S 2378 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CPPV-OF CUPF.RTINO BUILDING.EI,IicfklCAl, PERMIT NO.
;7rJY1,DING DIVISION APPLICATION/PF.RMI'P PING PROD-MBICHANIFIC S 2378
BUILDING YROJF.CT IDENB'IPIL'ATBON
• BUILDING ADDRIZSS: 1 ✓k�R'' Au✓i p ±SANITARYNO. Ub
aftAPPLICATION SUBmrOAL DAfE7 faT 4 r!R:SNAME: IONS: COM AGTORNAME: LIC NO: CONTROLN
CHITECF/ENGINE R: IC NO: ADIDESS.
NW.CONTACT: PfiONE: V BUILDING PERMIT INFO
�� � ❑ Consulwnt Fecs Paid by Applicant(Initial) BLIx EL f PLUMB ME❑CH
LICENSED CONTRACTOR'Srdep DEC..w of hap QT ELECTRIC ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby a[Brm that I am IiccnsW under nrovisiom of Chopin 9/wmmencing
CaZ, with 5ation]IMp)of Division3afthe Nosiness and Professions Cade, nJ my license is RERF- IUB
{ups PERMIT ISSUANCE [D F full foreeand effect. ❑SFDWL ❑KITCHEN REMODEL.
Ur" Lice Clas Li,Or< U APPLIANCES-RESIDIiMI'IAL []ADDITION [D PLUMBING RE-PIPE
FF..ZtV Blum Comrdcmr—A
InQ0. ❑MUIM-UNIT ❑STRUCTURAL
ARCHITECTS DECLARAT ON
F h Z I understand my plans shall he used as public records PANELS MODIFICATION
oz�- UPT0200AMPS
❑INTERIOR ❑CHIMNEY REPAIR
OI-
yWj Licensed Professional 201-17WAMPS IMPROVEMEM' �SWIMAIING POOLS
C6 OWNER-BUILDER DECLARATION ❑BATH REMODEUREPAIR �DEMOLI'NON
O .,.I OVER HKXAMPS
0.' '.a License Law for the
W U I hereby.111"our Inm 11, exemnt Iran the Cnmrunor ❑OTHER
iy5 6 following roman.(Scotian]—b Busies.used Professions h.- My city or county SIGNS ELECfRICAt. 2-0
0:5 ye which reyuims v nennit m cumvuct al¢r,improve.Demolish,ser mpair any structure
1�,�jj.. pnatio ifs isxnarec..1 n"hire,lheappherinl lorsuch permit In file a signedstalemenl SPECIAL CIRCl11T/MISC.
2 } that he in licened pursers m the proviaivanafthe Cenvemr's License Law(Cbapter9
GAO (commeneing with Sectirs7111)ofDivision J orlhe Business and Professions Core)-1 TEMRMI-W, Oft DOLE INS, COMMERCIAL OMC�MFRCIALv
that 1.Is exempt IhereGnm and the basis for We alleged exemption.Any violation of ID NEW BLDG/ADDITION ❑DEMOLITION
W--y Section 7031.5by.nyupplieant for.permit subjects lhe.PPllcam m a civil penult,of POWER DEVICES []TENANT El TWO SERVICE
2,} not marc than five hundred dollars($500), IMPROVEMENT
❑I,as owner of the propeny.onny employees with wag.,a tbeirsole compens.ian, SWIMMINOP LE FC7TRIC
will dnthe worainll the sunciure isnot imadcdorufered forsale(See 71114,Business OTHER
ly 3 and Prnfasions Cale:The Contractor's License Ww does not apply m an owner of OITIIJITS-SWIT -FIXTURES
�' .. propcny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvemetns are nut intended or offered for NI7W RISIDIWrIAL FLE SQ Fr.
