S 0710 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY DI COPVISION MECHALECT ICAI PItLLNIIT Na. 0 O
BUILDING DIVISION APPLICATION/PERMIT LW1111NG-MF.CIIANICAI. � Vl
BUILDING PROJECT'IIFI?NTIF'ICATIO
BUILDING ADDRESS: SANI'IARYNO, APPLICAG NSIIBMI'FFALDA'I'E
- 1og35 IJ, i,ro�F �p, cur �nNo , CA _RSol4 �S��T�g_IZ) 2
WNER'S NAME: D PHONE: - CO 'TRACTOR'S NAME: - LIC NO:
t/('IT 1N/C CONTROL#
�ARCIi''ITT�CI' GINF,ER: LIC NO: ADDRESS: YI ! 0
CNy1�)iU JI tJ C- - 2,5 Z6 AMZ E t0 LAS L.A, CA WI
CON IAC F�♦/FT PHONE: - IBUILDING PERMITINFO
9A\ Lb 1"aAo z1 3-6zz-3584 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB -ARCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑ ❑
1 hmahy abort that I um licensed under provision,of Chapter 9(Commencing encin• - m
❑az h JOB DESCRIPTION
WOO with Smtion7000)of Division3ofthe�esinessanJ l'mfessinm Corfu.and mylicemcis PERMIT ISSUANCE RESIDENTIAL.
�I-ly_ min a Classaercem.
VUF License Class Lic.K ' ❑SFOWI. ❑KITCHIiN REMODEL.
yah Date Conlmcror APPLIANCES-RESIDFN'DAL []ADDITION ❑PLUMBING R&PIPE.
(.,pan ARCHITECTS DECLARATION PANELS
❑MULTI-UNIT ❑STRUCTURAL.
Z O 4 1 understand my plans shall he used as public accords
OZ-- - MODIFICATION
UPTO 2W AMPS E3 INTERIOR ❑CHIMNEY REPAIR
Fa`�= L¢cnscd Profewmwl 201.1000AMPS IMPROVEMENT [DSWIMMING POOLS
CY OWNER-BUILDER DECLARATION OVER]"AMPS ❑BATH REMODIi1JNlil'AIR ❑DEMDLffIDN
C I hereby affirm Thal 1 am aempt from the Contractors..ta, oAr,e Law
is for the
ap506 V following reason.(Section 7031.5,Rosiness and improve,
d.. Code Any city or county SIGNS ELECTRICAL ❑OTHER
F�O,�a, which rcqulres a permit re uonstmel,ulcer.improve,demolish,or repair nay slmclurc
rn Ja primmits issuance,alio requires the applicant for such pcmtiun fileasigned smtemenl SPECIAL CIRCUIT/M LSC.
} that he is licensed pursuant it)the provisionsof the Comracuma License Law(Chnpter9
�C (commencing with Section 7000)of Division 3 of the Business and Professions Coded os TEMP.ME'E'ER OR POLE INST. COMMERCIAL
e.%�y that he is exempt therefmm and the hands far the alleged enempdon.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
�•ym Section 7031.3 hY arty applicum fora permit xuFjnm,lhe npplicannnucivil pennby of
POWER DEVICES ,�,"�"'�
FZY mumom than five hundred dollars($500) LLW AN'1 ❑FOODSERVICE
W=0 ❑I,as owner ofthe property,oremployeesth wa es Their sole compensation, SWIMMING POOLFLECTRIC IMPROVEMENT
ywith g,as El OTHER
will Ao thewnrk,and the slmemm ix nrn imm�dul or nlicrcd for alio(Scu.]04A,❑u,inexs
4 3 and Professions Cnde:The Continue s License law does not apply m an owner of OUTLETS-SWITCHES-FIXTURIiS
propcny who builds of improves thereon,and who does such work himself or through
his own employees,pravidcd that such improvements ore out intended or otimed for NEW RESIDENTIAL ELECT SQ IT
sale.If.however,the buddingor impmvemeat is sold within one year ofcompletinn,the SQ.IT.FLUOR AREA VSQ.FT,
coxamr4milder will have the burden ofpmving that he did not build or improve for pur-
pose of sale.).
Cl I,a�owner of the progeny,am esdusivdy contracting with licensed coma Hors to TOTAL:
construct the project(Sec.7044,Business and Pmfassiona GdeJ The Copossamrs Li. - -�
cense law does not apply to an owner ofpropeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEF.
who contracts former,projects with a contracklis)licensed pursuant the Contractors
Liam a Law.
