B 0262 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL P17RMIT NO 0 2 6 2
C,STrY OF CUPERTINO PLUMBING-MECHANICAL
+ BUILDING DIVISION APPLICATION/PERMIT SOOOI
•BUII.DING PROJRCT IDENTIFICATION",ji' '
BUILDING ADDRIi55: + t SANITARY NO. APPLICATION SUBMITTAL DATE
y'
OWNERS NAME: - I'IIONIi: CONTRACTOR'S HAM LIC NO.
rz rnai yob) «'i 20 • dSOG i �cvs�e "r.,7" /r�fl/YY7 NIC caNTROL«
CHIECr/ENGINEER: LIC NO: AD RISS ❑
/��0. u�o 20S uiro re-
CONTACT: PHONE: "HUILDING PLRMff INFOr
❑ Consultant Fetes paid by Applicant(Initial) BLDG HI ECT PLUMD MECH
❑ ❑ ❑ ❑
IJCCNSCOCON IRnCfORS DECLARATION QTY. �ELGQTHC PERMIT s ' 'IEEE JOB DESCRIPTION
- I hereby offmn that I am licensed de prof Chapter 9(ten muttering _ _
r.
OCz .n seel'on 9lron)orD fore Brt, rte.ane pr fe.:,n,Code seamy licenses RESIDENTIAL:
WOO wtI'LRMIT ISSUANCC
F. in fuFare and [-I$FOWL ❑KITCHEN 21MODIL
4rLicensensa Cl... .V0=H#/9 Li ( 9 �
—Q e#
APPLIANCES-REMDF.MPAL. ❑ADDITION ❑PLUMBING RH-PIPE -
FZW Done X: 7 C¢n' Contracuv Moos v.a Pi/•
vi6y ❑NIULTI-UNIT ❑STRUC'EURAL
ARCHI'l1iCCS DECLARATIONPANIHI.S
Imidnothndm lam shall be used a,public records lip
MODIFICATION
yr
P
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l]P-70200 AMTS ❑INTERIOR ❑ 11 R
oz—
'W Licensed Profosmed 201.100CAMPS IMPROVEMENT' ❑SWIMMING POOLS
OWNER-BUILDER DECLARATIONOVER 1000AMPS ❑BATA REMODEIAEPAIR 54DEMOLITION
WG I hereby affirm that 1 oat exempt from the Comornam's License Law for the
�qci((OyU followinyrn.
ea,. (Section]U3L5.lboune„and Pmfassinn,Code AnELECTRICAL
so,aumany SIGNS ELECTRICA ❑OTHER
B13 W E7 which requires a Permit to construct.a1mr.improve,demolish,or repair any sbucwre
prior to its issuance.also tequiies theapplicunt turf such permit In BEO n s lla,il anfmnwn SPECIALCIRCUIT/M ISC.
N
CyyC''GG'.'.yy that he is licensedpursuam as the provisions of the Contmcmrs License Law(Chapter 9
W2 (a°mmencing with Sutinn]IXNB oI Divieion3 nl the❑usinc,vand Pmficiat to Cooiid r 'IENARME'ERORPOLEINST, COMMERCIAL;
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADUI'I'ION ❑UIiMOLI'I'ION
W Section 7031.5 by any applicant for u permit subjects the applicem to a civil penalty alPOWER DEVICES ❑TENANT' ❑FOOD SERVICE
not more than five hundred dollars 1$500). IMPROVEMENT
FZC ❑I,as.wnerofthe prnpeny,or my emploYecswith wages astheinnlemmpenxmion, SWIMMINGI'OOLELEGIRIG
(r will do the work,and the structure is not intended or offered for safe Oac.JIH4,13more,% [:]OTHER
W 3 m and Pmfeaeions Code:The Contreetor's License Law does not apply ,,na owner of OU-11—CIS—SWITCHES-FIXTURES
prnpeny who builds or improves @croon,and who does such work himself or through
his oxo employees,provided that such improvements sooner intended or untred for NEW RESIDENTIAL ELEC R SQ I7L
sole.IL hawevar,the huilding or improvement is sold within one year ofcompletion,the SQ.PT.FLOOR AREA So%FL
mer-buildeT will have the burden of proving that he did not build or improve for par- P A I D
paw of sole.),
❑1,as owner of the property,am exclusively contracting with licensed contractors In I' JUL AN
msanel the project(Sec]oda,B,Ixinaxs and Pmrosxions Code:)no Contmemr's Li- t / - L D $ MIISID
cense L.aw dues not apply to on owner of progeny who huildsnr improves thereon,and QTY. s ' 'PhUMFF1NG P.ERN41T 'FEE/(1''
who Lavedef not appmjecn withaamtmwnr(s)licwnaed pur,uanl mnhe C.naannr',
License Law. PERMIT'ISSUANCE
❑
I am exempt under See. .B&PCfor this reason CIlY Ur uurr-nuhlU
ALTER-DRAIN&VENT-WATER WA) VALUATION
Owner Dat,
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE dose U'
I hareby nfllrm ander penally ,at ila ary one of the following declamtiem: '
I have and will armadm.a Cenifiemeo(Corson mselGimmeror Workers Campion- DRAINS-FLOOR.RODE,AREA.COND' S'LORIIS TY IR CON S I'RUCI ION
s var n,as pmvi led for by Section 3908 of the Lanor code,for the porbnnor,c of the
work for whichthis permit is issued. FIXTURES-PER THAI' 110+./ JT,•cao
A 1 have and will maintain Worker's Compensalinn lnstreac,'as required by Section
3700 ofthe tabor Codes for the performance tithe work for whichthis permit is issued. GAS-IIA,SYSTEM,'INC.4 OUTLETS OCC.GROUP AI'N
MY Worker's Came,...ion Insurance comer and Policy ntyllher ort:� JOIC-OS GAS•-EA.SYSTIiM OVBRCIP.A)
Currier.�«L.[[(,!+�{—PION FROM
/WORKERS
CERTIPICA EOE COMPENSATION
INSURANCE
WORK'?HS'
C.OMPRNSATION INSURANCE GRIiA51%ENDUS'IRL WASTE'EM'IiRCIi1TOR BUILDING DIVISION PEES '
Thus he.nand a..he completed if the permit is for one hundred dol tarn($I00) GREASETRAP
in less.) - I'LANCIIECK PEE
I certify that in the Performance of line work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.21X11-7.
