S 0217 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINp BUILDING-ELECTRICAL PERMn'NO. q
AL
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT JURANIFIC S On'1 7
IIUILDINf,PROJECT IDPNfIFICATIOry J L1
BUILDINGADXESS 0350 SANITARY N(1. APPLICATION SUBMITTAL DATE
ice. / 0� inU _
OWNER'S
al��/J/!// ✓%y ✓'l/((/ N/CCL N'I'NOLa
ARCHITECUENGINEER; LICNII: AODREti}i://' EJCONTACT: / ! A ' PHONE' ,a n'��•/ l✓ BUILDING PERMIT INFO
(�V .V'v 7✓hf� Il.J(
Consultant
ltant Fees Paid by Applicant(Initial) BLDG ELELT PLUMB MX
V ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm then 1 am licensed under Forsaken of Chapter 9(commencing JOB DESCRIPTION
DMZ with Semion]fNq)ofDivisirn7nfthe Buxinessmmd fccsiom CW a mylicenx is RR-SI�pFNT1AL:
'00 PERMIT ISSUANCE
(-�� in toll fnnamal cRm ❑SFDWL ❑KITCHEN REMODEL
QUI L,cen eCls Lic.X APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RF:d'lPF
FF..Z``D�f,pore Commcmr
F-❑ren ❑MULT-UNIT ❑
RAL
RCHITECFS DECLARATION PANELS MODIFICATION
Z 22 Z I understand my plans shell M used as public recoNe
OZ�O UPT00AMPS INTERIOR ❑SWCHIMNEY MING POOL
F
I.L}i Licensed Pmfnsinrml 2014000AMPS BATHR MODE 0 SWIMMING POOLS
t .
OWNER-BUILDER DECLARATION OVER IINI(IAMPg C:1 BATH REMODIi1JREPAIR ODIiM01.ITION
yy I berchy v1Erm that 1 vm exempt from the Crmmcu+rs License Law for the
p(04 U following mmor.(Section 9131 S,Business ani Pmfea,k Code:Any city or county SIGNS ELECTRICAL ❑OTHER add Ac,
LL 3 W which requires a permit In construct,alar,improve,demolish or repair any structure �u�it-
Fqq'4.,OQ prior to its issuance,also mquircs the applicant far such permit o file a signed statement SPECIAL CIRCUITIMISC.
That he is licensed Furnace,to the provisionsoftheConuacroRLicenseLaw(Chapter 9
(commencingwithSection]gltl)of Divisionlnf,hc Business ani Professions Crdc)nr v11.E1NST, COMMERCIAL:
C0TEMP.METER OR I
4µ�ca OC that he is exempt therefrom and the basis for,he alleged exemption.Any violation of [I NEW BLDG/ADDITION [I UF:MOLITION
DXl Lt. Section 71111,5 by anyupplumatfornpermi,subjects theupplicanuoncivil pcostly of POWER DEVICES ❑TENANT El FOOD SERVICh;
yen not more than live hundred dollars(16500).
IMPROVEMENT
F 6 1,asuwnerof,herun.or mearloees with woes as their solecom tion, SWIMMING POOLE ECI'RI
❑ P Pe Y Y p Y B penxu
will do the work and the nrammn,is not intended or offered for.sale(Sec.7614,Business
W and Professions Cade:The Commutes License law does not apply to an owner of OUTLETS-SWITCII - RES
properly who builds or improves,heteon,and who does such work himself or through
his own coulnyces,provided that such improvements are not intended m rffcred far NEW RESIDENTIAL ELECTR SQ FT.
sale.if,however,the building or itnprovcmentis sold within one ycarmfc.ride id the SV 4e1[FtOOgA A SQ.PI'.
owner-budder will have the burden of forcing that he did not build or improve for per,
J G 1� 1 199/7
pose of sale.). TOTAL:
❑1,as owner of the Property.stn exclusively contracting with licensed contraction m BY,
omswa the project(Sec.70LL Business end I'mfessirns C•Ac:)The Cmd.cmrx Li.
