S 1145 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C ITY OF CUPERTINO
BUILDING-F.LF.LHANIAI. _ PEgMIT NO,
• 'BUILDING DIVISION APPLICATION/PERMIT PING PROJENG-CT IDENTIFICATION
S
BUILDING PROJECT IDENTIIRL'ATION
BUILDING ADDRESS: - - SANITAkY NO. AP1'LICAI'ION SUBMI'I'IAL'UATII
tkq
OW :SNA ONE: TRACfOWS NAME: LIC NO: '1
fJ$.I IlClldV y[-+SO'. SIC CONTROL#
'C,I I'TELT/ENGIN1iER: LIC O:. DDRESS T l _ ❑
10 A R3 S.
CONTACT: PHONE: BUILDING PI7RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB s MhCH
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby vifirre that tan+Iicenscd under pmvis ne,of Chapter 9(cnmmamem. JOB DESCRIPTION
w0c) with Section 7")of Division 3 ofthe Business and Professions Code.and my license i.s PERMI"f ISSUANCE. RESIDENTIAL: .
in full forcaund effccl. CIS ❑STOWE, ❑KITCHEN REMODEL
�UEJ License Clav:_ - Lies# C APPLIANCES-RESIDEN'I[A), ❑ADDITION [-1 PLUMBING RE-PIPE
FX(y Dntc Oommnor
y<G ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
X~OOym yp ss I ed aspublic ri PANELS MODIFICATIDN
OX=fQ - UP TO NXI AMPSERIOR ❑CHIMNEYREPAIR
LleteledPmfcclmdo 201-1001AMPS PROVFWENT SWIMMING POOLS
•,] OWNER-BUILDER DECLARATION OVER Half AMPS BATH RF.MODIi EPA ❑T);; y I'ffU[�.g
C w< 1 hereby afnrm that I nm exempt from Ne Cnntmcmrs License Law for the \-i,-,T'—
1x06V following reason lgectinn]x71.5,Bu.loess and Rafesxiom Code:AnY citYmmumy SIGNS ELECTRICAL ❑OTHER
W O which requires a permit to construct,alter,improve,demolish,or repair any structure
.aJ
prior its issuance.also requires the applicant ter such Permit file a signet statement SPECIAL CINCUIT/MIS('.
n
ya,
WE he is hecnsul prouatn 1.he Emal sines of the Contractor's Lieenso Line(Ch.prer 9 "
�a�pO I---..- cing whh Seerian]Ilfl(17 of Doision 3oDW Bodressand Professions Csdlnr TEMP.METER OR POLI:INST. COMMERCIAL:
L 2 p that he is exempt therefrom and the basis for the alleged exemption.Any violation of - - [I NEW BLDG/ADDITION ❑DEMOLI'I]ON
XI Stiff.7031.5 by any applicant for.permitsubjectv the epplicanun a civil penalty of POWER DEVICES C1 TENANT ❑FOOD SERVICE
r} not tone than five hundred dollars(5500). IMPROVEMENT
s'0 ❑ Lns owner ofthe property,or my cnq'loyeos with wages as their sole compensation, SWIMMINCIPOOLELECTRIC
$may will do the work,and the structure isnmlnncndWoroffered l'nrsole(Sec.7044,Business ❑OTHER
I'l �_ sad Professions Coda;The Commences License Law does nm apply to tin owner of OI3TLL"I'S-SWITCHES-pl%TURES
d 3 prnpeny who hails'.or improves thereon,trod who dons tcM1 work himxlf or Through
his owa employees,provided That such improvements tiro WE imendel proffered for NEW RESIDENTLALELECfR S
sale.IL however the Wildmile,improvement is sold within one year of cmnplction,the SQ.fT.FL(IOR AREA E/SQ.FT.
ebulWer will have the burden of proving that he did not build or Improve Ion pur-
Poser
of sale.)' - A PAI D
❑1,as owner of the property,am exclusively contracting with licensed conimeors to
construct the project(See.7Bi4.Business and Professions Cale:)The Commences Li-
cause Low does not apply Its anowner of property who lmilds or improves thereon,anal QTY, . PLUMBING PERMIT Ff. n1 QQ
whotmauemfurstier projects withacommetm(s)licensed Commmoes - JAN 13 ANS,
Licensc Lt.. PERMIT ISSIIANCI:
11
❑I am exempt under Sec. ,B&P C lin this reason
ALTER-DRAIN&VENT-WATER(liq U'�I,iTryIYU
Owner Date
WORKER'S COMPENSATION DECLARATION RACK PLOW PROTECT.DEVICE. I O ,
Ihcrchy a men under penalty of Ps'Tiury one of the following declarations: - - `
• Ihavc and will maintain acenificamofGmsant arbinsnrefin Wade'.Compen- DRAINS-II,OOR,ROOF AREA.COND. Stow"I 5'YPE C(INNI RUC'LON
twice,es provided far by Section 3700 of the labor Coale,far the performance M the
and,for which this Permit is issued. FI%TUREti-PER TRAP
❑I have and will maintain Soo kegs Compensation Imuraneq as required by Sectinn
3700of the labor Code.(.,,he pedfamarecof the work for which this permit is issued. GAS-CA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My WerkSS44Cpm Wm SII �/an.11me.er and polm,99WWQQ�B�e�er orJ^�,
Carrier: StEE WmkY,ysq Policy No,:� "jh. GAS-IIA.SYSTEM-OVER4 RA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEYINDUS'1'RL WASTE IbITERCHI'TOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
This section need not be,completed if Ne permit is for one hundred dollar,is I BE GREASE*1
or less.) PhANCHF.CK roll?
