S 0109 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUII RTINO BUILDING.RLECfRICAL PERMIr NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0109 11. O 9C1
BUILDING PROJECT IDENIIF'ICAT'ON Q J
JIWLDING ADDRESS SANITARY NO. APPLICA'DON SUBM IITAL DNI2
22840 M61ZCEDE5 1 D Ip U CA
N H Nfh] �I��s PHONE: CONTRACfU 'S NAM( � _ LIC NO: N/C CU "'O B
p III rClTlliNG1 IiF, : 0� LICNO: 1; ADORES.' W5 46�O� VP
F La F ❑ ��
C N'FACT. PHONE: BUILDING PERMIT INTO
�� �� ❑ Consultant Fees Paid by Applicant(Initial) BLD lil-plilis PLINM cffrlj
LICENSED CONTRACIUR:S DECLARATION Ql'Y ELECTRIC PERMIT FEB: JOB DBSCRIIaT10N
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
X with stttion]qNO nt Division 391the Hoomesnaod Pmfeaxinnx CtiJeand,nny Itemise ix F 11 F I 1'
'p 1'IiRMI r ISSUANCE
�Ec� in full force and effect. ❑SFDW'1, [-j KITCHEN Rh:MOUliI.
<VO Liccnsc Class Lisp APPLIANCES-RUSIDLN'I'MIT []ADDITION ❑PLUMBING RE PIPE
y<ii Date Contracmr
ARCIII'FECT'S DECLARATION I'ANEIS ❑MULTI-UNIT ❑STRUCTURAL.
F'vX I understand my plunsxhall he used as public records
MODIFICATION
OX`=" UP TO 200 AMPS E3 INTERIOR OCHIMNEY REPAIR
MHof^", ensed Professional 201-10AIAMPS IMPROVCMENI' (]SWIMMING POOLS
OWNER-BUILDER DECLARATION )VER l0k)AMPS ❑BATH REMODLVREPAIR ❑DEMOLITION
p�IY C< 1 hereby affirm that 1 am exempt from the Contmnnr's Licen.m haw hie the ❑OTHER
X O d U fallowing roma.(Section 701 L5,Husiness and[I fee..on,Code:Any city nr county SIGNS ELFCrR]CAL
IL 3 a y which Inquiry a permit m eom0um,alter,impose,demolish,or repair any shoaure
Og prinrmlesi....for'doinepinen iheapplicam ror,wch pe.ino file a.signed statement SPECIAL CIRCUIT/MISC.
� G�, that he is licensed pursuant the previsions of the Contractor's License Law(Chapter9 I I
BIL 00y� hannmennng with Section7NNI)of[)labs...Jof the Buxincva and Prufyvioos Code)or TEMP.METER OR POLE(NST.
a that he is exempt therefom and the basis for the alleged exemption.Any v.o....-of IoW It TUITION El DEMOLITION
Section 01131.5 by any applicant fo u,semtitsubjccts the applicanuoacivil pcnulty of POWER DEVICES ,I ANT FOOD SERVICE
aur more than five hundred dollars WOOL PROVEMENT
C=, ❑Lmnwncrofthupmpeny,ormycnipinyccewithwagcs ustheirsnlecompenmiion, SWIMMING POOL ELECT
2F• will do the work.and the structure is not intended oniRered for aide 704,1.]business OTHER
W and Professions Code:'1'he Conlmm9Ls Llcum.e Law does not apply m an owner of OWLETS- WITCfil3-FIXTURF'_S
a 3- property who builds or improves thereon,and who does.such work himself or through
Tax own employee.,provided that...M1 inI....Inaers are nm;banded ter offered for NEWIIA1,I'l FCIR SQ FT
sale.IL however the building or impovenwin is sold within one year of complctiun.the SV IT.FLOOR AREA SQ
crhudder will have the harden of moving that he did nut build nr improve for par- gpJ�V`
to
own
till
porn of idaf 'IOT'AL:
D I.as owner of the property,nm exclusively contracting with licensed contractor In
conxwci the pojecl(Sec.71114,Business and Pmfcssionv Cods:)The Cnnhueeir's Li
reme
law mks nntapply to an owner of property who builds or improve.Nhereon.and QTY. PLUMB PERMIT FEE
who contracts for such nopen with a conwctoN%)licensed pursuant to the Contractor's
License Law, PERMIT ISSUAi E
I am exempt under Sec. .H&P C lire IN,east
ALTER-DRAIN&VEIO
NT-WATER(H2O VALUATN
(Toiler ])air
WORKER'S COMPENSATION DECLARATION RACK Fl.(IW PROI'IiCT.UEVICIi
I hemhy atlirm unJm menahy n(perjuryone til the lidlowing deal'orations'.
