S0816 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPERTINO - BUILDING-ELECTRICAL P' IFNO
BUILDING DIVISION APPLICATIONIPERMITPLUMBINGMECHANICAL 0816
BUILDING.PROJECT IDENTIFICATION
BUILDING ADDRESS: // � � � � SANITARY NO. APPLICATION tiUH\11lTAl.,DATF,
WN` SHAME: •� YHONF `CRD �
f N LfC NO:
Y NIC GONI'HQL.N
910
ARCHITECIHF.NGDEER. LTV, O: AI ❑
4.
CONTACT" PHONE: - BUILDING PERMIT INFO
❑ Consul,ant Fees Paid by Applicant(Initial) 11. ELLCI I'll mGCu
LICENSED CONTRACTT OR'SDI:CLARN'ION QTY. ELECTRIC PERMIT I'L'fi
1 hereby altirm that I m licensed under poor inn.v of Chapter 9(ars nencing JOB DESCRIPTION
O0Z with Section 7IXXl Di of the Holiness an Je dfi license is RESIDENTIAL
WO t cjsro PERMIT ISSUANCE
aFSO icfullu CII an ❑SFUWL [I KITCHEN REMODEL
VU Liccnx Class Lich I 'IDEN'DAL
FZLLI Oic Comms ❑ADDITION C3 PLUMBING RE-PIPE
❑MULTI-UNIT ❑SRUcTURAL
ARCHITECTS
Z p m Z 1 unJemmnd or plans shall M used a public records PANELS MODIFICATION
m- UPTO 2W AMPS
OZ-Ls ❑INTERIOR 'i1MNIiY REPAIR
F�t:w Licensed Professional 2(11-HXX)AMPS IMPROVEMENT [Sw MMING POOLS
OWNER-BUILDER DECLARATION
C C Q1 hereby affirm that 1 am exempt front the Contmao's License Law for the OVER IIXXI AMPS ElRATH REMODEUREPAIR ❑DEMOLH ION
X O d V following es.on,.(Semon 9(1313,Buzincss and Yrofusini 6rJe:Any city nr county SIGNS ELECTRICAL
C:1 OTHER
D1311l- which ere irca a Irermh In carrion,after impmee,detmthxh,n,cion any"enure fe
qFq u.,OQ prim,pa,:,,armee,ulsn tequirex the applicant l'nrmch pctntitto LIa,,igncdswmmem SPECIAL CIRCUIT'/MISC.
2W�'J that he is llanwd penssum,to the ppv,oinns of the Connector'sl:sects Law(Chapter)
�ap0 (annmcncing with Section 7000)of Division 3 of the BnsinassnnJ Prol'esxhas Corc)or TEMP.ME I ER OR POI-17 INS F. COMMERCIAL'
d d e C that he is exempt therefrom and the basisfar the ullegal cxumpdnn.Any vinlutien of ❑NEW BI.DG/ADDITION ❑DEMOLITION
m Santo.70,11.5 by any applicam fora permit suhjects the applicam to a civil penalty of POWER DEVICES
not more than rive hundred dollars($500),
[]TENANT ❑FOOD MikViGE
F=QLas owner of the rt.orm laces with was%as their sole coat ation. SWIMMING POOL ELECTRIC IMPROVEMENT
E c ❑ property. remp r s Penn
E. will do the work sw
and the is not intended or entered for sale(See 7(W,Business ❑OTHER
W �_ and Profassions Code:The Commnors License Law docs not apply to an owner or OUTLETS-SWITCHES-FIXTURES
0.3 pr.,ny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements art nm intended or offered for NEW RFSIDENTIAL ITECTR SQ FT.
sale.If,however.the building or improvernica is sold within one year of completion,the SQ.FT.FLOOR AREA 5/SQ.FT.
er-h older will have the burden of pmving that he did not build or improve for put- PAID
pox aL.mla).
