S 0055 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING PIiRMIT N0. — _ �. ..
CITY OF CUPF,RTINO p� _•G�'-- -T —_TV_
BUILDING DIVISION APPLICATION/PERMIT rLUMBINOMh:CUAMCnI. l'M:/
BUII.IIING PROJECT IIIBFTIhICATION J� v
HIIILDING ADDRIiSS: SAN["TARY NO. APPLICAB']ON SUBMITTAL DAT[
C111-
'N' 'S AMI `C PHhlO I � LI'RAF RSNq` I� ICN
CIII'I-ECf/ENGINEER: LIC NO a J D 1"5 : a'eV/ — �• eIYO. �� I ❑
CONTACT: PHONE: V BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG F.I.EC' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATIONQTY. ELECTRIC PERMIT FEE
I heathy motor that I am Ilcehnmi order Pmvimur,of Chapter 9(eornnancing JOH DESCRIPTION
O�Z with Sati0n 7lNNn ofDivisinn3 of the Business vnd Professions Code,andmylicroi RESIDENTIAL:
0 0 PERMITISSUANCE�y full force'm dfec [ 5' ❑SFDWL ❑KITCHI'N REMODEL
j LicenseC Lite.# ApphIANCHS-H&S1DIiN'fIAL ❑ADDITION ❑I'LUMIIING allPIPE
�<L Dam commdor_
g.'y ARCHI'IELTS DECLARATION MODIF
PANES ❑MOCH-UNIT' 0srRUC
'NRA
2O m z 1 derstand my plum shall he tired m public records A10DIPICATION
un
0Z'/•O Oil 10200 AMPS ❑INTERIOR El CHIMNEY REPAIR
F�.F.W Licensed Professional ' 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
Q �-4 OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATA REMODEL/REPAIR ❑DEMOLITION
,¢.I I hereby ufOml Bort I am eaclnPt form the Conavaor'v lianre Ltiw for the
�0 L U following .(Section 7031.5,Business and Professions Code:An cid t ❑OI EI:R
XX g reamn y y or county SIGNS ELL'C'I RICAL
W 3
WE` which requires v permit to construct,aper,improve,demolish,or repair any s'mcmrc
prlonn'nx isxnunre,also heyuiresthe applicant for such penm
nh tile asignml smtermtSELsJi CIRCUMUMISC.
� y thmhcislicensedpunvammthe Pmvisim"mthe Comm", License lnw(Chapter9
W�aOC (commencing with Section ttp0)af Uivisi0n3ofhhe tlusiness mA PrnfessiOns Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d y o eG 'list he it exempt hot f it I and the hams
dijedsege uexampm m any violation of ❑NEW RLDG/ADDITION �DEMOLITION
m Section 7031.5M1 en u dicer fore penalty of POWER DEVICES
IW,"yam not mordmis five handled dollars($500). C1 TENANT El FOOD SERVICE,
gp6W E] 1,as owner of the property,or my employees with wages asth Oofe camperradi ❑0TUER
n, SWIM M ENG POOL ELECTRIC ll�iPROVEMIENT
will do Joe work,and the strucwre isnuanointed cridl,ord for mile(See7fW4,Buena,, TIIfiR
t�s13� and Professions CMe:The Contractors License Law does not apply to an owner of OUTLITS-SWITCHES-FIST URES
pmpeny who builds or improves thenou,and who does such work himself or through
— k
his own employees,provided Nm such impnwcarat,oro not intendedor offered for NEW RESTD17NTIAL ELECTR SQ Cr.
sale.IL towevev the building or improvement is sold within oneymr0f c0mpIti, the FI'.FLOOR Eb $/SQ.1el'.
