S 0858 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDINGJ(Initial)
L. PERMIT NO.
BUILDING DIVISION APPLICATIONIPF,RMIT PLUN12NGAL C 0858 O C 4
n1111.DING Pft(1J IICAT'IOry J Q J V
BUILDING ADDRESS � r C[J� / a ;�pPq////J/� SANITARY NO. APPLICATION SUBMITTAL DATE
OWN A k ,'(] I .�EY/�D U CO//NT`-'/)k/_ li/ „�V' (IRNIC CON"1'NOhkof
\RCHITECT/ENGINEER: LIC NOCONTACT ./ NE: / BUILDING PERMIT INFO
❑ Consultant Fees Paid bInitial) BLuc E iG'I' PLUMBLICENSED CON'I'RACIOR'S DECLARATION QTY ELECTRIC FEEI hereby affirmthat 1am licensed underprovisionsof Chapter 9(commencing JOB DESCRIPTION
QMZ IhS<cannT1I 1), a eftha Basincssunithr ei a Cok,and my license is ?! RESIDENTIAL:
WOO in PERMIT ISSUANCEebW;: mull foceand cl . ivi.ln. ' ns � ❑SFDWL ❑KITCHEN REMODEL
aUU Licenu laze Lek APPLIANCIS-RESIDEN ❑ADDITION ❑PLUMBING RE-PIPE
l-Z W Dam C-houth
F.OH
ARCHITECTS D R ❑
PANELS MUCITUNI'F ❑STBUCT'URAL
Z p on Z I u istavi ml my plans shall he used as public records MODIFICATION
OZ4O UP TO 200 AMPS C]INTERIOR [I CE HMNEY REPAIR
tQ-l?FW Luamod Professional 201-1000AMP5 Ih11'kOVF:MENT ❑SWIMMING POOLS
0.YF.; OWNER-HUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR El DEMOLITION
Ki M d 1 hemby nflirm thatI ant eacmpt hornthe Contraaor'x License Law for the
kO ems,U following mass...(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OT [R
41
which req pe t t t t It p demolish, p any structure
O
�.. 6 print to itsIo)requires thapplicant] such pemtt file a signed shaminctt SPECIAL CISCO I'I/MISC.
fOld pN.'a that he is licensedp tt th provistorsoftheCorefirachoses License W (Chapter9
==`em (commencing with Sueono)(Knof Division l ofthe Immue. d PonficisammCodoor TEMP.MCI FEE OR POLE INST.
d a o yy Ihm he is cscmpt Iheoafmm and he basis for he alleged enemptinn.Any vinlvtion of El NEW BLDGIADDITION El DI:MOLI'I'[ON
W-, Section 7031.5 by any applicant for a permit subjects the applicant n a civil Penalty of POWER DEVICES C)TENANT ❑FOOD SERVICE
not more than five hundred dollar,S500).
F Z.YIMI'ROVHMI:NT
�0 ❑Lotowner k,the Progeny. lie myemployees with wages mtheir ale(Sec.compensation, SWIMMING POOL :LF,CfRIC
F will dothewms and the in Com isnot s Licensed n Law
ds not apply
to ti.Business ❑OTHER
w and erofea.iom Cndoa.The Conwmors License w ,do does not apply I.an owner of OU'1'hP.'I'S-S CHF.S-FIXTURLS
3 progeny who builds or improves thereon,and who Joelsuch m rad tte himself tartaric,h
his own employees.todirprovided that such improvement%am nm attended!or.Rend for NEW RES aN'IAI.F,LECTR SQ Ff.
sale,b uwer will c have
th burden
n of paving
ithatold within on Wild
or improve far the SQ.PT.FLDDR AREA SISQ.Irl'.
er-builJcr will have 0e burden of proving ma he did not W iIJ or improve for pur-
qtu:of sale.l.
