00010081 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 0 0 r0 I o O
IU
ITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDEN HFICATION
ILDINGADDRESS: SANITARY NO. APPLICAT[ON SUBMI I9AL UA'II
W'NERS NAME PHONE: I fQIqAcrm'S NAME L C
NO:
(I+ NIC I CONTROL x
Jae
.Gll['TI:GI/IiNGINBIHj: LIC N(1'. ADDRLSS',
joCONTACT: PHONE: BUILDING PERMIT INFO
/ /� /I ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME❑CH
LI ENSED CONTRACTORS. ECLARAI'[OONX /y QTY ELECTRIC PERMIT FEE rCJ�
I hereby affirm that l am licensed under proviaons of chapter 9(commencing JOB DESCRIPTION
WO�Z with Sectin.70W)OTDlvision3ofthe Busincssand ProfessionsGdqv./an�dmy licensers RESIDENTIAL
F W O in fall force and elTeel. PERMIT ISSUANCE
xU f' License Class Lic.x ❑SFDN'L ITCHEN REMODEL
p Zcjj Dae Connudor J/s7N.O.Q i�PAX� APPLIANCES-RESIDENTIAL ❑ADDITION []PLUMBING RE-PIPE
may v [IMULTI-UNIT []STRUC'FURAI,
ARCH[I'ECTS DECLARATION
ZCCtinZ I understand my p1m,shill W used as public records PANELS MODIFICATION
tn- UI'T020AMP.l'
pZ-� [I INTERIOR [I CHIMNEY REPAIR
col-
Licensed Professional 201-1000AMPS gp.-,�IMPROVEMENT []SWIMMING POOLS
X� ,'4j
OWNER-BUILDER DECLARATION DYER I(XX)AMPS
BAIH REMODEI,REPAIR []DEMOLITION
C C Q I hereby arfirm that I nn+crena,I the Commelor's hlcunee Law dim me
pLL,V in lowpng reason.(Section 7031.5.Business nil 11rafe.,ions Calc:Any city or county SIGNS ELECTRICAL COFFER
W 3 LL y which requires a permit m construct,alter,improve,demolish,or repair any outcomeJ o J
prior to its issuance.also requires the applicant for such Permit o file aligned smumet SPECIAL CIRCUIT/MISC.
iLha he is licensed pum min to the provisions of the Contractor's Licume Law(Chapter 9 �' ~Commpp
W CC, (commencing with Section 2100)of Division 3 of the Business and Professions Cate)or TEMP.METER OR POLE INST. L, w 0•. f
m5: C that he Lv exempt therefrom made basis im the alleged esentptlon,Any violation of ❑NEW BLDG/ADDITION C1 bEMOUTION
DoH Senior 731.5h Ileum for a permit mHects the applicanllo a civil Ely of POWER DEVICES
y hundred
1 pens E3 TENANT ❑FOODSERVICE
no,marc Than five hundred Jnllars(85(07). IMPROVEMENT
F1 1.as owner of the property,or my employees with wages as their arde compensation. SWIMMING POOL ELECTRIC _
F. will dothework,andlhesouclure enol intemicalmoRered beside(See 7041,Business []OTHER
Waw and Proft,ssions Code The Custmanr's Lmcnsc Low docs not apply m an owner of IOCTLETS-SWITCHES-FIXTURLS
properly who bait,or po—,thereon,soil who does_muh work himself or thnmgh
his own mnpinyecs,provided that such oupoortimms arc not Interred or oll'erul for NI?W RESIDEN"PIAL ELOCI'R SQ FI'.
,.[,.if.Mw'coen the mildingor impmvement iseold withmone Yemol completinn,the SQ.PT.FLOOR AREA S/SQ.IT.
neT.ImIder will have the burden of proving that he did not build or improve for pur-
pow of sale.).