not wnploy any prison in any manner so as h)become into to the Workers'Counter- ENERGY FEE
Z satin.Laws of California.Date WATER I(EATER WNENTPLECI
Z GRADING PEC
Applicant
NOTICE TO APPLICANT:IL after making this Cenificate of Exemption,you should WATER SYS'IEMI ILHAI'INC, SOILS FEE
F become subject m the Worker's Camp oreflon provisions of the Loma Cade,you must
Wti forthwith comply with such provisions or this permitshall be deemed revoked. WAFER SERVICE
0
/U Z CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL 1'LMR. SG FT, AID Dam Rcerile#
U O 1 Hereby affirm that them,a mtad.n melead!.,,ngeaay rer me narf.rmnnee of
the weak far which this peearn isissued(Sec.309].Civ,CJ
OU Fonder,Name 'TOTAL:
W Lender's Address , TOTAL:
6, I enni[y that have read this application and auto That ten above information is BUILDING FEE
x rF+ N correct.l agree to comply with all city and county mdinxncee and,nate laws relining to QTY . MECHANICAL PF,RMIT'' ,t PEE
V Z building cnnsmrd.n.and herehy truth... reprcwntvtiver aphis city to cater upon theI I SEISMICFHH
above-mentioned property fm inspection purposes. PERMIT ISSUANCE:
(We)agree ns save,indemnify uad keep harmless the City of Cupertino against IiE.ECE'RIC FF.E
liabilities,judgments,crecamd expenses which may in any wry accmeagainn,aid City ALTER OR ADD'i'O MI.CH.
PLUMBING F[li
inconsequence ofine granting SNTAN Sthispermit.
APPLIC "ADI RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.fItNI CFM7 MECHANICAL FEE
50 iRE ULA'I'EON S.
., for
AIR HANDLING UNIT(OViiR 10.00( PM) CONSTRUCTION TAX
arc of ApplicanUCnntn¢Hnr I / Dat EXHAUST HOOD(W/DUCT) HOUSINGNIFFIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the xpplinmtorfuutmbuilciingt)ccupentmomorhamileba,amousmamraI HEATTNGIINET(E)100,000RT11)
us def, M
by the Cupcnion Municipal Code,Chapter 9.12,and the[Icahn and Safety
Code,Scelion 25532(a)° - HEATING UNIT(OVER 100.0(X)BTU)
❑Yes No PAID
VIiNT11.AT'ION PAN(SINGLE RLSED) —are Receipt p
Will the applicant or future building occupant use equipment or devices which 1{OILER-COMP(JIIP OR IDILIMMI BTU)
nit hazardous air ammminams as domed by the Buy Area Air Quality Management TOTAL:
District? �N. BOILER-COMP(OVER 100.1100 BTU)Yet, :/
Ihnve read the hazardous mutcvials reyuirctnems under Chuper6.95nf the Cnlb AIR CONDE'LIONER, ISSUANCE DATE
fomia Hea1m&Safety Code,Sections 25505,M533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.E7
building does nod currently hove.tenant mut it ixniy ec,gmobilltymnotify Lha occupant
of the requirements which most as,met prier t.illmse.nf.a Cenifica¢of Occupancy
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE
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INSPIRATION POINT, MONTA VISTA
(FMLY. STEVENS CREEK RD.) - ,+nr I++ROAD--��
.
MSr161 I! I tSltS 1! Ifl/I Ya.l1 i Ilap / -\
- 60.12 a0 i _ IM1x YO� IC0.1, i- la 100.1E s^ i o
7✓r 8 B BB �� 67 ' �' 6/ S� 40 .I 30 6_ 3/
» a »
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027 AG II7-A 3
16-A-15 AI 6 141' 7 »!13•A 6 )2A 9$ IC ;\ j 89
L... 1 --noa loon 'I;olx �eb-- I�•T—iSi T ..It+a... Z
-ulaP• -rn.4. PCL.1 to al.I2
60A3 +I, to �• lV » •O
3 64 i8 25 26 69 c i 35 iP 34 ., 55
74 ' i :I� PCL.B PCL.0 xai6 ..OE¢p gagq._ Y I G 8. 59 66 .
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17 16 IS 14 -- +le Y • P y '4
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lo4x __� l--- _-i"_i4_o.l:___�_ lao.Zfi___ -t I /•
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n_4. 23 24 1 23 - =i of i� e` 't+�r �w PCLA �.
. 2-- /O 9 - 36 =� ; xy 57 ��� g�v0,�-.
73 - I» MI IPCL.3'�/6 Jam.
.23 AC • ' I ��/•• A.O.S./90/7
(FMLY ' SYLVAN WAY) tf�Py'ixrer
e n m4.1x ao.0 rt +iln
ROAD)
STEVENS
P.M.559-M-I
(FMLY. PERMANENTE
STEVENS CREEK P.M. 351-M-47
R.O.S.469/5/
AOS.569/32 -
8K
357
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