20865 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1 sRNBT,D. Q 1
• CITY OF CUPERTINO BUMMING.-ELECMECH NIC L 2 O 865
BUILDING DIVISION APPLICATIONIPERMIT Pl.u]IRINc-uecunNlc,u. S0001
BUILpING PROJECT IDENT'IFIL'ATION
CALDINGADDRESS: IY� SANITARY NO, AI'I'LICATION'SUItMIITAL UA'TE
c Y _ 4
WNER'S NAME: PHONE: CONIRACIOR'Mi,AMI?: LTC NO. NIC CONTROL.#
A.r• S��,k;� /►'Masou16Z33W ❑
CHITECT/ENGINEER: LIC NO: 1`2 1) ''S,
CONTACT: PHONE: G BUILUING I'GRMIT INFO
3� ❑ Consultant Fees Paid by Applicant(Initial) BLLD�G/ -ELECT PLUMB MECH
2 ❑ ❑ ❑
LICENSED CON I RACTORS DECLARATION .QTY ELECTRIC PERMIT FEE
p wino sem om](XX77mt Intl licensed d p :"n.-of Cnnpter 9 Unmtt rue JOB DESCRIPTION
1 nercny tl .-.
TO ) Ube nus awr fzians Cook and my la e RESIDENTIAL:
ad 11I7ftMIT ISSUANCE
DEL
ELL.. -nfall fmce and el t.ZN b233 (� ❑SFl)WL ❑PLUM KITCHEN k1iE PIPE
aVr, License 1�Comm APPLIANCES-RESIDENTIAL OADDITION El PLUMBING REPIPE
y Q W Date SY"_• s-( Cnnuacmr� )
ARCHITECTS DECLARATION ❑MULTI-0NIT El STRUCTURAL
F,=to PANELS MODIFICATION
z Danz I understood my plans.shall he used ac public recordx UP T021XIAM1'S
❑IN'I ERROR IMNEY REPAIR
I:E2LW Livened Pmfcsxioral 201-100DAMPs IMPROVEMENT SWIMMING POOLS
C C 1 hereby ufEmt mm 1 am OWNER-BUILDER DE he RAGOaor's License Law for the OVER EKED AMPS ❑BATH REMODEDREPAIR ❑DEMOLD[ON
a r from
X O C V following reason.(Section 7031.5.Business and Profersiuns Code:Any city or county !:X*
RICAL ❑OTHER
LL 3 LL h which acquires a Permit to ronswct,alteq improve,demolish,or repan any someone p
F�OQ Tom t t. : w I. q Theapplicantf by in fl Signed i ement UII/MISC. 2
�rW�y'4 'hath i Ipursuant t TheP' :u Ito L t In L L (Chapter 9
o1 kc (commencing with Section]NXP of Disson 3 ofthe Bm'nx d Pare,urs Codc)or OR POLE INST. COMMERCIAI:
a a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADUI'PIUN ❑UEM01,1 TION
u�.`^m
Section 7031.5 by any applicant for a Permit subjects the applicanuo a civil Penalty of ES ❑TENANT ❑FOOD SERVICE
not marc man five hundred dull...($51X71. IMPROVEMENT
C=Q Las owner of lM1e pmflenY.nnny en+pinyecs with wages ns their sola compcn,mtinn OOL ELECTRIC
94 will do the wark.and the ememe is not intended or an...J fasAe(See.7014,Busma,, )'1'HIiR
W3 m and Professions Calc The Comr,¢mr's License Law docs not apply to an owner of I'I'Cl1ES-PIX'NRES
property who builds or improves thereon,and who vhw ,such work himself or through
his own employees,provided that such improvements arc nal imm�ded or offered lar NEW RESIDF,NTIAL ELECTR SQ bT.
sale.If,however.the building or improvement is sold within one year of complexion.the SQ.FL FLOOR AREA ESQ.IT.
