S 0203 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINCI DHD.DwQ- it I RICA J PERMIT NO,
BUILDING DIVISION APPLICATION/IaF.RMIT PLIIMBINC,-MF.CIIANICAI. Q
BUILDING PROJECT IDENTIFICATION J
qSANITA:RY:NO. AI'PLICA'fION gUIiMITIALDATIiBUILDING ADDRPSS:O -R'SNA E' P rin
E: LIC NO:./ 0,,w JOU5 /_ O p CONTROI.f
RCHITELT/ENGINE•ER: LIC NO: RESS: N�
CONTACT. �� PHONE: . me C941 ' BUILDING PERMIT INFO
TlC1C G� �{G�'3�d 3331 ❑ Consul ant Fees Paid by Applicant(InlHap BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'$D[CLARATIONQTY ELECTRIC PERMIT FEE 1 JOB DESCRIPTION
1 herchy affirm that[.,a IicenseA under pruvisinns o(Chxpmr 9(commencing,
Qa'Z with Section 70gBm'Division 3ofthe Basin...nd Profcasi,.r Cole,and my license is
YI
00 PERMIT ISSUANCE
F full force an L SFDWLIAL ❑KITCHEN REMODEL.
�UW Li«se Cl., Lie,« 0253&1 - _
APPLIANCES-RESIOEN'f1AL ❑ADDITION ❑PLUMNING RE PIPE
r in
in IS Dam one,on
DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
OI.
j 1understand my plem,bull heated as public records PANELS MODIFICATION
:J UPTO2c0AMPS ❑INTERIOR ❑CHIMNEY R17PAIR
a = Licensed Professional 201-Ig1(IAMPS IMPROVEMENT 0SWIMMING POOLS
IY dF OWNER-BUILDER DECLARATION OVER I000AMPS ❑OATH REMODF.IJREPAIR �DIiM01.11'101
I hereby air,.that I am exempt from the Comm un's License Law far the ❑OTHER
KO P.VF. following reason,(Section 7031 S,Business and Profes,ions Cole:Any city or county SIGNS ELECTRICAL
F LL O hQ which requires a permit eco ccmmuct,aher,improve,demolish or repair any stmemre
J prior,.its icsuonce.alsa requires the.pplicmt formch permit.Bleadgned scoment SPECIAL CIRCUITIMISC.
Fr ay Nat he is licensed Panama to the p...Won,of the Commissaries License Law(Chapter 9 ,
u� (commencing with Section 7010)of Division 30 the Business and Patficssions CoslOnr UzMP.M ETER OR POLE I NST. COMMERCIAL
L o eOC that he is exempt meoef.m amt the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ro Section 70313 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more than five hundred della,($500) IMPROVEMENT
F�C ❑I,ns owner of the p.,crt,army,.pi,.I with wages.,their sale compensation, SWIMMING POOLELECTRIC
will do the work,and the structure is not imteaded orofiered boreal,(Sec.704,1.Business ❑OTHER
Wend Professions Code:The Cnnlmctors License Law dues not apply.an owner of OUTLETS-SWITCHES-FIXTURIS
property who builds or improves them.,and who does such work himself or,hrough
his own employees,provided that such improvements ore not intended or nfrmd for NEW RESIDENTIAL ELECTR SQ FT. SQ,T.FLUOR ARBA $/SQ,FT,
sale.Il;however,the building or improvement is sold within one year of ea mpletion.the
ow olaulder will have ted barren affirming that he did at build ter improve fm par- PAID pose of.lel.
❑ h as owner of the property,um exclusively contracting with licensed contractors to IOTA].:
construct the project(Sec.7(L/4.Buallleai and Professions Calc:)The Contractor's Li-
cense Low does not apply toanowner ofamperlywho builds orimproves themnnand QTY. PLUMBI NO PERMIT FEE r UN 25 RECD
who contracts for such projects with a commetons)licensed pursuant to the Coulacla''s
License law. PERMIT ISSUANCE
❑,I um exempt under Sara ,B&PCforthismason
ALTER-GRAIN&VENT-WATER(EA) GITY VALUATION
Owner area - ✓
WORKER'S COM of
DECLARATION BACK FLOW PROTECT.DEVICE En
I herchy affirm under penahy of perjury one of the following Worker's C e:❑Ih.vemd will mainmioa CeniOcale sfConumto self-insure far Workers Compcn- DRAINS-BOOR.ROOP.AREA,COND. TYPECONSTRUCTION
satins,as provided for by Section 37M of the Labor Cole,far the ammmunics,of the
war for whichthls permit is issued. FIXTURES-PER TRAPhave and will maintain Workers Compenmtion In urance.as required by Section
7 ),,fine LMmCale,f rlheperformonce ofthe work forwhich Ibis permit is issued. - GAS-HA.SYSTEM-IINC.4OUrLETS APN
My WarkyaCm ganion� Sranm,4rriermd PMicy�yP ly �rs-�.