❑Inns exempt under Sec. ,B&PCI is reason PERMIT ISSUANCE
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VAI CATION
DECLARATION BACK FLOW PROTIiCI'.UCVICF. RECEIVED
1 herehy affirm under penalty of perjury one of the follming dcclaratioma:
❑ Ihnvevnd will muinminu CerTiMn¢of Cnn,ent m,clf-insure far Workarx Compem DRAINS-FLOOR,ROOF,A R HA,COND.
mind.as provided for by Section 3700 of the Labor Cade,for The penomm oven of the S II'pIQ1�B{LJBy TYPE CONS'RUCTION
�rk for whichthis pennil is issued. FI%'TURES-PER TRAP YLfb O 4
,1 have and will maintain Winked Compensation hem urra,use required by Section
340E ofthe labor Code.fonhe perfommnceof the work for which this permit is issued. GAS-RA.SYSTEM.I INC.4 OUTLETS C.GROUP pP
My Worker's Com t`an lnsyy��aayy��e.c�orner and Pol icy nym b :
Carrico ai- ns Jj �f'&W Policy Nn:lgkk amu,— -I,�t-,, GAS-EA.SYSTEM-OVER 4(EA) LJ
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASEANOUSTRE.WASTii INTERCEPTOR
(This section need not b t oomPlemd il'O a pennil ix fornnc hundred 6o11s,181018 'BUILDING DIVISION FEES
or leu.) GREASE TRAP -
that PLANCHECKFEE
(certify person in
arfumanymanneeof The work for subject
bjet)it(1 the Wo.aiemo4l shallpan. SEW IiR-SANITANY-
nol employ any person in eDa manner as m become whjeet to the Workers'Gmmpam STORM GA,2191 F'. ENERGY IyiE
Q z ration Laws of CaliRsmia.Data WATER HEATER WNENTIELECTR
Z Applicata GRADING FEE
becameNOT
TO APPLICANT:If.aftCo making this Cerprovisions
of h Exmnption,you should WATER SYST'E REATINO
a become,uomp m The Worked Compensation Permit
ons of the Labra Code,you must SOILS FE[
forthwith comply with tach provisions nr this permit shall M1c Acemul revoked.
S Q WA'T'ER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ,Ch PAID
U O Iherehyaffinn'.list them is a enmwelim i lendingageney for the performmecal Date Re i#
(-' the work for which this permit is issued(Sec.3197,Cie C.)
0 Lenders Name 'TOTAL: I
pY Lenders Address 'TOTAL:
0. I ccnify de,l have mad this application and.,.,a dard the above infommmion ixBUILDING hili
Ln correct.I agree to comply with all city and county ordinances and state laa,laws relating QTY. ' MECHANICAL,PERMIT FEE
7J
U G building continuation,and hereby auNnrlce representatives(if[his city In enter.,).the SEISMICFEE
above-mentioned property for inspection purposes. ME
ANCE
(We)agree To save,indemnify and keep harmless the City of Cupertino against ELECTRIC EEE
liabilities,judgments,costs and expenses which may in any way same agaioludd City ADD IO MECH.
in consequence of the granting ofthis permit PLUMBING IEE
APPLICANT UNDERSTANDS AND WILE.COMPLY WITH ALI.NON-POINT HANDLING UNI'1'(TO III,MIO CPMI
SOURCE REGULATIONS. MECHANICAL FEE
NGUNIT(OVER10,000CFMI CONSTRUCTION TAX
Signature of ApplmcantaContrector Date OOD I W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION Flili
Will live applicantor fume buildingoc....at score of handle bto.ol us materialET(TO 100.000 Ii'TU)
as defined by the Caper ins Municipal Code,Chapter 9.12.end the H.1ch and Safety
Code.Station 25532bd? HEAD NO UNIT(OVER 100.000 BTU)
.D Yc, No /
VENTILATION FAN(SINGI.Ii RESID) PAID
Will the applicum or hamae handing by the B use equipment or devices which Date Receipt
emi[huaaatlous olr cumeminunte as donned by the Boy Area Air Quality MvnugemcnT B011.lik-COM P(JI{p OR IfN1,I1Bf1 BTU) -
DLarin? TOTAL
❑Yes )kNo BOILER-COMP(OVER 100,0001HU) -
I have reed the havudous materials requirement,under Chapter 0.95 ofthe Cali- AIR CONDITIONER
Rmla Health&Safely Cale,Section,25505,2.5533 and 25534.1 understand that if the ISSUANCE DATE
building does not currently have-tenon'.that it is my responsibility be notify,lheoccupant NEW RESIDENT]At,M ECI 1. SQ.FI'.
i cards of which must he met prior to ssuance of a Certificate
fO � Y
o»ner.ra.t n Z y
Vale
TOTAL. ISSUED BY:
OFFICE /