c,-builder will have be Funder of proving that he did nes build or improve fell I
pi
orPur-
po a of sale.). TOTAL
1,as nwner of Oto pamicil..nt exclusively contruuting with Emwed co nnmmn to
construct the project(Sea 7W4.Bacmes,and PrafessinI,Cude:)ToaCoauocudsLi-
cense taw does not apply to an owner of property who hndiN or improves thereon,and QTY. PLUMBING PERMIT FEE'
who cataracts for such projects with a emnrne or s)licensed pursuant o the Contractor
License Law. PERMIT ISSUANCE
1 am exempt ureter Sec. .B&P C fohs reason
ALTER-DRAIN&VENT-WATER HA) Y
VALUATION
vOw, Dam
WOR KER:SCOM
olly ext $ATIOND 1the RATION {ACK FLOW I'ROTIiC'f DEVICE D O
1 hereby w imrm under penalty of perjuryone of the following d Worker's
Cl
Ihme and will maintain sction 3700 of the Labto rCode.for for Worker's Cnmpem DRAINS-FLOOR.ROOF,AREA.COND. S HIES 'TYPIiCONSTRUCTION
..lion,as presided for mi Section d. of the Labor Cale,for me performance of the
El I have
this Permit issued. PL\'TURFS-PER TRAP a�
1 have and will maimvn Workers Compensationrkfiee.as required by Section
3]Wolmcl,rM+r Cale,for the perlarmvncc o[thc work for wM1ich tris permit is issvN. GAS-EA.SYS]TM-I INC-4OUTLETS OCC.GROUP MIN
My WorV{'cfCona+c esti+ mcc,F—�rr Pondy No.:nw qy�
Carrier. { A Iv Pnbe Nn.: Win GAS-EA SYSTI?M.OVER 4(EAT
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUNDUSTRI.WASTE IN rERCRPI'OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Ibissection need not be completed data Permit is formaloundreddollin($1a)) GREASETRAP
PLANCHECK FEE
or less)
Toy anythatint in any inlancrofs beconosk r whisachthis parthe Workers
issued.[,hall SIiWER-SANITARY-STORM EA.21N1 FI'.
not employ any person in any manner an as to hwmue xnhjM m We Wakcrn'Contpen_ P.NIRGV PEE
Z .Tom Califorom.Data WATER HEATER W/VI!N'IIELECTR GRADING FEE
zon LApplicant 1
M NOTICE TO APPLICANT:IL after making this Ceti of ExemPtinn,you should WATER SYSTEM'BEATING SOILS FEE
a , become.subject to the Worker's Compensation previsions of the tabor Code.you must
� ~n- frMwith comply isitbsuch provisions or this pernat shall be deemed revoked. WATER SERVICE ---
CONSI'ItUC'IION LENDING AGENCY NEW RP_SIDEN'IIAL PLMB. SQ.FT. PAID
'U Z calls#
I hereby amrm that mn ere is constitution leading agency for duce,donnanceof
�- the work far whieh an,Permit is issued(Sec.3097,Civ.C.) T
Q F' Lenders Name TOTAL:
} pJ Lenders Address TOTAL:
FEE
y I cenay that 1 hmo read mis application sad.tme num me above information is
1•. to cancerIagmaH+comply with all city and wontyondhnutces and state laws rcmtirg In QTY. MECHANICAL PERMIT FEE PIS --E
V z+ huildimgconsoucian,mndnurchy nnthmire represmm.tiveN at city tocntnnpnn the
.base-mentioned property for Inspection Purposes. I'EHb11T ISSUANCE 'I.IT RIC FEE
(We)agree to save,indemody sad keep ham icss the City of Cupertino against pp
Iiabilaics.judRiner,casts and......hich may in any way accrue un.imtaid City ALTER OR ADD TO MECH. O THING FEE
in
consequence of me gaming of thio Permit.
APPLICANT'UNDF,RSTANDS -D W L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ta"CPM) MECHANICAL FEE
S .R17GULATIONS.
_ AIR HANDLING UNIT(OVER IO.IXNI CPM) CONS'1'RUCTION TAX
'
Signature at APPlicwVCmnlr + 1}m EXf1AU5'T HOODfW/DUCT) HOUSING MITIGATION PI!H
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Intonation,material HEA'TIN'G UNIT G 0 I W."BTU)
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety HEATING UNI I'(OVER I W."BTU)Section 25532OC
�Yce ❑Nn VENTILATIONi+AN(SINGLERESIU) PAID Data Receipt#
Nill the applicant son fututc building occupant soxr equipment or dcviccN which BOILER-CONTI'(31IP OR Ishiss)R TO)
I Institution,air contaminants as defined by the Bay Area Air Quality Management TOIAI
Lbmk�'&d�,
[TOILER-COMP(OVER 10C."ROD)
❑No
AIR CONDITIONER ISSUANCE DATE
J lM1 1 'tor 1 q is u25 Ch'pt M1AS of II Cab SaluyC /J�ns25s 5511 W255)11 J :mtheventec NI?W RESIUEN'I'IN.MECH. SQ.FTcurre tlyM1 JEEnam m y nry+t bfpt tfy me .pant is w' h n t f met P u ofi C ruf atcpI cz., yzM sB // Wt✓c� TOTAL: ISSUED BY.
OFFICE