U.dII__J A'tT 671 Policy No.:S'a+a IV �O VT GAS-FA.SYSTEM-OVIiR4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GNEASPJINDUS'1'RI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not becompbated ifthe Permit is forms,hundred unit=($10l) GREASETRAP
or less) PLANCHECK RII3
I citify that inthe perforntanoe of the work for which Nis permit is issued,l shall S17WER-SANITARY-STORM EA.2W FT.
not employ my person in any manner so as to become subject.the Workera'Compen- ENERGY FEE,7s ,shun Lars.,of California.Dme WATER 11 EATER WNENT/F.LEC R
zApplicant 1 GRADING PEE
h NOTICE TO APPLICANT:If,after making his Cerrficam of Exemption,you should WATER SYSTEMIT EATING Soli's FEE
abecome subject to the Worker's Compensation provisions of the Lubar Code,you must
W forhwithenmply withiamh p..visions or this permit shall be darned revoked. WATER SERVICE
QPAID
CONSTRUCTION LENDING AGENCY' NEW RESIDENTIAL PLMR. SQ.PT Mae ec pap
U Z cR
1 hereby ann that there is aconswnion lending agency for the performunce of
W [[[..
...iii the work for which this permit is issued lSec.30 7.Civ.C)
IkI-1
Lenders Name - TOTAL:{Ug1 Lenders Address TOTAL:
I certify that I have mad this application and tam that the above infomamimn is BUILDING FG
FN correct.l agree to comply with all city and county ordinances and state laws reining to QTY, MECHANICAL PERMIT FEE SEISMIC FI
U z building construction,and hereby aummim representatives mfthis city tenter upon the
above-memioned preperty for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We) gree to save,indemnify and kap hunnlexr the City of Cupertino nguinst
liabilities,' menu,cata and cxpc awhich may many way acerae against said City' ALTER OR ADD TO MECH. PLUMBING FEE
in con, q e 'e of the gm ming of th' mail.
APPL T UNDE STAN ' I BILI.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT Go I0,0g)CFM) MECHANICAL FEE
SOU E ULAT S. '
AIR HANDLING UNIT(OVER I0,010 CFM) CONSTRUCTION T X
. f pplictur rut tm Dau EXHAUST HOOD(W/DUCI) HOUSING MITIGAT0
HAZARD S MATERIALS DISCLOSURE
11 a applicant or future building occupant store or handle hazallous nonlethal H EATING UNIT(TO F BB(MMI BTU)
as JeOn the Cupenion Municipal Code,Chapter 912,and the Health and Safety
Code.Section 2553200? _ HEATING UNIT(OVER,Iflip"BTL)
Oyes ON. VENTILATION FAN(SINGLE RISLD) PAID
Dam Racipt
Will the applicant or future building occupant use equipment or devices Which BOILER-COMP(IRP OR IMAYA RTU)
,mit huaa dmfs air ronmmi...1.as defined by to,Bay Are.Air Quality Management TO
District BOILER-COMP(OVER 100,M)BTU)
❑Ycs ❑:No
I have roedlbe hautdet.mamnile requilemat.under Chapter 6.95 of the C.li- AIR CONDITIONER ISSUANCE DATE
Tania Health&Safety Code,Sections 25505,25.533..it 25534,1 understand that if the NIiW RESIDENTIAL MECH. SQ.FI'.
building does not currently have a tenant,that it is my responsibility to notify the oecupam
of the tequiremcnu which must be,met prior.itssu.of o Cronies.of Occupancy.
Owner or amhoriud agent Date TOTAL ISSUED BY:
OFFICE.
Hours Mon.-Fd. 8:30 am-5:00 pm
Sal.10:00 am-3:00 pm
Sunday Closed
ALLY§ON FORREST PICKARD
.mxwo.mvE m[cowcmwx
(408)370-3331
SHOWROOM: Pager:951-4295
1450 Dell Avenue,Unit C FAX:(408)370-3110
Campbell,CA 95008 License 0628381