B 0377 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELFYLFRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT FLUSHING-MECHANICAL 50001 ®0377
BUILDING PROJECT IDENfIFICA'TION ON 1 1
NUILDING ADDRESS: SANITARY NO. AIWLICATION BI1BM11119'Ah )AI
10,1— as s , � c-
OWNER'S NAME: PHONE: CONI'kACq'OR'S NAME: LIC NO'.
•��'A_' \ y�e�'Z(ola Nrc coNTRol.a
ARCHITECT/ENGINEER: LIC NO'. ADDRESSV. : ❑
CONTACT: PHONE: BUILDING PERNIIT INFO
�� ry ❑ Consultant Fees Paid by Applicant(Initial) BLDG 1'LEC'I' PLUME B MECH
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby canon Nm 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QWCZ m Sccion7001prfDivi,ion3 NIM Buouresard Pmn,,i m,Codr,endmy Ii,eme is RESIDENTIAL
6100 tar PERMITISSUANCE
F��F in full l'orecanJ ,. � S ❑SFDWL ❑KITCIIEN REMODEL
QVV License=� -� Lisp APPLIANCES-RESIDENT1A1, ❑ADDITION ❑PLUMBING RE-PIPE
h Edi Da. comms,.
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
ZONZ l understand my plans shall be used as public records PANELS MODIFICATION
04-14-0 UP TO 201 AMPS 1 ❑INTERIOR ❑CHIMNEY REPAIR
F.rntW Licensed Pmfcssiond 201.100AMPS IMPROVEMENT SWIMMING POOLS
Y WNER-BUIhDEN DECLARATION OVER]"AMPS ❑BATH REMISPELiREPAIR El DEMOLITION
Q 1 hereby ufnrm Char I am exempt from me Connector's License Law for the `�
G d V fnllowin Section 7031 5,anoresv and Is fic,lom Code:An t r ❑OTHER '��\ C_Q,
g rcmna(, y ci y or county SIGNS ELECTRICAL
36 h which requires
..a permit to c ics the,palter,plic improve.h Permit t file
repair any structure
I"'1='i�innQ
that
mrsmregoithe theapprcaof for hes Candice
hmnenLa signed stove.`. ` SPECIAL CIRCUIT/MISC. Q Cl
That he it liscmal pursuunun the provisions nl he Comrenor'.License law(Chapler9 1
WE C (commencing with Section 7")of Division 3 ofthe Business and Profusions Code)or TIME METER OR POLE INST. COMMERCIAL:
F 6 oy that he is exempt monfirnm and the basis for the alleged esemptirr.Any violation of ❑Nf'W BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a Isminu bijece,the applicant Ida civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not moa than five hundred dollars(55(0).
IMI'ROVFh1ENT
=Q 01,as owner nl the pmpcny.or my ctnployces with wages as compemm�on. SWIMMING POOL ELECTRIC
G and profession,
ands xwc.aisnntinLndedc ow does r.,rp,ly 7044,Business ❑DTHIiR
Cf o
lam prJon,whons Cnsm ient u,es Inns'.License Lawducenotapply.tenownerof OUTLETS-SWI'I'CHP.S-FIX
' .S
his o proton,who boils.or lmpmvm them.,and who als a tech work riled or or through
his own employeese pmvidW that such improvements an not iyearm or offered for NEW RF.SIUENTIAL E1.13CI'R T
talo If.however,the have the bur en of proven is eNhddwithin t Wild of annple fes the SQ.FT.FLOUR AREA
-builder rill have the burden of peeving that he did not boils fir improve for par- •,,,�..-
0 1.a sown` It /� D
h as owner of the Seopeny,.B exclusively convening with licensed contra.....to T(YI'AL: \
construct the project(Sec. Professions Codriflse Oontmreon. Li- (1 z
pmjec I
w mLawdtxe not apply mon with
a commiltmy ice buildsePeru. 1.the Contra orsand QTY. PLUMBING PERMIT FEE
who Laasfonuch Foliose,b-wird acrnvanor(s)littnced panuss ro the Contractors III IuN �j 9 199
License Lew. ` PERMITISSUANCE I J
E]I nm exempt unser Scc. .B&P C for this reason
Owner DateAM 17R-DRAIN&VENT'-WATER IEA) VALUATION
WORKER'S COMPCNSA'I'[ON DECLARATION BACK FLOW PROTECT DEVICE ^
I hcrchy affrzm under Nosh,of perjury enc of the follnwing declarations. C)V
❑ [have and will maintain a Certificate of Consent toself-insure for Worker's Compel , DRAINS-FLUOR. F.ARE .GOND. STORIES TYPF,CONSTRUCI'If
cation,as provided for by Section 37M of the labor Code,for the erfornionce of the
4w rk for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,a required by Section
(0 of the Labor Code,for the perfnnmmeeof the work for which this peonil is issued, GAS-EA.SYSTI'M-I INC.4 OU'T'LEI S OCC.GROUT' APN
Cameoonnumber cre
peri'�I1su�ecanic and PPolido Y�tc-1, I l GAS-EA.SYSTEM-OVER 4IF.A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This xaiun need out be..un.plclod.I the permit is f coin hundred dollar,(SIpan BUILDING DIVISION FEES
or leo.) GREASETRAP PLANCHECKFEE
1 cent be that is the perfnnt urec of the work Enr whi,h,hi,permit is issued I..hall 56W ER-SANITARY-ti IDHM 13A.2g1IT.
