20101 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1 1
CITY OF CUPERTINO BUILDING T11.EG9'RIGAI. PERMIT NO. I�O 1 O 1
BUILDING DIVISION APPLICATIONIPERMIT PIAMBING.MECHANICAL G
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY N(]. APPLICATION SUBMITTAL DKI'F
:DEB n) c 3
2-49
'
OW ER:S NAME PHONE: CONTRACTOR'S NAME: L_ LICNO:
C O L NIC CO 1NOLM
k11TECT/IiNGINIi:R:� L1 NO: . lO ❑
t FS�fion77�)
G�DONNEE: C7 `J/ M (�N BUILDING PERMIT INFO
/00 j ❑ Consultant Feas Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
/ VNICENS[D CONE CfOR'S DECLARATION QTY. ELECTRICPERMIT FEEy of ran Nat I am licensed under provisions of chapter 9(eommenoing JOE.DESCRIPTION
"ZB00)of Divisinn 3 ofthe Business and Professions Code.and my license is RR NIDA{�Op PERMIT ISSUANCE
J e�[e t. SFDWL ❑KITCHEN REMODEL
`--TLicit—1 Y Comractar f< < E APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE.
hQq ❑MULFI-UNIT ❑STRUCTURAL.
ZO Z� ARCHITECTS DECLARATION PANELS
I understand my plans sW11 he used as public records MODIFICATION
0Z-0 UPTO200AMPS 14NTERIOR ❑CHIMNEY REPAIR
Fy. W Licensed Professional 201.1000AMPS IMPROVEMENT [j SWIMMING POOLS
OWNER-BUILDER DECLARATIONOVER 10p AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
C C Q 1 hereby affirm that I am exempt from the Coronaries License Law for It¢
fallowing reason.(Section 103 I.S. n
5,Business d Professions Cafe:Any city or county SIGNS ELECTRICAL ❑OTHER
W a W y which requires v permit to commuci,alter,improve,demolish,or repair any sometime
C E'0� prior o its issuance,also requires the applicant fm such permit to file a signed statement SPECIAL CIRCUITIMISC.
ythatheislicensvd,unoa ttathe provisions of the Ctmracmrs License Law(Chapter9
�+1 00 (commencing with Section 9000)ofDivision 3 of the Business and Professions Code)or 'TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violiamn of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031.5 by any applicant for a permit subjects the applicant to u civil pcmulty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
ZZy not mom than five hundred do0ars(5500). IMPROVEMENT
❑Q ❑has owner of Nepmpeny,annyempinyees with wugesa.theiraole compensation. SWIMMING POOL ELECTRIC
will doth,work.and theswcmre is not mourcloilmoRemd fincale(Sec.1044,Business ❑OTHER
6 a m and Professimes Com, The Comnebas License Law doss not apply to an turner of OUTLETS-SWITCHES-FIXTDRE$
OUTLETS-SWITCH -
property who hoileE or improves thereon,and who does such work himself or through
his own employees.provided that such improvements lire not lated m o8ered for NEW RESIDENTIAL ELECTR SQ R.
sale.ll',however,the buddingor[mprovenm l is sold within one year mf completion,the SQ.FT.FLOOR AREA VSQ.FT.
owner-Wilder will have the burden of proving that he did not build or improve for par-
pose of soave
❑1,a owner of the propemy,am exdusivdy rnntracting with licensed conuvctoa m L' 0.
consumer the project(See.9014.Business and Professiums Cale:)The Cmtm, s Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE G /
who contracts fn-such projects with a cotnracmrs,licensed pursuant in the Commences
License Law. PERMITISSUANCExempp y
❑l am exempt under Sec. ,B&P C for this remnn ALTER-DRAIN&VENT-WATER(IHA T� ////???
ALUATION
�5 Owner Date
j WORKER COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
N I hereby affirm under penalty of lsrjury one of the following declarations:
I have and will maimaineCeriOcateo2onscnt to self-insum for Worker's Compen- DRAINS-FLOOR.ROOFAREA,VA 3, 01 STORIES q'YPE CON9'1'IiUCTlO!
station,as provided for by Section 3900 of the Labor Corte,for the performance of the
work fm which this permit is issued. - FIXTURES-PER TRAP s t
❑I have and will maintain Wodoes Compensation Insurance,as required by Section
:,'s,�' t
3900of the LubarCode,for the peifonnamee of the work far which this permit is issuad. GAS-FA.SYSTEM.I INC.4 syp I-TN OCC.GROUP APN
My Waim's Co - action Insurance cyme r and Policynurmyc are'
Cam'er: .r+T/1 n M Y' Policy NaJd a / -7 y/ GAS-IIA.SYSTEM(TV�R meq1)
CERTIFICATE OF EXEMPTION FROM WORKERS' v bh W/
COMPENSATION INSURANCE GREASEIINDUSTNL AS BI E� PYTOR BUILDING DIVISION FEES
(This wa,dooncednm becompleted if the permit is formic hundred dollars(SIIIU) GREASETRAP. it
of lax) WENERGYFEE
I,edify that o ffic perforomme,if the work for which his permit is isweJ,],,hall SEWER-SANITARY-STD EA.20p Pf.
not employ tiny person in tiny manner sn vs to become object Ise Ne Wmkeri Ccmpen-nation laws of California.Date WATER HEATER r - 7MtiN i NOTICE TO APPLICAND IL after making Nis Cennicate of Exemption,you should WATER SYSTEM/IRE O hand.adieet to the Workers Compensation provisios of the Labor Code,you mustforthwith comply with suchprnvisions m this penothil llfar deemct1mvoked. WATER SERVICE
OCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr.I herebyafOrm Nat Nem is.emcarodion lendingagency fo the perf.mmncc of
W tti Ne work fins whichthis permit is issued(Sec.3099,Civ,C.) TOTAL:
ULenders Name
WLcndcr's Addict TOTAL:
I cvmify thio 1 have real this application and state that the above infotmatinn is BUILDING '
:.t h correct.l agree to comply withal[city and county ordinances andsmte laws relating m and QTY. MECHANICAL PERMIT PEE SEISMIC FEE
V bulldiagroodartion, hereby authorize representatives of this city m enter upon theis
above-meminned property far inspection purp,,es. PERMITISSUANCE f ELECTRIC FEE
(Wet agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way accme against onto City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00 CFM) MECHANICAL FEE
SOURCE 'GULATIONS. t
/ O AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
$go n Applicant] nmrecmr ate O EXHAUST HOOD(W/DUC[7 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
in Ne applicant orfuture Wilmot ovespanr.tore or handle West material HEATING UNIT fl,10.003 B'1Of
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cafe,Section 25532(a)9 HEATING]]NIT(OVER 100,000 BTU) _
El Yes ❑No VENTILATION FAN(SINGLE REBID) PAID
Date Receipt
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(SHP OR 100,000 BTU)
smajous air comaminunta a defined by the Buy Area Air Quality Management TO
.tact?
BOILER-COMP(OVER 100,0111 BTII)
❑Yes ❑Nn
I have real the hazrdnus anderials requireumb,under Chapter 6.95 of the Cali. AIR CONDITIONER I ISSUANCES DATE.
fnrnin Health&Subtly Crile,Sections 255115,25533 and 25534.1 mtdemmnd that if the NEW RESIDENTIAL MECH. SQ.FT. _
building dors not currently have a tenant.that it is my responsibility to totally the occupant C ` G-
oftherequirertsnTe which mustbomel prionoissuuttee nfa Cenificam of Occupancy. �A /NJG
Owner or outhoriud agent Dare TOT ISSUED BY: t
OFFICE