sate.IL however,the Inildingnf improvement is sold sithin.ne,rinefcompicti.a.the SQ.ITT.FLOOR AREA vSQ.FT
er-builder will have the harden of proving Wal be did rot hoild or improve for par,
Pascal T O
I,as owner of the property,am a ele,ively e.houctiag with licensed contractors m
construct the project(See.7044,Buaiacns and Proressions Code:)The Con¢aamra Li-
censeLawdoesnotapplymanownerofprnpeny who builds orimproves thereon,and QTY. PLUMBING PERMIT FEE
whomntrams for such projects with a enni eemr(0 licensed pursuanuo Tho Cntnmcmrs
S License Law. PER MIT ISSUANCE
lam aempt unJerSce. ,B&PCfonbisrcavon
ALTER-DRAIN&VIiNT-WATER(EA) VALUATION
her Date d
WORKER'S COMPLNSA'FION DECLARA'f10N BACK IlOW PR0TI3CT.DCVICG FF
1 hercM1y affirm under penally of perjury one o[the follnwin6 dedomtinns:
I have and will lruinoinuCenifcam of CoamnunselGinmmfor Workers Compcn- DRAINS-FLOOR.ROOF.ARF.A.GOND. SgpBIGq TYPE.CONSIRUCTIOD
action,a providW for by Section 3]IMI of the lama Cale,for Inc performonre of the
w kfor which this permit is issued. PIXI'IJRES-VIiR'FRAV
hove seat will maintain Wnrkurs Cnmpemndun Insurunca os rcqulrtd by Section
J]glof the laMa Gdw fur the performance of the work fur which this hermit is iswed. GAS-IiA.SVSTIiM-1 INCA Ul1T1,fTS OCC GROUP APN
My Workefc Cy�mir�lo��nce c+vrier and Policy ou _
Cartier: C-T -- YN O _Policy No.: O GAS-BA.SYS"ITM�OVERY Q?A)
CBRTII ICA'TF.OP li%IiMIT10N PROM WOkKIiRS GREASI%INDUS'fk1.WASTE INTERCEFOUR
I COMPENSATION INSURANCIi BUILDING DIVISION tEE,S
11.1 ion need oat be eampleteJ ifthe permit is lanme hundred dollars lSllMB GREASEIRAY
I'LANCII
or less)
toy any pm inthc lnHonwnceofthe thanforowniehth permit iscrs Ca i3O.- SEWER-SANITARY-S1T)RM CA.200 Irl'.
'employ any any mannermm omya'ubjecyJ Woders'Cnmpem ' ERGY PEE
�z A"Inl.aw..n(Cxljj"ia.Doti�1�eWYY6 s �999 WATER HIiA'I'IiIi WNF:W/ELECEN GRADING FEE
7 O Applicant �P f��
a NOTICE subject
A�wto es ufkAn g this ,isi n s of of Exemption,you a airs t WATER SYSTIiM/fREATIN(i
(, 'N' hecnme cone Iy the Wnrh ro Comms or this provisions of the Lahr Cate,you nmst S IL I
fonhwiW comply with each provisions or thin permit shall be JanteJ revoked. WATIiR SERVICE
A 0
CONSUCTION LENDING AGENCY NEW RCSIDEM'IAL PLMB. SQ.1. PAID
`7 '0 T RDate Rcceiptp
thereby atlirmthm them iso conslnum
tion lending agency for the performance of
the work(or which this permit is issued(See.J(M)],Cos.C.)
p F` TOTAL:
LenJers None
V Lender's Address TOTAL:
kl BUILDING PEE
I eenify that 1 have read this applicmian m and stethrt the above informmion is
ycorrect.l agree monmply with all city and county ordinances and start laws relating To QTY. MECHANICAL.PERMIT FEE SEISMIC FEE
U 7� buildingconswctiom.nd henhyamhon,acreprcsentntiven ofthis cirym cnrerupnn the
above-mentioned progeny for inspection purryrscs. PERMIT ISSUANCE. ELECTRIC FEE O
(We)agree to save,indemnity and keep harmless the City of Cupertino again"
luddlities,judgmenis.costs and expenses which inay in any way accrue against said City AL117R OR ADD TO MECIL PLUMBING THE
uri ou ssu nen.4the gmmlug of this pnnnit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHAN[CAI,FEE
SOURC OLA11 N5.
p^ 'oII�IQ(,], AIR IIANULING UNH'IOVER HT"CFM) CONSTRUCf10N TAX
Stgnu fApphc.n nt sent IF UV.ttra EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
IIALIR OUS MATERIALS DISCLOSURE
Willtheapplianto nr fmurebailding occupant smreorhvndle huvrdousmatcrita HEATING UNITOOIIMODEST BTIH
as def Iced by thc Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Codd.Section 25532(a)^ ' HEATING UNIT(OVER 100,1100 BTU)
❑Yea gr,t' VEMI'ILA'I'[ON PAN(SINGLE RESID) PAID
Dam Raeipt M
WHO the upplieam or(amre building a r.,oar t use W.ipment or devices which BOILER-CAMP THE OR HAT00 RTI➢
,it humrdnus air contaminants as defined by the Buy Area Air Quality Management !DATF
)inrimT BOILER-COMP(OVER 100,11110 BTU)
❑Yea �No
I have read the hazardous mmerial requi¢mems utukr Chipterfi9.5 of the Cali- AIR CONDITIONER '^ISSUANTurns Health&Safety Calc,Sections 25505,25533 and 25534.I understand dot if the NEW RCSIDENTIA,MECII. SQ.FF. / )-� / R
I uildin of eu fy have.tenant that it in nq resp n'thdity to nobly the Iecupant lll///o! enc h mast he met prior m issuance of a Cenifr aof( vp ncy.Ownero uvthom do 'TOTAL: ISSUED BY: T
OFFICE