S 0611 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-ELECT RICA], PERMIT Nu.
CAL
BUILDING DIVISION APPLICATION/PERMIT TING PROD CT IDENTIFICATION
BUILDING PROJECT IDF.NTIFICAI'ION
BUILDINGADDRFSX SANITARY NO. APPLICATION SUBMITTAL DAPI
107+1 �.v er o Z7j
OWNER'SNAM ;HONE:3 _ CONr CI'OR'S NAME: LIC NO.
8 NIC CON'fROi,p
'HIL'iCT/E GINEER: LIC NO: ADD ESS: - ❑
If ;er 20 Ave_ �u(o
C(;N'I'ACT PHONE: BUILDING PERMITINFO
wI I - ❑ Consultant Fees Paid by Applicant(Initial) )C ELL pL M M
CONc
LICENSED T'NACT R'S DLCLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed model pnvislons or enafter 9(ammce Ing JOB UESCRII'TION
AaZ withSmhm talo)of Divoioo 3 efihn Businessand Professions Colo.and nay Banco is RESIDENTIAL'
W p O PERMIT ISSUANCE
FW• in full force andi2vo. '-ldg17 ❑SPDWL ❑KITCHEN RF;MOUEI.
6UV Liecnsc Cl ISS Ltc. / 1 APPLIANCES-RESIDLN'1'I AL ❑ADD]'T'ION C1 PLUMBING RI PdPE
t✓Zw Dale PftL221 97 Cn amount
m Q p, ❑MULTI-UNIT" ❑STRUCfURAI.
ARCHIT'ECT'S DECLARATION PANELS
ZO Z in Z understand my do be used as public roomed, MODIFICATION
UP 10200 AMPS ❑INTERIOR El CHIMNEY REPAIR
L�.F.,Q .cd Pmfmsinnvl 201-10x0 AMPS IMPROVENUPSI' ElSWIMMING POOLS
OWNERBUILDERDECLARAr1UN OVER IIxp AMPS ❑HATH REMODIiI.EEPAIR [I DEMOLITION
Ci Q I hereby af@na Ilial I am exempt from the Conmaeor's License Law for the
d U following reason.(Section 71131.5,Busino,es and Pmf omv,Codc Any city nr county SIGNS ELECTRICAL ❑OTHh:R
W a WIT" which requires a ryarmi,m conMrvcl,alter,improve,demolish.erector am Htueue,
prior him, 'I y l"a of,socandf hp 'u filo,uigyrdshaamairm SPECIAL CIRCUIT/MISC.
'bar he is licensed is IIobe,re,kan,of0 Contractors,L L (Chapter9
ce G S vCOMMERCIAL:
O foam acne ng Scmioa 71x1B0Uf�vs nn]nf'hc Business dP (:. ns Code)or TEMP.METCR OR POLE INST.
LFRON
0.a e 'hat he is scientist therefrom and the basis for the alleged eacmption.Any violation of ❑NEW BLDG/ADDITION OSFRVI
Section 7031.5 by any applicant for a pcnnit subjects the applicant to v civil Penalty of POWER DEVICES ❑TENANT FOOD SI?RVICE
I more than five hundred dollars X5000). IMPROVEMENT
ESG ❑ Las owner of the Property,elm loeee with wa theiraole cam lion, SWIMMING POOL ELECT RIC
My in y Fcs as Paves [I OTHER
F+ will Profcut ession,
ondr: the outum,a tot s License Law red
a cele(Seel oam ovener of
Ia�l-' and Pmfecsinns Codc'The Gimmemr'a License Law docs no,apply m con owner of OUTLGfS- WITCHI3S-FIXTURCS
0.3_. property who builds or improves thereon,and who does such work himself or through
his own employees',provided that such improvemend arc not nuanced nr ofibred for NF.W ..1DBNTIAL ELLC'1'R SQ P
'aleIf,however,the building or lmpmvcmcrn is sold within one year completion,the SQ.Pf.FL OR ADA
s erbuiNor will have he burden of Proving that he did not build or improve for per- ��� N
ro ). TOTAL 3 (/D
1 lith i miserly, exclusivelycorrecting lb licensed " m
constructmp ) t(s 70948 : and Professions cd .)TnCon, t :Li-
can L d ,,pply, fP K� y h h Id: - p to d QTY. PE MBI .RMIT FE t I
whoannmo, Tor wehprDeus with a conmaWnr(s)licensed punuanl to the Contractor ����
Lkcmn Lvw. PERM IT ISSUANCE
El 1 am i-al under See. ,B&P C for this mason
At:[ER-DRAIN&VENT-WATER(EA) VALUATION
Owner Da'e
WORKER'S COMPENSATION DECLARATION (SACK FLOW PROTECT.DEVICE.
