50052 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MFCHANID0L0-0
BUILDING 0
dU11DPROJECT IDENTIFICATION 11JJe —
I ,
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'FI'AL DATE
218-Cr SFI A TrU C{= Q2'
OWNER'S NAME: 1111 PHONE: CONTRA ) "NAM LIC NO
• M2, CH�QIy �7��883 1 ) G/ NIC CONTROL#
MRCHITECT/ENGINEER: LIC NO: URESS: ❑ &q
� 1a SRN c2. 1s�r, w K. tit r
CONTACT: PHONE: �rr BUILDING PERMIT INFO
LSVID y1 Pip NCY 9`t6 38g(o ❑ Consultant Fees Paid by Applicant(Initial) BI,�IMELECT PLUMB MECH
Ir�� x K In
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby,affirm and 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
Cl`gZ whh section v�alaNivishm3nf Ne Business and l'ndcsio..Cn c.,ndmyliciamick RESIDENTIAL'
WOO PERMIT ISSUANCE
1-,t Io tell Race an,clr ❑SFDWI. ❑KITCHEN RCMODEh
QUV License Class Lie# APPLIANCES-RESIUEN'FIAL XADDITION El PLUMBING R&PIPE
FZW D �'li-°y Contractor
Q CI'S DECLARATION ❑MULTFUNIT (:1STRUCTURAL'
Z F 1 and, bed my plan.,shot]be used as public mends PANELS MODIFICATION
OZ�O UP T021NtAMPS ❑INTERIOR ❑CHIMNEY REPAIR
1-HF'W Licensed pmf,ssional 201-IM)AMP / IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER HNNIA 5 / ❑B ATH REMODEVREPAIR [I DEMOLITION
Q 1 hereby affirm that 1 on exempt room the Contractor,Licrns Law for the
OW U following Torino.(Section]031.5,Bore and Professions Codc.Any city or county SIGNS h. ❑OTHER
00 3 W y which requires a lcrmit to construct,alter,improve,demolish,or repair any structure
F�OQ, print toot,issuance,al,areclaims flanpplicantfor such permit m file u,igned statement SPECIAI. RCUITI .C. i w
99 } that he is licensed purtuannn the Previsions of the Comructora License Law(Chaprar9 Ism A I n
(commencing with Section 7000)of Division Sof the Ru,ine,sand Professions Codes or 'TEM P.MET ER0 POLE AT COMMERCIAL'
6 a e a that he is exempt therefrom and the basis lin the staged exemption.Any vmladmt of W BLDG/ADDITION [I DEMOLITION
Scroam 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICE] {Wy�y
ad=' A r (�74 ❑I'UOD SfiRVICIi
E.
Z Y n more than five hundred dollars S50% t OVIRE 0
Q 0I.as owner the Import or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC I'p R,
wt0 will do the work,md the Inarlare is nmlmended omOcred fors,,,(Sec.7,tL Rosiness ®!' RU s�I�
W m send Professions Code The CommcmrF License Law does nal apply m an owner of OUT LET'S-SWITCHES-FIX'ILJR17S 1IIY,,a
a 3 progeny who builds or improves thereon,and who docs such work himself or through
his own employees,provldW that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ F.
sale,If,however the building or improvement i,sold within one year ofcompletion,the SQ.FT FLOOR AREA SISQ.FT.
own,,hmlar,will have the harden al'Pm ing that he did not build or improve lin our
of salr.). v
pow A,
Fl1,a,owner of Ne progeny,am exclusively contracting with licensed contnemis m • )
rennmct the project(See.70,14,Business and Profession,Code:)The Contractors Li- 6
Icanse Low does not apply to anownerofpmpcrty who builtLof improve.thereon,and QTY. PI. GPER ITT FEE
who contract,for such projects with a cnnmamr(O licassed pursuant ,,the Common",
LEceme Law. P[RMIT :SU
I am ex<mp t�IiJer Sec. ,d&P C for this reason
ALTER-DRAIN&V - ATP ( VALUATION
Date
weo WORKER'S COMPENSATION DECLARATION BACK 11-OW PROTECT DEVI .