I certify than mho pedoentuce of hework for which Ni,trad,is issued,Lmall SEWER-SANITARY-S'i'ORMEA,2011111'.
not employ any person in any manner so as to become subject to the Workers'Concept, ItNIikGY FEE
z ..tion lawud California.IJate WATER HEATER R'/VTNVELECfR
z2 Al,dicard i GRADING M17y NOTTCETO APPT:LICANIf,ager making this Cenincmc of Exemption,you ahauid WA]'Hk SYSTEM/BEAfING SOILS
foF["
a [^ become subject m the Worker's Compensation provisions I'the Labor Code,you must
L1J Iti r0twith comply with such p,o isiu,no,this permit Sm
hull he deoedo,oked, WAI'1iR SERVICE
CONSTRUCTION LENDING AGENCY NEW RIiSIDEN31A1.I'LMIt. SQ.FT LAID m Receipt#
L) z I hereby affirm that there is o construction lending agency for theperfmmancenl
Cfr H the work for which this permit is ismod(Sec.309].Cty.C.) TOTAL:
OU Lender's Name -
* Lender's Addmw IGTA L:
I certify that I have mad this application and.mese that the above information is BUILDI G FEE /6
L.r ;n comecL l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FTE SIDSh CFEE !�
L) Z building construction,and hereby authorise mpresenmtives of this city to enter upon The
above-mentioned prnpeny for inspection purposes. - PERMI'1'ISSUANCIi
(We)agree ua In
It,save, tied keep harmless the City of Culwnino against 1?L[?Cl C NCE
liabilities,judgments.costs and expenses which may in any way accme agninm said City ALTER OR ADD TO SUCH, PLUMBING
in consequence of the gmming of this permit.
APPLICANT UNDERSTANDS_AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T0 Iy000CFM) MECHANICAL Ri
SOURCER. ONS.
/� -�y AIR HANDLING UNIT(GIVER 10,I1fX1 CfMl CONSTRUCTION'fA
SignmumofApp'antlCo actor Date EXHAUST HOOD(W/DUCT) 1 IOUSINGMITIGATION E
HAZARDOUS MAI ERIAIS DISCLOSURE -
WilltheapplicantorfumreWildingoccupant store or handle hazardous material HEATING UNIT(TO URLXM BTU)
as defined by the Cupertino Muoicipat Code.Chapter 9,12,and the Realm and Safety
Code,Section 25532(0' - HEATING UNIT(GVHR 100,000 BTU)
❑Ye. ❑NnVEN]'ILA'1'ION FAN(SINGLE BESIDE I'AIU
Data - Ncttipt#
Will the applicant or future building a'cupam ace equipment nr dal cs which #OILER-COMP(3HP OR 1(wB4OBO BTU)h hmarluus air contaminant as denied by the Bay Area Air Quality Management TOTAL;
)istricR BOILER-COMP(OVER 100L003 BTU)
❑Yes ❑No
I have read the hmmdous roerid,reyuiremems mode,Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomim Health&Safety Code,Seetions 25505,25533 and 25534.I undemand that if the NEW RESIDENTIAL.MECH. SQ.PT.
building does not currently have a tenant,That it is my responsibility m notify the occupant
of the reyuiremems which must be met prior to issuance of a Certificate of(ecupancy,
Owner or amharioul agent Dam 'TOTAL: ISSUED BY:
OFFICE
Y
PROPOSE ® FLOORPLAN
4 BEDROOM CLOSET
= ;1 MASTER BDRM
LF-
`i
• ilk; ��, ii
BATH MASTER BATH CLOSET
r—
LIVING AREA
620 sq ft ASO/
JAN 13117998
8C0�. INSPECTION
DEP
Les Schrieber- 1498 Jamestown Dr. CI�OFCUPERI/NOrMEN]
✓, (408)446-0288
EXISTING FLOORPLAN
` bl:
1
CLOSET
BEDROOM BEDROOM
CLOSE r ..
it MASTER BDRM
! -- - - - -
i
BATH !,. MASTER"BATH CLOSET
LOSETIi
LIVING AREA
620 sq ft
JAN 131998
Les Schrie er- 1498 446-0288 Bf�IIPOFT ION DEpAR74E
.4CUPERTINO NT