S 0893 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON'CUPFR'PINO
BUILDING-FLEC'I'RICA Is PI? MIT NO.
BUILDING DIVISION APPIACATION/PERMIT I'I.l1h PROJBINGECT
Tunibiruntu 0893
BUILDING 1'ROJHCI'IDENI'Ib'IG'I'IDN'
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMII'IALDAn'.
084f jk`t&Xj&I-L Dn, crf)�v l2 Zai
OWNEB'SNAME: u PHONE CONTRA CONTRACTOR S NAME: LIC NO. NIC CONTROL Or
t�W
• ARCHIITEECCUINNGINEER: LIC NO: ADDRESS: ❑
CONTACT PHONE: BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hercb,affirm that 1 am Bettered under prooisma of Chapter 9(commencing JOB DESCRIPTION
O�Z with Section 3 ofthe Rusincssand Prolession-Codc.and mylicense is RESIDENTIAL
¢; PERMIT ISSUANCE
��� in full force and eR<m, ❑SIUWL [:J KITCHEN kEMODIA.
se: i- License Class Lie.it APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
N Q L Date Comment
❑
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT STRUCTURAL
ZO'"Z I understand my plans shall he used as public records CHIMMOD[NEY
OZ=O UP TO Np AMPS El INTERIOR ❑CHIMNIiY REPAIR
FEnFW Liclmul Professional 2014000AMPS IMPROVEMENT 0SWIMMING POOLS
Q F, OWNI7R BUILDER DECLARATION
yo a OVER 1000AMP5 ❑BATH REh10Dh:IJREPAI DIiM01.1'I'ION
pJ 6'fffyy���Q I hcfehy million that 1. cxmnpl from the Contmctm's License Law for the ❑0THER L.Illg
VL U iollnwing rcuam.(Station 7031.5.Business and Praia agars Code:Any city or county SIGNS ELECTRICAL
"E' wh th l permitt n t h p J I h p y%tmcmre
F 4'0Q Prior I I m Iw dapplicantl hp tt II 6 Letemrnt SPECIAL CIRCUIT/MISC,
W�QO'�,>•] hot he licensed tt th p 'rn Id L eco l L [Ch,, it, COMMERCIAL'
(,( talwiti,will,Scroll 70tlta t'Divis 1 I Ilhe B ,ince dP m"aln,Colli or TEMP.MLI DIt OR INILE INST.
a X e eL that he is mro n o thercfmm mod the huvis for the alle,crl exemption.Any ,ioblin,of [1 NEW BLDGIADDITION E]DI:MOLI'UON
Scaian 7031.5 by any applicant lir a permit.subjects tic applicamm m civil pnmhY of POWER DEVICES ❑TENANT E)FOOD SERVICE
m more than live hundred dollars($50)) IMPROVEMENT
E=QD1.as awnerul the mr,wriy.nrtoy complayees with wugex as morsolc compensmmn SWIMM I NG POOL I?LHC'I'R IC
will Jo the work,and the d acmrc is nal intended r mnertm lir sale(Ste.7041.Busmts, ❑OTHER
Wf OUTLETS-S W I'I CHUN-IBX TURES
a 3� and r,ar awn,-sonde:]Be cnntmmn/n ueanw Law nnax sect apply to.n owner nr
pmgny who hot Ids or improves thereon,and who docs such work himself or through
his man employees,provided that such inmprvamems am sat intended or offered for NEW kESIDENTIAI.IiLEC'IB 'Q
SQ.FT.PWOH AREA $ISV.IeI'.