1 hereby affirm tMcr penalty to pc jury one ohhc follw sesure for Worker in on
[have and ode twimainection 37(X),,Ce Labor Codefinite Workers Compcn- DRAINS-FLOOR.ROOF AREA.COND.
smian,s provided far by Section 3]ql of he Labor Codc,finite porfurmunce of thr STORIES If '1'YPL'CONSI'kUCfI01
etok far wh rli flu d)cont 1,i,med. FIXTURES-PER TRAP
1 have and will maintain Warkrh Compensation Insurance,as mounted]by Section 14
3700ofthe Labor Cade,for the performance oftbr walk for which this Permit i,issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC GRO?V A'N
My Worker's prieudion ln, rnce,artier and Policy number are: , v
Caricc ate [icy No.: CAS-IiA.SYSTEM-OVER 4(GN
TIF 'I' ( v 1 FRO W)RKP.RS'
�ja�A'I FIRhM.'RANCE GREASEANDUS'TRL WASTE INTERCEPTOR
(Thisseclion need not be completed ifthe permit is forcer hundred dollars($100) B 'LUI GDIVISION FEES
nr feta) GREASE:TRAP PLANCHEC
1 ceni]y that in the performance of the work fa which this permit is issued,I shall SEWER-SANITARY-STORM EA. PI'.
not employ any person in any mariner .
so a,to became subject to the Workers Camper- ENERG FG WE
Oz ,,tion Wwsnf Ca]ifomia.Dette WATER HEATER W/VENTIELECTR
z O Applicant ` GRADING EE
r-1 y NOTICE TO APPLICANT:IL otter making this Ccni]iane bf Exemption,yrnt should WATER SYSTEM/TREATING
a > bcenme subject to the Worker,Counteraction f the Lama Cad,you ma,, SOILS FEE
1permit
naso
� 4,nhwiN comply with such provisions or this permit shall be discount revoked. WATER SERVICE
0
] z that me cis a construction ON LENDING AGENCY NEN'RESIDENTIAL.PLMB. SQ.IT PAID
U lforwhich nn thn.ifi issSe30lending,,cosy Tenho perlinmunecof Uotc RAP,
Pthe work for which this gnmit is issued(Sec.310],Ci,CJ
Q U Isntler's Name, 'IOtAL:
Li dcr',Address TOTAL:
F ynI cumly[hat 1 have rend this application and.stam that the uhovc infianatinn is BUILDING IPA?
h correct.l agree to comply with all city and county ordinances and state taws relating to QTY. MECHANICAL PERMIT FEE
Uz building construction.and hereby authorize representatives of this city to enter upon the SEISMIC FEE
done-moraine l peopeny for inspection Purposes. PERMIT ISSUANCE
(We)ugive to rave,indemnify and keep harmless the City of Cupertino a,ma,, ELECTRIC FEE
habi,ities,judgnsents.costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH.
in cnn,equcnce of NNi
e ground,of s permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10,000 CFM)
SOURCE REGULAT NS. MECHANICAL FEE
��- --�' �] � ] �9� AIR HANDLING THE'I'(OVER 10.030 CFM) CONSTRUCTION TAX
Sigtmtumof Ap - o / ��'O- pate EXHAUST HOOD(WIDUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION IEE
Will thca,plicant or future building accuNmtstoreor handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Core,Chapter 9.12,and the Health and Safety
Gds,Section 25532(a)^ HEATING UNIT(OVER t00.Ogl BTU) -C]Yes Fl No
• VENTILATION FAN(SINGLE RESID) ['AID
WIII the applicant or are bM , use ea r devce which
Date Reccim Or
,mil u,air contaminants,a,desJ by the Bay Area Air Quality Management BOILER-COMP(31{pOR 100,000 BTU)
District?
AL:[-1 Yea, Fl No BOILER-COMP(OVER 100,000 BTU)
1 have read Ne hmuNous materials reyuirenants under Chapter 6u5 or the Cali- AIR CONDITIONER
ISSUANCE DATE
fomia Health&Safety Cad,Sxlions 25505,25533 and 25534.1 undersmnd that done NEW RESIDENTIAL MECH. SQ.FT
building Jac,nosort Invention,Nat it is my e,pomibilo,m notify Nr occupant
of the my,imment,which must be met prior m issuance of a Cenilicate of 0sca,da,
Owner re omhorizW agent Data TOTAL: ISSUED BY:
OFFICE