1 hereby alum under pemdlY of al Con one of the mofolewmgWmkcr``,,Co
Ikuve and 9000 mvinum uCrnifianeolCenxenl to self-insure fiarWurkoPa Grmpen- DRAINS-FLOOR.ROOF.ARCA,COND. grpgl CS 'IYPCCONS'I'RUCfIOP
edion,as provided for by Section 3900 of the Labor Code,for the Forbearance of the
work lire which this peril in I...oA. FIXTURES-IHR TRAP
1 have and wIII common Worker's Compenwtion Insurance,as required by Station
3701 of the Labor Code,for the performance of the work for which this pcnnit isomer. GAS-EA.SYS'IEM-1 INC.4 OUTLETS OCC.GROUP APN
MyW k CI)lalc ' 1 vndPolicv wnbc {{. V�. GAS-EA.SYSTEM-OVP,R4(EA)
Ca 'c Pat,No. ! f
�f ` CERTIFICATE Oh EXEMPTION FROM WORKERS' GREASIJINDUSTRL WASTE INTERCEPTOR 0011,40. COMPENSATION INSURANCE DING ]VISION FEES
(Thissnc'io I need not beeomphlellfthepermi'is f cote hundred della,p$100) GREASE'I'RAP
nr Icxs.l PLANCIIEC
Ican dythat inthe pcHnnnunce of the work for which this permit is issued,I Nball SEWER-SANITARY-S'1'ORM EA,201 FT,
nemploy any pronoun my manner na ns Io became xue,0 to We Worker;Cmnpen- ENENERGYod
Z efor I.awe mf Cnlifomia.Data WATER HEATER W/VENT/ELECTR GRADI 'E
ZQ Applicunt
i..t Z) NOTICE to APPLICANT,It,alter making this Carotene,of Fsemp,ien,you should WATER SYSTE VTREAJING
ahcamn subjtta m'hu Workeds Can er-nion provisions of the[,he,Code.you mus, SOIL$
Cil res hamwi'h comply with such provisions or this pound shall be declared no-ked. WATER SERVICE
PAID
CONSTRUCT ION LENDING AGENCY NEW RESIDE PLMH. SQ. D: Receipt#
I hereby affirm that is a ennsmuntion leading agency for the performance of
;I. . the work for which this Knound x i...cal(Sa.3097,Civ.C.) 'IGIAL
O Emit,,,Name
Lendu's Address 'TOTAL:
1 certify that 1 have read this application and state that 0e above information Is BUILDING EE
Lt V1
comes,I agree m comply with all city andcounty ordinames and state Lown totaling to QTY. MECHANICAL PERMIT FEE
V z baildingcolepernam and o0c rc
hmmbyudhorpn remcnm'ivofdhis cm de
'nycnupon the SEISMICFiti L+
`+ alwvo- aideread Property fur unification purposes. PERMIT ISSUANCE LLECfR1.FEE
(We)nKo e m rove,indemnify and keep harmless the City of Cupertino against
linbili'ies,judgments,costs and copenseswhich may in any wayoccme against said City ALTER OR ADDTO MECH. PLUMBI GFEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECH ICAL FEE
U CF REsGULATIONS.
����27 AIR HANDLING UNIT(OVER 1111101 CPM) CONST UCfIONTAX
Signature of App icanUCn towdel Date EXHAUST HOOD(W/DUCT) HOUSI G'MITIGATIONFEE
'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bulldingxcuponl store orhandle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by he Cupmlino Muriclpal Codes Chapter 9.12,aaal'he Health and Safety
Gale,Section 25532(0)! HEATING UNIT(OVER 100,010 BTU)
❑Yes El No VENTILATION PAN(SINGLE RESID) PAID
Ira Reals'p
Will he applicam or future building oec asout use cquipmem or device'which BOILER-COMP(3HP OR 100.0x0 RTU)
emit hmardnus air contaminants us defined by the Bay Area Air Quality Management 'IU'1'AL
Di...ad[r BOILER-COMP(OVER 100.000 BTU)
❑Yes E]No
I have madtho hanlous mmerialsrcqui'e'nem,andercdapter5.95e1'the Call- AIk CONDI'I'IONLR IS$UAN 'DA"CE
ra
forma Health&Safety Code,Sections 25505,25533 and 25541.1 understand thin it the NEW RESIDENTIAL.MECH. SQ_FT.
Banking does nes,rrenlly have mmntn6 that.,ivnyea"re ihili'y tonotifythe occupant
If the requirements which;1111 be rte Pnor nes isemance of v Certificate afOaupvncy.
Owner or ambinnue l again Dadc TOTAI.: ISSUED nV'.
OFFICE