r-builder will have the contortof proving that he did not build or improve for poo ✓ Q ((//
posonnal,hT TOTAL: �r l ,1s
I,m owner of the property,am exclusively contracting with licensed enntracre to
cause Law des moa(Sas to an
Business and Prow his bus ds or
The Contractors Li- 'I
who
wdtsfori apply teas witha of property wcensed nor improves thereon,:or QTY. PLUMBING PERMIT PEE
who contracts for rush projects wl'hne0mrvmm[s)IiceneW pursuant to the Conaomnr'eLicense Law. I PERMIT ISSUANCE /vya
❑ 1 of exempt under Sm. ,It&P C for this reason
ALL lilt-DRAIN&VENT-WRIER(EA) VALUATION
Date
WORKER'S COMPENSATION DECIARXI'ION BACK FLOW PROTECT.DEVICE
I herby affirm under vcoahy of pe Jury nee of'ea following deductions:I have and will memoir a Certificate of Consenno sd6insare lir Worker's Con:pen- DRAINS-FLOOR,ROUP,AREA,COND. Si ORIES TYPE CONS'I'R UC'i'ION
m'ion,as provided for by Section 37M of the Labor Code,for the performance of the
work for white Itis Kana is issued. FIXTURES-PER TRAP
I have and wmai
ill ntain Worker's Coensition Insmance,us required by Serino
700 of the"Ito-Code,for the pantomimist of the work for which this permit is issued. GAS-EA.SYSTEM-I INC,4 OUTLETS OCC.GROUP APN
My WorkesCa On, ani Insurance comicr and Policy number ,�I,1 ¢
Carrier: �^ � �- Policy Nn.: I_�\ ryyJu� CAS-EA.SYSTP.MOVER4(EA)
CERTIIrI'CAT O.EX—EMP ION FROM WORKERS' GREASHANDUSTRL WASTE IWERCINITOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Peisse,ionnced no the cnmpleAed it the vernal it forow.mridreddollam($Into OREASETRAP
or less) PIANCHECK IyiE
I certify that in the performuace of the work forwhich this permit unissued,Ishall SEWER-SANITARY-STORM EA.20 FT.
oat employ any person in nny not nm be
so as to come subject to the Workers'Compact- ENERGY HE
Ozse non Lawsaf California.Date WAIFUR HERI'17R WOVE NT/ELiiLTR GRADING FEE
2 Applicant
NOTICE TO APPLICANT If,after making this Cer'ifca'e of I3xcmption,you should WATER SYS'I EMI'TRIiATING SOILS HE
a F' bemme subject In he Workers Con.pe onfion provisions it the Labor Code,you must
fonhx all comply wihhsnch provisions or this pem ishall be deemed revoked. WA'IT:R SERVICE
UtQ RUC PAID
z CONSere Nit armar"NDINGAGENCY NfiW RESIDENTIAL PLMB. SQ.IrI'. nl sip'#
C.J Q thereby af0mlthm there ixemnnmaion lending agency for the performanceof
the work focwhich'h�iiy{pa 'is issued(Sec.3097.Civ.CJ
W (~ Lnn It,',Name N t 'I'OfAI.:
ULenders Address 'OCTAL:
I�.o 1 certify that 1 have read this application and state that the above information is BUILD G HEFF-I y correct l agree to comply with all city and county onlinchaw and state laws mining to QTY. MECHANICAL PERMIT FEE
U ] building cousmtc'ion,and hereby amhoriu representatives of this city In enterutamthe SEISMIC Fri/
abovcrnemioned property for inspection purposes. PERMIT ISSUANCE
1 Me)agree to save,indemnify and keep hannicss the City of Cupertino against ELECTRI FEEas
IiahBlties,judgmmhs,costs and expenses whiclimay in say wnyaceme againatsnd City ALTER OR ADD'10 MITCH.
in coniegoenor of the 6.arm,of fix permit. PWM NO 1'lili
APPLI CANT ON DERS'FANDS AND WI LL COMPLY WI1'H ALL NON-POINT Ai R HANDLING UNIT(TO 10,000 CFM(
// MECEt (CAL FEE
SBORCER VS. '-f 7/ 'S/27
-=+ AIR HANDLINGUNI'1'(OVId,1f1',d,CpM) CANS'I'RU IONIANSignator ofAppl'eaVConhmchor Dad EXHAUSTHOOD(W/DUCT) HOUSINGMI 'GATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will'h<upplicvm or fuwreboildin6 mcupan score or handle havnnious'metrial HEATINGUNIFOU10I,(100BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Herth and Safety
0savat?
de.Scclion 25532m), HEA'T'ING UNIT(OVER I W JNN)BTU)
❑Yea C1 No VENTILATION FAN(SINGLE RESID) PAID
Dom Ra #
eip'
Will the appRcrnl or rum.huildillg omcupunl use ryripmem or devices which
unit Interactions air connotations as defined by the Bay Area Aar Quality Management ROILHR-CUMP(31P OR (N1IN)(1 KI III 'TOTAL
BOILER-COMP(OVER 100.000 BTU)
Yes ❑No
have ad the hadous materials is under Chapter of the Cali- AIR COND1'TIONEN
mwqu re ISSUANCE DATE
forric Health&Safety Code,Seminars 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.I'r
building does not currently have a nation,that h is my resporsibdlly to unity the ocenpan'
of the'equiremen's which must be met prior to income of a Centime,of Occupancy.
Owner or ou'horized ogem Date TOTAL ISSUED BY:
OFFICE