cense Law does not apply to an owner of property whn builds or improves lnamma,und QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contrai licensed pursmtnt ut,be G..motors
License Low. I'ERMI'I'ISSUANCE
1 am exempt under Sec. .B k P C for,his reason
Owner Dale ALTER-DRAIN A VENT-WATER(EA) VALUATION_
Wm under
COM PI3erjory on DECLARATION BACK PLOW PR0113CT.DEVICE? V O'
have
andwaffirm uain a emahyofrfCo oneofthe fnsumiintealitionmesCo:
❑lbwsu re idulfar byeCion 3700 of the Latour Code,for the Workersce of th- DRAINS-FLOOR.ROOI:.AI2F;A,Q)ND' STORIliS 'I'YPF.CONSTRUCTION
scion,as provided far by Section 3](X1 of the Latour Code,for the performance rel the
w kfar
ea id this permit is inaed. Iq%'TURPS-PER TRAP
1 have and will maintain Worker's Compensation iefor co as required by Sectio
3ANI of the Luper Code.for the Par of the work for tai ich,bis ermit is issued. GAS-EA.SYSTCM-1 INC.40UTLGrS OCC.GROUP APN
My Workar's PB ecce Qct 'unmetwrlennuI Policy I c� OZ GAS-I:A.SYSTIiM-OVI3R4(EA)
Cruder: Policy
CERTIFICATE li%EMPOON FROM WORKERS' GREASEINDUSTRL WASTE INTERCEPTOR
COh1PE SATION INSURANCE BUILDING DIVISION FEES
(This secfionnad not be completed if,he permit is farnne lmndred dollms(SHX) GREASETRAP
or leu,) I'LANCHECK PER
I certify that in the performance afthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.21X1 FT.
not employ any Person in any number so as to hcesque suhtt
jeco the Workcra'Cialman- ENERGY FEE
OZ cation Laws of California.Date WAI ER HEATER WIVEM'/ELECIR GRADING FEE
Z Applicant
NOTICE TO APPLICANT.If,after making this Cenifcmeof Exemption,you should WATTik SYS713M/I'R13A1'ING
I" bwnma subject to the Workers Compensation providers of the LaMu Code,you nets, SOLI S FEE
Wforthwith comply with such no,com nr this permit that hederrad revoked. WATER SERVICE
0
a' CONST RUCTION LENDING AGENCY N13W RESIDENTIAL PI,MB. SQ.PT PAIp Da¢ •ip�p
V Q l hereby natin thatthere is a consta ttun lending agency far the performance of
D. ^ the work for which Nis permit is issued(Sec.3197,Civ.C.) III, T(
0 U Lenders Name 3TEAL:
Lenders Address TOTAL:
'�a G 1 a,,ify,h.t 1 have rend this application and ditte that the above lamination is BUILDING FEE
Fr V) correct.l agree to comply with all city and county ordinances and Stam laws rammingin QTY. MECHANICAL PERMIT FEE
V Z building construction,cord hereby authunu representatives of this city to enter upon the SEISMIC FEE I +5
above-vomit ned part for inspection purpeau s. PERMIT ISSUANCE
(We)agree to xevm
e.indemnify and keep harmless the City of Cupertino against ELGCTRIC PEE %
liabilities,juJgmems,missend expenses which conymany way came agalns,said City ALTER OR ADD TO MUCH.
PLUMBING FEE
on onsequence of the gramirl of,his pem+iL
APPLICANT UNDERSTANDS AND WILL COMPLY WI fit ALL NON-POINTAIR HANDLING UNIT(TO 10,000 CIM) MECHANICAL Fh' X
SOURCE REGULATIONS.
AIR HANDLING UNIT LOVER 10,(1(111 CPM) CONSTRUCTION TA•)
Signature of ApplianVCommcter Data MHAUST HOOD(W/DUCT) HOUSINGMI'FIGATIONFEF.
HAY.AR WUS MATURIALS DISCLOSUREhandl
Will the applicant(it future building wstorehandl
enpaafnor e hvmdnu,x material 1II3A'I'INC UNI'1'fl'U IINI,(XNI BTIA 'wy
as defined by the Cupertino Munict al Code,Chapter 9.12,and the Health and Safety 1
Code,Suellen 25532(x)] � I IHAHNG UNIT(OVER I DFW BTU)
E]Yet ISN" VENTILATION PAN(SINGLE RESID) PAID
/
Data1 atp
Will,he applicant m Tenure building occupant use egoipmcm or devices which BOILER-COMP(3HP OR IOJ,000 BTU)
emit burnishes air ntrom I defined Area,the Buy AAir Quality Managcnanl + TOTAL:
District? BOILER-COMP(OVER INFORM IOU)
❑Yes 7r
iR
have read maintainsthe smaintainsmaintainsmaterielsrryuimrnenu AIR CONDITIONI
under Chapter of the Call. ISSUANCE DATE
(term an I fety Cede,Sections 255(15,25533 and 25534.1 nndersmnd that if the NEW RESIDENTIAL MECH, SQ.FT. �/ g
buildingdoes t cumtlyhuveatem I.{hata,smy resptmsihI try u+not ytha c pant (O
ofth ns x Elate
rem'suarecofticet
Ow cr ambo ogcm D ma TOTAL: ISSUED BY: 7 Q
OFFICE