I,m owner of Iho property,.Bovine,
and Professions
with Iiceoeed entruchor's i- TOTAL: I
<nnumm me project(Sec.](N4,tluviness and Professions Code:)The Contrumors Li-
ncLaw does not apply Bs an owner ofpmEwrty who builds or improves thereon,and QTY. PL M B IN s RFT FEE
who commas for such pnsjeas with a commehons)licensed pumuam tut the Commmark
License law. PERMIT ISSUANCE
1 are esmnpt under Site :B&P C fonhis reason
ALTER-DRAIN&VENT-WATER(EA) VALUN'ION
Owner Doc
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO ECI'.DEVICE
I hereby alarm under penally.f perjury one of me fnllmving declaration 13I have and will maintain aCenificamof Conant to self-imaicfim Worker's Compem DRAINS-FLOOR,ROOF.AREA.COND.
suntan,vs provided for by Section 3700 of the Labor Code,iia the Esse formance of life STORIES TVPIi CONS'TRUC'TIOI
wt kfor whichibi,permilkissucd, I FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
q ortheiab.r COJ.forth f.rmanc nfthe work rat which this peentit is ix mad, GAS-EA.SYSTEM-I INCA DO LffT5
My Work C nramd PnlicY num 10af OCG GRODP AI'N
Cum Policy Sh, GAS-EA.SYSTEM-OVER 4(EA)
C17RTIFICNI E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE.INTERCEPTOR
BUILDING DIVISION 17F.ES
(This section need noet ficampletad ifthe pshom,is far urc hundred Jolla.(SI(kq
or less.) I GREASE TRAP PLANCI HECK OUT
Icenifythat indite perfnrmmt<c of the workforwhich thiipermit isissued.Ishall SEWER-SANITARY-STORM H.A.2W 14.
not taamloy amy person in my manne...a,to heatmc sohjcct to the Workeri Compen- ENsB cArT n
ZZ coom Laws of Calilomia.Date WATER fll-ATER WOVEN'T/F.I.ECfR
Q Applicant GRADING FBI'.
h SIM ICE TO APPLICANT.11:alio making Ihi_e Ccnifiom of Excmptmn,you should WATER SYS'I ENvI REAT1NG
a ; become subject m the Workcra Comperosminn Issrok oro of the Who Cute,you most S 1iANSP
,..� forthwith comply with such powisionsor this permit shall he deemedrevoked, WATER SERVICE Id
c. Q
UZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLhf B. SQ.FT. 1d1 P01D --,
IM1en•M1y affirm that them is aconnmaion lending agency for the perfnnnan<e of Date 11 Rc� ak
I, � the work for which this permit is issued(See 3y97.Civ.C.1
Landers Name
C) {U Lenders Adishm, t TOTAL:
1 ttnify mm 1 have relit lM1ix application and store aha the abuse information is BUILDING FEEYV
FN cnect.I agree to comply with all city and county ordinances acid same laws miming to QTY. MECHANICAL PERMIT FEE
U building conamalio,and hereby ruthorim representatives of this city to enter upon the SEISMIC FEE
abnve-mentioned property for inspection purpo.es. PERMIT ISSUANCE:
(We)agree m save,indemnify and Accp bulimic,,the Ciry of Cupertino against as 16 ELECTRIC FET:
labiliti<s,ptdgtncnu.costs and expenses whichmay in any way h'cmc againq said Guy ACT ER OR ADD TO MITCH.
in mmecheacc of the 6.no,of 0i.5 permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIH HANDLING UNIT 10,0x1 CFM)
MECHANICAL.FEE
SOURCE REGULATIONS. f
ON
AIH HANDLING UNIT(OVER 101100 CFM) CONSTRUCTION TAX
Signator,.(ApplicunVComructor I [)ate EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION PF.F.
HAZARDOUS MATERIALS DISCLOSURE
WE.the applicant or Onurc Mti taenpam sore nr handle haeardoas manna HEATING UNIT TO 110,0X0 BTU k
as defined by the Cupertino Muni C.Je.Chaplar 9.12,and the Health and Safety
Code.Section 255320)] HEATING UNIT(OVER 1011.110)BTU/
0Vv N VENTIL AI'ION FAN(SINGLE RES ID) PAID
Will the applicant or future building occupied use equipment or devices which Date Receipt k
Diiha LrJaus air conmmimuns av I tied by he Bay Arca Air Qualify Manugetnem BOILER-COMP W
(311P OR I ,OMt BTU)
ii
TOTAL: k
❑Yes No BOILER-COMP(OVER 1011.0100 BTUI
I have read the Worsham,mammalsAIR CONDITIONER ISSUANCE DATF
reyuiretrtcnts under Chapter h95 of the Cali- e
former Health& S y Cale,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FP
building Joe, It, oily haveatenunl,Dal it ix my resrymsihilil mnn'ytMr cupanl
of the m^" me ich mum Inst pdorw i umwa o a Cc heal arty. '/J�/I
O e r lh r ate 'TOTAL: v S� � A f�
SSUED BY:
OFFICE