S 1291 .a
APPLICANTTO FILL IN INFORMATION WjTHIN RED LINES-USE BALL POINT Pkv'
'ONLY
CITY OF CUPERTINO BUILDING-� .AL PEg7pITNO /�
BUILDING DIVISION APPL4- OF PERMIT PLUMBING RLECTRI.k.AI. \ 1291-/Q 1
BUILDING PROJ MCHANI 9CAilON V 1 L 91
YDI�
BUILDING ADDRESS: �� { , _ SANITARY NO. APPLICATION SUBMITTAL DATE
9t4 �l <
' OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO
kaR,(Z DIC IL . A5L-`zOZ,l9 ►gSstC: rw�tj1S , S'q-11 LZ- N/C CONTROL#
ARCNRECf/EITGINE'R: LIC NO: ADDRESS. �xtt� '
( ' 3 i/`]r-
CONTACT: PHONE: BUILDING PERMIT INFO
S i *'�T'" `��qn^ (L�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELSE-sCT� PLUMB MECH
O� LJ LK, Ea
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT 'FEE
1 hereby affirm that I an licensed under provisions of Chapter 9(commencing .. JOB DESCRI ION
OCZ with Section]0M)ofDivision 3 of the Business and Professions Code,and my licenseis' f2E$IDENTTAL..
m O p PERMIT ISSUANCE � �
Fa,. full force and effen. gg �^ y Z�
WUF' License Class ? Lie • L ❑SFDW_ L4fCRCHEN REMODEL
a'ZW Date'�q� Contracmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-U El STRUCTURAL
Z FO h Z 1 understand my plans shall W used as public records PANELS MODIFICATION
OZ-Ls UP T0200 AMPS ❑INTERIOR El CHIMNEY REPAIR
W Licensed Rofessioval 201-10MAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS.
C C 6 I hereby affirm that 1 am exempt from the Contrmors License Law for the OVER I WO AMPS,- El BATH REMODEVREPAIR (]DEMOLITION
1 O afro
U following reason.(Section]031.5.Business and Professions COM:Any city or coumy SIGNS ELECTRICAL ❑GHT ER
3
0. which"now,a perms m construct,cher,improve,demolish,or repair any swemre
F= 6 print to its issuance.ilea requires the applicant for such pearit to file a signed statement SPECIAL CIRCUIT/MISC.
}- Out he is Hamed paroam in the Provisions of dm Cmhactors License Law(Chapter 9
u�i�ap�0 (commencingwith Secuonl000)ofDivision3ofd Businmsad ProfmionsCdc)or TEMP.METER OR POLE WST. COMMERCIAL:
G 1 c that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION- ❑DEMOLITION
XnII- Section]031.5 by any epplicard far a permit subjects@eapplicanumit civil perWtyof POWER DEVICES
morn ❑TENANT ❑FOODSERVICE
nor nwrc than five hundred dollars y employees
IMPROVEMENT
f20 ❑LoW.mk,fthe peounclremy employees oraffesh wules as dmrsole'vwle c-mpmsxtim. SWIMMING POOL ELECTRIC
(.. and do the wens Cob: he ore tor intended Livens Law ths,not
lapply to an.Bmer of ❑OTHER
L 3 w and property
who
Code:The Contractors dunLicense Law does not apply to if owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improvesr such i,and who d-ea such wort deed or
or through
his awn wo,i as,provided shin such improvement.are not intended or Offered for NEW RESIDENT EC2'R SQ FT
mvis Shower will
building borin of proint masseavidinone Wilda comDldion.the SQ.FT FLOOR AREA :-5/SQ.FI'.