sale.ILhowever.the building or improvement is sold withinaneyem of ammpletion.the
owner-builder will huvc the lumen of proving that he did not build or improve for par- P !�A ' D
,wow of'aide). TOTAL:
❑1.us owner of the property,am exclusively contracting with licensed conracmrn to
candrm the p,,,j",1Scc,7DW,Business and Professions lone:I I oc Comor...i s-
rearm
i-
c rmLi.does not applym.nowmr nl pmpeny who holds or improves tbemun,and QTY, PLUMBING PERMIT FEE DECLV I CI)
whocontrsmsforsuch projects with a eommemdsl licensed prommultothe Cunlmatols LV 11CIJ{7
Licari Iaw. PERMIT ISSUANCE
I am exempt under Sec. .B&P C far this..,an fly 111- Iiiji-i-
of
Owner \ • Done
of ALTER-DRAIN&VENT-WATER(EA) VAL A ON
•
WORKERS COMPFtJSATION DECLARATION BACK PLOW PR01=DEVICE
I hereby affirm umler penalty of perjury one of the foil wing declarations:
(]I Mile and will maintain a Certificate ofConwnl to self-inwm for Worker's Camper- DRAINS-FLOOR,ROOEARIiA.CONE). STORIES TYPE CONST RUCTION
inner,as provided for by Section 1100 of the Lhsr Code.fur Ire p,rfinna a of the
ark for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workels Compensation Insurance,as required by Section GAS-EA.SYSTIiM I INC v Ol1TLLT5
3700of the Lnlxu Cede,for the performance of the work for whichlhlspermiti-Aced. (ICC.GROUP AI'N
My Workers Conmpensotion insurance carrier and Policy number am: GAS-EA.SYSTEM-OVER 4(EA)
Carrier: Policy hi
C,WHEICATEOPINI!M PTIONFROM WORKERS' GREASI%INDUtifRh WASI'Ii INTIIHCIiFITIH
COMPIiNSADON INSURANCE
DING DIVISION FIA?S
(f his station need not be connplemd Hire permit Ls for lachundrcddollars(SIM) GRF,ASE'1'RAP
1'LANCfIECK FEE
or less)
toy any liar in Om pnrl'onmil, oftire,orfo For which this thepertritWis issued.'(7lshall SEWIiR-SANITARY-ST(IBM ITA,21X1 PI'.
' nm employ any person in any stoner nn m to hwnnw nub'Icct In the Workerv'Gnnpeo- ENERGY TEF.
Z cation Laws of Culilorniw Duo WATER HIiAIER W/VHNFL7I.ECI'R (TRADING FEE.
OAppheant
4 NOTICE TO APPLICANT 11.alit,nuking this Cerri ic.m of Extmptioa you should WATIiR SYS'IPM/TREATING
SOILS FEE
F+ become sobjeO ,the Wake-Compensation prvisiam of the Lahr Code,you all
lyr had,rithanmply wlthsuch au,i,irr,in,this permit shall he decowdsevoked. WATER SERVICE
E Q
CONSTRUCTION LENDING AGENCY NEW RF,SIDENI'IAL PLMB. SQ.FL PAID
Date R.... a
L) p for
whito this nhcrcissued(Sec.30lending agency for the performancc of
1-' the work fnrwhich This permit is issued(Sec.JII97,Civ.C) 'D)TA L:
O Lender's Name 'TOTAL:
r W lenddI Address BUILDING FEE
Om I agree that 1 have read this application and sum that the state
l information is
UZanrccn logrccmcomply herchyldtyand county ordinances and sum lmwarclaing to QTY. MECHANICAL PERMIT FEE 51315MIC TEF.
U Z building nmsmonnion,and heathy mtborirn wprcsenmtives ml this Oily.crim,upon the
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE ELF.CI'RIC TEE
(We)agree um save,indemnify and keep harmless the City of Cupertino against
Iiahilities.judgamm, u,saml expenses which may in any way amour against said City ALTER OR ADD TO M BCH. PLUMBING FEE
m consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBM)CFM) MECHANICAL FEE
SOURCE REGULATIONS. ---sss,,,///
/` AIR HANDLING UNIT(OVER 10,11(1(1 CPM) CONSTRUCTION TAX
Si mrt:rcof Applic`im_ ntmt'll, / Done EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
ffAYARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle heandous marerial HEATING UNIT(TO 100,010 BTU)
as defined by the CupeAno Municipal Cod,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IMAP If I'U)
Coda Section 25532(.)!
❑Yes E)No VENTILATION FAN ISINGI.Ii RI!S1D) PAID Use Receiptp
Will the air containfuture(defined by upant the
cea Air unt ordManaemes ent BOILER-COMP(3HP OR 100,100011'TU)
emit hnramnus vin contaminants as JcGnn1 hY the Bay Area Air Quality Management TUIAU
Dosmima? BOILER-COMP(OVER MOM)
❑Ycs ❑Nn
AIR CONDI'nONER ISSUANCE DATE
1 alumS S,Iia h Cook,
Six nmutcr255 requircmtnts modOr 553Chupmr lla ofthe fire
RtmiuIficalb,i,se,&9urriad,I oa ler,s,thati 2s Tryand25534.Ito "omanJ Ihnl ifmac NEW RESIUI!N'IIAL MliCll. Sp.PI'.
hu illi rte lair nmcurrently huvc vtaill Pon"
IIomymspmsi en eanotify@camoo,y.
of the requiremm�ts which roust M1a tact prior am isxumnce it CcniOcmc of Oocupm¢y.
Owner or.uthnri ted.gem Dont TO'I'AI,: ISSUED BY:
OFFICE