S 1662 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-ELEC"1'RICA L PIi 1'I'NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MBCI[AN ICA], 1662
BUILDING PRoptcr IDENTIFICNI10
BUILDING ADDRESS,. SANITARY NO. APPLICATION SUBMHTAL DA'Z'E
1/53 ort sAlrer Or . lel- 9a
OWNER::NAM PHONIi C 'RACTOR'S N1AM'Ii: n/ LIC NO:
f r sC.Y1 Q/� 55-- 1 qS7 y-f el.� r• 2- e' N/C CONt'ROI.M
HCHITF.CIENGINEER: LIC NO: APORM ❑
CONTACT: PH,tx,?: BUILDING PERMFIINFO
51
�� I o ❑ Consultant Fees Paid by Applicant((initial) BLDG ELECT' PLUMB MECH
O ❑ ❑ JRr ❑
LICENSED CONTRACTDBT DECLARATION Q'yY. IihECTRIC PEHh11'I' IZEF:
I hereby affirm that 1 am licensed!under provisions of Chapmr 9(commencing JOB DESCRIPTION
X00. with Section 7000)of Division 3 of the Business and Professions Craft.and my license is RESIDENTIAL:
O O PERMIT LSSl1ANCfi
wG in full force onJ dfcct. I]SFDWI. ❑KIT CHGN REMODEh
�UU Liam',Class U1.It APPLIANCES-RESIDENTIAL El ADDITION i-CPLIJMBING RIi.I'll'Ii
H�W Da'a Cn.tur"or
anDcARCO]'I'PC'I"S DECLARATION PANELS ❑MUI11T-UNIT' ❑STRUCTURAL
z o un L I undersand my plans shall M used as public records MODIFICATION
OZ=`p UP TO 200 AMPS Ll INTERIOR [I CHIMNEY REPAIR
r,Qtw Lieemed l'mfmsi...I 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
9p.]
OWNER-BUILDER DECLARATION OVER(_)AMPS ❑BATH REEIODEUREPAIR ❑DEMOLITION
I hereby allimt that I am exempt from the Cnmmanr'x License Law for tine
O L U fullowin Seciam]0315,Business and Professions Code:An cit t ❑IJTHIIk
g rcnson,(, y y or coon y SIGNS[LIiCI'RICAI.
which requires a patron to crostnu,, fluer.'Improve,danad'uh,or repair any nrucWrc
e'8�0 prior to it,isnunntt.Idnt reyuires the applicant li,rsuch pemahw file a signed amlene,al SPECIAL CIRCIII'1'/M ISC.
an too he islicensd
opurs.anlInmepunismo,ofde,Counselors[Alarm Law(Chapter 9
^�Q (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE IN".. COMMERCIAL
a d o y that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW HLDG/ADDITION ❑DEMOLITION
^y Section]0315 by any applicat,for a Penson subject the applicant to a civil penillyof POWER DEVICES A ❑FOOD SERVICE:
not more than live hundred dollars($5(X1).
E, 1,as owner uf,M1ePmpeny,or my employees with wages as theirsole cnmpensame, SWIM M I NG POOL.ELECTRIC F.MENT
wdldothewod.,nnA the suuewrcia Dol imm�Jnlnn,Berea for salo(Sce.](N4,Business Eon 'R
W C m ad Professions Co]it:'the Contractor's I-ireme Law does not uIlly In an owner of OUTLETS-SWITCHES-PIX'I'URES 71
66 pmpeny who hni ids or Improves thereon,and who does such work himself or through
N1-
his own mnployces,provided,hal such improvements are nal intended or offered for NEW RESIDPN IAL ELECI'R SQ PL
sale.If.however.the building or improvement is sold within one year ofcompletiomma SQ.IT.FLOOR AREA $ISQ.fT%
onerier-buildef will have the burden of proving that he did not build or improve for pur-
Pon'of sale.).