prsc o builder will here the burden of proving dor he did nw build or improve(Or pm-
pose of sola.). ?\
1,as owner of Ne progeny,an exclusively contracting with licensed contractors to TOTAL:
construct Ne project(Sec.7014,Business and Professions Cdc)The Comracmr'x Li- r
ceme law does rom apply in an owner of property who builds or imposes thermn,and QTY PLUMB 'G P FEE
who mnmaca for such Minces with contractors)licensed pursuant to the Conuactor's s
License law. PERMIT ISSUANCE I
Iarb excmptioder Sec. ,B&P C for this reason
Owl Dam ALTER-DRAIN&VENT- ER ) VALUATION M
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVI
el"Z1 hereby afford under penalty of Ndury one of no fallowing doe assummu: -3 O O O O
ile and will maintain aCenificateof Consent in self-insum far Workers Compen- DRAINS-FLOOR.ROOF,AREA,CO STORIES TYPE CONSIIt�ICTION�
sstim,is provided for by Section 3IW of Ne tabor Codeth
,for e pefformarec of me
_..work for which this permit is issue. FIXTURES-PER TRAP
I how ad will maintain Warkds Compensation Insurance,in requited by Section 1 r'
3710-f the labor Cods,for Ne Perf-ranee of the work far which shin peril its_issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
My W�uk Co.+ pe ,inn los ttcartiePit Nry z 76- GAS-EA.SYSTEM-OVER4(EA) DEC.GROUP APN
Camel: R `�` 3 Ik-kB,N1`SD
ERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
Missectionned twtbe completed ifrhe permit is f-rmehurx6eddi lars(5100) BUILDING DIVISION FEES
or less.) GREASETRAPI -
IcmfytlutinNepeformanceofNeworkforwhichthispc tisismd,Ishall SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner s0 ax m become sub et to the Workers'Compen- ENERGY FEE
Z variant Laws of Califomia.Dam
WATER HEALER WNENT/ELECfR
C)O Applicant GRADING FEE
z y NOTICE TO APPLICANT:If,after making this Certificate of E,warluon.yea should WATER SYSTEAUTREATING
F' become subject m @c Workers Compcnsatim pmvisians of the labor Cde,you mum SOBS FEE
ti
forthwith comply with such pmsision,m this panful shall M deemed revoked. WATER SERVICE
0.
UOQ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET PAID
l hereby affirm Wt drove is a construction lending agency forte pertorunce of Dam Receipt#
LL du work for which tha pemuus issued(Sec.309],Co,C)
Q U Ledeev Name TOTAL:
F C Leder',Address - TUM Z O 0
I certify that I lave red this application and state that she above information is BUILDING HE
N cmeet.I a,mc in comply with all city and canary mdimmees ad stem laws relating in, QTY MECHANICAL PERMIT FEE
(.) Z duldivg construction.and hereby authorize representatives of Nis riry renter upon the SEISMIC FEE
` above-nrenrioted property for inspection purposes. PERMITISSUANCE
(We)agree m cave,indemnify and keep harmless the City of Cupertino spina ELECTRIC FEE
Iiabilacs,judgments.costs and expenus which may,in any way accrue against said City ALTERORADDTOMECH.
in anuquena f the granting of Nin Period. PLUMBING FEE
APPLICANT .DERBY SAND WILL COMPLY WITH ALL NUNPOINTAIR HANDLING UNIT(TO IO,-oO CFM)
SOURCE R L 10 MECHANICALFEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Si14 n r an ecta aro EXHAUST HOOD(WMUCf)
HA]ARDO t ATERIALS DISCLOSURE HOUSING MITIGATION FEE
tM applicant orfiame Wilding«mpantme mharnde haraNms material HEATING ILXTf(TO IOO.WO B"IU)
as defined by the Cupcninu Municipal Cde.Chapter 9.12,and the Health and Safery
Cdc.Sstion 25532(a)p - HEATING UNIT(OVER HILOW BTU)
VENTILATION FAN(SINGLE RESID) PAID
' Wtll the applicant m future Wilding occupant uu eluipaavr m devices whi<M1 Dore Receipt#
t fashions air constructors as defined by the Bay Ana Air Quality Mantemsent BOILER-COMP(JHP UR I W,qp BTU)
IOTA
1 Damm0 Yes [�Nn BOILER-COMP(OVER 100.000 BN) /
I have read de hamNau materials a mdse AIR CONDITIONER
tLT requiman Chapter 6.95 of she Cali- ISSUANCE DATE
I/ forma Health 69ily Code.Seceum 25505.25533 and 25534.1 andcrsund that if the NEW RESMENTIAL MECH. SQ.IT
bidchgdes t yhaveatewnL shat is is my ovpomibiliry 1. my Jae occupant G-^ Z 3
of sae ch roumbe rmi-1—c alaof0ccupanry
Z 9 _
iDam TOTAL' BY.ISSUED
m �` OFFICE
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SCALE: APPROVED BY: DRAWN BY f
o � DATE: - - - - REVISED - - -- .
ICE
COPYCA4- 4 �U rSER� c.f �
- _ DRAWING NUMBE➢ -