minded. WATER SERVICE
0
Uz GGN55'RUGTiONm;ion leading
agency NEW HI351Uf:N'['IAl.I'LMIi. SO IT ['AID
1 hereby million but is s ed(Sec.30 Icmding agenhy for the perfnnnun c hf Uem
[Uts Landrek for which This permit is issued(Sec.3097,Cl,C.)
O U Lender,Nanra Lk-Y/-TAE,:
Lenders AJdrtx TOTAL:
1 certify that 1 have read this application and nam to,
the uMsvc information is BUILDING FF.F
f0.A moecL.I agree m comply with all city and county oNinances and etmc lows maiming"' QTY. r MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FIiIi
ahnvrrmemioned p openy,fur inspection,ampaw,a' PERMIT ISSUANCE
(We)agree to save,indemnify and keep hnnnlass the Ca,of Cupertino against ELHC'I'RIC FEE
Imbildies,judgmenas,costs and expenses which may in way accrue agaimt said Co" ALTER ORADDTOMECH.
in consequence(if the granting of this permit. PLUMBING FEF,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM7
SOUR(/, EEGULATION�S� A /1 MECHANICAL illi
1 \ ` 'WI s AIR HANDLING UNIT(OVER In.fNMI CFM) CONSTRUCT[( AX
Signa-gym Jre of AJppb...thaW.th2imtmm`orL.IIr V Dame EXHAUST HOOD(W/DUCT) HOUSING MITIGATI FEE
HAZARDOUS MAI ERIALS DISCLOSURE
Willmr,phrantor lumenboilJing nccurymt storeor Landis Invardous material Y I IEATINGUND(TO 100,00BlU)
as datmeal by the Cupertino Municipal Code,Chapter 9.12,and he Heuhh and Safety
Code,Section 25532001 HEATING UNIT(OVER I00,000 BTU)
C]Yaw ONn
VIiNTILATION FAN(SINGLE RES ID) PAID
Will The applicant or future building occupant use t m devices which late Receipt
pp gs pun ea AirQu BOILER-COMPUHPOR I00,003BTU)
emir hnzallous air mnhnninanb as de0ncvl by the day Area Air Quality Management TO A%,,
Diavid't
E]yes - El No BOILER-COMP(OVER 1011,000 BTU[
1 have and the hazardous materials requirements under Chapter 6.95 of the Cali- L AIR CONDITIONER ISSUANCE DATE
Rome HeadN&Safety Cade,Sections 25505.255JJ and 2551.1 undcrstamd that ifthe NEW RESIDENTIAL MECH. S(j,FT.
ofthar,mi theals which
have be Met dhath issuance
C0itymnmify Lheocccy.
of LM1e requirements which suet be and prior m issuance site Cenificme of(kcupancy.
Owner or authorized agent - Date TOTAL: ISSIJET)fly
:
OFFICE