I]I,as owner in the property,am exclusively eomoroing with licensed contractors to TOTAL:
instruct the project(Soo.7044,Business and Professions Code:)the Cnntmaors Li-
cerise LarItesnucliply in an owner of property who bullus or improves themon.and Q'I'Y. PLUMBING PERMIT FEE
whit contracts liar such projects with a emnmmorts)licenned pursuant In the Comroarr's
License Law. ' PERMIT ISSUANCE ,SQ
❑ 1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WA'1'HR(PA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE
I hereby union under penalty nl you jury one of the hideouts declamtmrx:
❑ leave mAwlll unuinwinaCcrOpculcofConnnuo self-insure l'ar Workers Canywn- DRAINS-FLOOR,ROOF,AREA,CON D, STORIES 'I'YPECONS'I'RUCHON
scion,as PrnvideA for by Section 3](1(1 nl the Labor Code,far Ore Ped"osmanca of dm
work for which this pemnit is issued FIXTURES-PER TRAP 1�6e40
1 have and will maintain Workers Compensation hoomence,as required by Section AL
3700of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYS'I HAI I INC.4 OUTLETS OCC.GROUP APN
My Work Co. eAm y mu(/me s mist and Policy nu)pl4„wy'9G /
Crones f. Y Policy No.:1_�, ('L�j. 0 GAS-EA,SYStI?MOVER4(EA)
CERT11BCATEOFE%Is PI'IONFROMWON j(RS'
COMPIiNSAIt(1N INSURANCE- GREASfiIINDUS"TRI.WASTE IN'11FItCT:PTUR BUILDING DIVISION Isl'iliS
('Resect(need net be annpldal it he panni,is for one hundred dollars($100) GREASE'I RAF
or less.) PLANCIIIiCK FEE
I certifythm intheperfmmaneemf the work for which this Permit isi.ssoal.Ishall SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any runncriers m heconm subjaetn.he Workers'Camper- ENERGY FEE
Z sawsof Culifral. Data WATER HEATER WNEWAHLECTR
OOcion LApplicant GRADING IEEE
to NOTICE TO APPLICANT:If,after nuking Ibis Certificate of Ewroptine.you should WATER SYS'1'I NIfIREATING
be,,) c mh,jxl m Ila Worker's Cmnpensatlon provisinas of the Labor Cala,you ams, SOILS PIKE
forthwith comply with such provisions nr this permil shall he deemNrevoked. WATER SERVICE
aQ
= Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ,Cr PAID Dae 1 ' t
U 0 (hereby oflimubanner,is a conumcnon lending agency for the pcHnrmanm of —WK
P13
the work for whiehthis permit is issuoil(Sea.3097,Co.C.)
Lenders Name OTAL;
O U Lender's Address IOTA
P. 1 cattily Id I have read this applice ion and state Thal the.how iofmnmtmo is - BUILDING FEE
In correct.I ague in cnanply with all city and snooty nrdinnnccs unJ slow laws relating u' QTY. MECHANICAL PERMIT FFIi
UZ building construction,and hereby authorise representatives of,his city m enter uponlhe SEISMIC ITE
abase mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEL:
Iiabilities.judgmenta,costs and expenses which may in anyway accmeagaimtsaid City ALTF.RORADDTOMECH. 100 1%
in consequence of,he granting of this permit MHING RE
YT
APPLICANT UNI)' STAND. AND W .COMPLY WITH AI.I.NON-POINT AIR HANDLING ON]T('1'0,".000 CFM)
S tIItC CONST UMI FEE
AIR HANDLING UNIT(OVER IfI,(IIIII CPM) CONS'fpDCl'ION TA%
Sig oApplica 'ommctnr Date E%HAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAIHR1ALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT GO 100,000 HTUI
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Ilealth and Safety
Code,Section 25532(a)R HEATING UNIT(OVER IBO.(HM)BTU)
E-1 Y11 E]No PAID
VEN'fILATI(IN CAN(SINGER RESIO)• pule Reccipttl Will the applicant or future building occupant use equipment or devices which
emit hazous
ard .Ir cast amtimems as refusal byte Bay Are.Air Quality M....amem BOILER-COMP CUP OR 100,000 BTIU IOTA O
District
❑Yes [I No BOILER-COMP(OVER 100.0111 RTU)
I haventruldchordonn materials requirements under Chose,695 nfthe Cali- AIR CONDITIONER ISSUANCE DATE
"orexia I louts&Safety Cade,Sections 25$(15,15533 and 25534.1 and ersland that if the NEW RESIDHN'I'Al,MF,CIL SQ.IT.
building docs nmcnurenly h.ven tenant thaI t y c artsihilllyelnnti fy lheoccupant r. 11 7 T1.y
e nun be f. ''care"
icum of Oc l�—
i ` e <<f—g y t .SCE gB
Own oris agent°� Date TOTAL: ISSUED BY:
OFFICE