i (] Innve and will maintainaCenifcvtn dConxnt to ulLinsurc for Worker's Compen- DRAINS-FLOOR,ROOK AREA.COND. STORIES i'YI'IiCONS'I'I1lICl'ION
nation,as provided for by SW imn 3700 of the labor Code,hr the pe,fomnvinc M the
work for which this permit is issued. FIXTURE-PER TRAP p
I have and will mainimn Wnrker'x Crnnpunsaiom Lawrance, A
a.mcluined by Section
J]Bonfthe Labor Cods,bathe priburn acef Ne work fill which this Permit is issued. GAS-EA.SYSTEM-I INC.4 ODUATS OCC.GROUP MIN
M orke's Compcnsatyp lnsu:`ee canicr unJ Policy numb rvee
orrWice`�j-/kn rY3 r�Y Prthrr Nn.:JurieiG7-47
GAS-Is.SYS rEM.ovea4Hln> AUG1V(a
CIiRT11dCATli OP EXIiMIIDON FROM WOHKIiRS' GREASIJINDUSTRL WAS IE INTERCI?PI'OR
COMPENSATION INSURANCE 1. LNG ON
(P his section need not at completed if(he pemtit is Gnune hundred dollars($I00) GREASETRAI' i
m lana) PLA CII iC �. -tHl f
I certify that in the performance ill that work ear which this permit i s issued,]shall SEWER-SANITARY-STORM EA.200 pI.
not employ any person to any manner sat as o become subject m the Worker.'Compcn- ENERGY LTH
Z saion]aws It California.Date WATER THEM HR WNENTELECI'R GRADING FEE
ZQ Applicant
h NOTICE'O APPLICANT:it..Her making this CeniGcvle of Iixemption,you should WATER SYSTCMO'REA'1'ING SOILS FEE
F become no m thr Workers Compensation provision.of the Iabnr Code,yo."lot,
tonhwith cmnply with such noci,on.. a-his pr mil shall he deemed re,nord. WATER SERVICE,
PAID
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,Fr. Date R rift
U C) I hereby amnn that there is a construction]ending agency for the performance of
LL the work hr which thin permit;,issued(Soo.1097.Civ.C.) TOT 1.:
C) F•' Lenders Name TO'T'AL:
r U Ueda,AAdics. BUILDING pip
6. I ready that I have trial this application and ntam information the above infiation is
1. rn s rect.lagrce to comply with all city and coumyormnances and state laws relating to QTY. MECHANICAL PER.... FEE SEIShDC E
U z hui]ding mmnwction,and hereby aumoriae rcmrexnmtives of this city to ether upon the
ubnvc.mentiuneA pmlmnY for insPcnnm purpusec PERMIT ISSUANCE EL FEE
I Web agree to save,indemnify and keep harmless the City of Cupertino against
Ilabilitiea,judgmenis,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECL PLUM GFI i
in consequence of the granting of this permit.
APPLICANT
L /UNDOAIIO \OSA SLI.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10.0(.000 C MECHANIC LFT-17.
SOURCE EGE'.A110 '. //
AIR HANDLING UNIT(OVEN ItA(MIR ChM) CONSI'RU( ION TAX
ig arc mf Applican nuvctnr �jlC,/, DCafe EXHAUST HOUD(W/DUCD HOUSING MITI 'ION FEE
HAZARDOUS MATERIALS 1 SCLOSIIRE
Will the upmllcant nr future building mcupousuoor handle hazardous material HEATING UNIT(TO 100.000 RTU)
as defined by the CuPeninn Municipal Code,Chapter 9.12.and the Ihuldi and Safety HEATING UNIT(OVER I00.NN)H'IU)
Circ,Section 255320)'t
❑Yes Fl No PAID
VENT] FAN RL'SIU) Date R 'ciplp
Win the applicant or future building occupant owe a4mpn c nr device,which HOILER-COMP UHP OR I(NI INN(RTU(
Ir' -mit hamrdous air conminimante as defined by the Bay Area Air Quality Managemem T( l'A L:
J• istdbR BOILER-COMP(OVER 11X1001)BTU)
❑Yes ❑No
I IIm'e mad the haamdnus materob icquiremcros wide Chapter 6,95 tl the Cali
AIR CONDITIONER ISSUANCE DATH
food.Health&Safety CtiJe,Sections 25505,25593 and 25514.1 nndentand that if the NEW RESIDENTIN.MIT 11 SQ.Fr.
building roes not currently have a natant.that it is my respimsibility to notify the meupont
f the reemremems which mus he mei palm In;..mmce of a Ccnlfemn of occupancy.
(honer m authnriud eItem Date To hA1.: ISSUED BY:
OFFICE