not employ any Pearn in any mmrner w,as.become%object to the Workers'Copper- fiNERGY hEE
Oz scion Law.wf California.Dam WATER HEATER W/VEN I/ELECTR
Z Applicant GRADING FEF:
i become bj APPLICANT:IL aper cooking this certificate of Exemption,you should WATER SYSTEM?REAPING
a ' been`suomp to the Worker',Compensun this provisions oft he Lobar Code,you most SOILS PEE
�
forthwith comply with such prounion.or this permit shall be deemed revoked WATER SERVICE
0
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ ET. PAID
V O Theobyti imuhat here is a construction lending agency forth,performance of Date R127,#
D. F the work for which this Permit i.issued(Sec.30PO.Civ.C.)
C) Lenders Name TOTAL:
Lender's Addre.a TOTAL:
F6. 1 cenify that I have mrd this offiJewion and dune that the above infisrmati)a is BUILDING FEE.
rp correct l agree.comply with all city and county ordinances and state laws refacing. QTY. MECHANICAL PERMIT FEE
V Z building comslmctinnt and hereby authorize representatives of this city menterupon the SEISMIC FEE
above mentioned property for inspection purposes. PERMIT ISSUANCE
(We)as.to cava indemnify and keep h,,.Ic,s the City of Cupertino uproot ELECTRIC PEE
Iiabilitiesjudgments,cod.s and expenses which any in any way accrue against said City ALTER OR ADD TO MECH.
in ..sequence of the granting of this permit. PLUMBING FEE /
APPLICANT UNDERS'PAND,S AND WILL COMPLY WI'TIf At.[.NON-POINT AIR HANDLING UNIT(1010.0011 CPM)
SOU.Ryr1Sl,H[GULATIONS. [- MECHANICAL FEE �
3w t A2n }w 5- ��1p ` MR HANDLING UNIT(OVER IOI00 CPM) CONSTRUCTION TAX
Signature uf'I'ticanUComme.r [)an EXHAUST HOOD IW/DUCT) HOUSING MITIGAfI(IN FEE
MATERIALS DISCLOSURE
Will the upplicam ar future building oaupanlsmfe or handle hazardous ma¢rial HEATING UNIT(TO 1110.000 BTU) 300 1
as defined by the Cupeelno Municipal Code.Chapter 9.12,and the Health and Safely
Cods,Section 25532(a)1 —�/ HEAB'ING UNIT(OVER Ilgkfgp BIG)
(]Yes I� V ENTILATION FAN(S INGLE R ESID) PAID
Will thea applicant or future building t use a ui Date Receipt a
pp gby then q pmentlity devices BOILER-COMP f3HP OR IW.000 BTU 0 ,
unit hazardous air contaminants as dennW by the Ray Area Air Quality Manage.`. �
Disniw7 BOILER-COMP(OVER I(RWBTU) TOTAL:
Waff
❑Yes ep�<
I have read the hazaJous materials AIR CONDITIONER
.5,2553 an under Chapter Cali- ISSUANCE DATE
finbui Health&Scurry currently
have
Sections 255115,25533 and 25534.I u notify th,hut if the NEW RESIDI3NTIAI.MECtI. SQ.PC /f
but{{{{{{��ssss11111cIII gdi not I,whicynts.he me,i.thatn ismy uace of.Cilitymnotify the occupant / ��
snstMmn prior.issuance nfa Cenineof Occu�ne /V
Don o �•_ `� ��
Owner mauthorized age. Date
TOTAL: SSl1IiD HW
OFFICE