El L owner ner of the property,am exclusively contracting with licenced contractors to TOTAL:
nnomo the pmjml(Sea 7044,Business and professions CodeJ'Ihe Commuor',Li-
ceLuwdoesnotapplywanownerofpropertywhoWildsormq)roves lhmeoirand QTY. PLUMBIN(!IPER FEE
who contracts for such projects with a tomo-ctratO licensed pursuant o the Contractor's
Licensee lsxs PERMIT ISSUANCE'
[]1 am exempt under Sev. .B&I'C for this mama
ALTER-URAINk VENT-W ':RG VALUATION
)tomer Dam /UATIO /'f/1
WORKER'S COMPENSATION DECLARAI ION BACK FLOW PROI EC,DEVICE D Ot/t/• 00
I hereby affirm under Penalty of perjury cone of the Ibaowing declarations:
❑I have and will maintain a Certificate of Consent teself-insure for Worker's Camper. DRAINS-FLOOR.ROOF.AREA.GOND. S'UBBS TYPE CONSTRUCTION
sation,as provided for by Section 37M of the Labor Code.for the Performance of the
work for which this peman is ismed. FIXTURES-PER TRAP
Jijl�Thavv and will maintain Workers Compcn,ation Insurance,as inquired by Section
3700ofthe Lab or Code,raffiradianineeof the work forwhich this permit'tissued, GAS-EA.SYS'I I?M-I INC.4 OUILETS OCC.GROUP .� A
61
My Workers Cpm Sdagsfulljc ala q+JyNa.y number 7
Gartree yQ$4J l/ h'AtNAlicy No.: GAS-EA.SYSTEM-OVER41liA) Z
CERTIFICA E F EXEMPTION FROM WORKERS' GREASFI[NDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
Cl section need not Yee completed Ohe Permit is for one hundred dollars lS 1001) GREASE TRAP or less.) PLANCHECK FEE
I cetifyffieumlhe ryrliarmwce rl the work for which Ibis permit is issued,[shall SEWER-SANITARY-STORM EA.200 FT.
employ any Person in any manner so as m heumee w hjea to the Worker'Cotapen- ENERGY Flili
Z satin Laws of California.Date WATER HEATER WNENT/ELEcI R - --
zO Applicata f GRADING FEE ��� 1� T"X
ti NOTICI"IO AI'PL[CANT.If.:dter making this Cenifcae of I!xentption,you should WATER SYSTEMO R17AI ING (/1_� U
F hccx+mc-vchi el to me Worker s Corn do rbc Labor Code,yon mtwt SOIL itV3E
Ju _, pcnan Pwv,u'oell II
� Imnhwith ttmtply with such Pmmnuns or this promo sM1vll be Jccmed rcvu,cd. WAIIiR SERVICE
Mz CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT PA i' a$����2nynn
UO I herehy alto mat them iso eo sharc in lending agree,far the perfonwnce nr j r �A N
W.f F the work for whichmis pool,is iasued(Set.107.Cr,C.) T(YIAL'
-
UI.rd, sNinnc " .
Lmndcrs Address TOTAL:
�. IT.I BUILDING FEE —
t1 1 certify that 1 have read thio application and some mat the starve information is
jZ correct l agree mcomply
and with alluth and countyordinancesof and seem lawsrelatingupon gm QTY MECHANICAL PERMIT FEE
V Z building amstmnion.and hereby authorize representatives of this city mentor urym the SEISMIC TEE
ulwve.naminned property liar in,widio.purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Colli nguinst ELECTRIC FEE
Iiabilllics.ludgenents.co.sls and expenses which may in any way Berne agulnslsaid City AEI ER OR ADD 10 MECIL
PLUMBING PER
in asequence d the RSTA WILL g mf suis pe W I
APPLICANT UNDERSTANDS AND LL COMPLV WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) MECHANICAL PEE
SOURCE REGULATIONS.
AIN HANDLING UNIT(OVER I(L(XXI CFM) CONSTRUCTION TAX
Signature of Applicata/Contmnor Date EXHAUST'FOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle haeardous material HBA'TING UNIT GO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade Scaino 25532fa11 HEATING UNIT(OVER 100.000 B'TU)
�Ycs ❑No PAID
VENTILATION FAN(SINGLE RBSIU) Date Receipt#
Will he applicant 0r future building occupant use equpor,or devices which BOILER-COMP(3HP OR 100,(100 BTU)
emit hornrdous air contaminants as defnd by the Bay Area Air Quddy Manugemem TOTAL 3.5`
�\
District? ❑Nu BOILER-COMP(OVER 170,0(X1 BTU)
Cl Yet,I trot,mail the humrdnusmaterial,fecommems under Ch:gffir 6.95 el the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505.25533 and 25534,I understand mot it the NEW RESIDEN'DAL MECH. SQ,FT. I 1
requirements
Which have amnenLthait isua reofaCrirymnmifymupin,m
nr the rtquiamems Which meet M con prior issuance of n Certificate of Occupancy.
Owner orannhonictl agent Date TOTAL: ISSUED BY:
OFFICE