1,vs owner of the propenyl am exclusively cnmraming with hoviord commnon to TOTAL: AN
mswet the project(See.90.W,Business and professions Calc:)'Itie Contractors Li- JAN 21 ANS`0
cause Law Joel not apply to an owner or pmpeny who bui ids or improves thereon.and QTY. PLUMBING PERMIT FEE
who wnuuns lorsuch Projma with a contract rn(,)Inrnxd pursuant to de.Connector',
License Luw. PERMIT'ISSUANCE
❑ tit exempl undersee. .B&P C.lar rich eca,an COY Ut UUreh 1 live
ALTER-DRAIN K VFN'r-WATER(EA) VALUATION
Owner Late
• W'ORKEk'S COMPENSATION DECLARATION RACK FLOW I'R(yrECf.DF.VICF, ��J /O �
1 hereby affirm under pcoalq of perjury one of the following declarations:
have and will maintain a Certificate of Consent m self-insure for Wenders Comps^- DRAINS-FLOOR.ROOF.AREA,COND. ST IF_S TYETCONSFRUCION
A, .na Provided for by Section 3700 of the Labor Cade,for the performance of the
n farwhichthis Perms is issued. FIXTURES-PER'TRAP
have and will maintain Worker's Compensation Insurance.os required by Sectiov
ll IhcE nr CtNe ewnc fares 'r t ^iii.-sex GAS-IiA.5Y5T1iM-I INC.J OUTLET'S OCG GROUP 7F
IN
Work y No.:n GAS-EA.SYS'IP_M OVER 4(EA)
Camcr: y No.:
CIHR IFICATE FEXEM
ON FROM WOR I. S GREASE%INUl15'I'RI.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION PBGs
('Thi-,clione,ad not becon,th, aliflhe pctntit is fonmu hundred Jnllarx(EI W) GHEASE'TRAP -
or leve) PL\NCHECK FEE
I cenilythm inmeperficmpeaefthe work orwhielObiv pcnni1 isissued:shall SEN'LH-SANT'I'AHV-STORM EA.2010 FT,
our cmplcy any prion in any.........as m Ircmmm mbjat o the W..ke"Conymm I?NI?RGV hili
Z lotion LawsotCullrornia.Data WATER HEATER
W/VE?NT/F.LECfR GRADING rZQ Applicant E
'
.y ,N. NOTICE:TO APPLICANT:If,after making this Cenilicxte at Exanption,you should WATER SYS'I'EMOREATING
F'^ became subject to the Worker's Compensation provisions ol'the Labor Cale,you mit SOLS M.
forthwith comply with such provisions or this permit shall be deemed mocked. WATER SERVICE
6. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. PAID Date eciplN
U O I herchyafBrde that isa construction lendingogency for the performance of
is work for which this permit iz issued(Sec 3(N7.Cir.C.)
oF•' Leader',Name 'IVTOI'A h:
V Lander',Address TOTAL:
} 111HOLDING FEE '
1 1 to see that 1 have real this application and score mm the star,l information,re is
F Z c nen.Iagtceextcomply with all city and county ordinances and stem Ixmrelating e QTY. MECHANICAL PERMIT FEE
C) Z M1ullding cnnstmmion,and hereby authorise reprewmmives ul'this city mentor upon the SEISMICFEE
da"con rriia:d pmlwdy for inspection puHxrses' PERMIT ISSUANCE:
(we)ngrce to save,indemnify and keep harmless the City of Cupertino against ELEC'I'HIC FEE
iiahil'nics,juJgna;ma,costs and cxpcaece which may many way accou aganot said City ALT UR OR ADD'10 MECU
PLUMBING FF,F.
APPLICANT
NDEf tic gmming Sthis Dactil.
APPLICANTULATIOS. AND WILL COMPLY WITfI ALL.NON-POINT AIR HANDLING 11NR'('rll 10,000 CFM) MECH,WLCAIJ li11
SOURCE REGULATIONS.
' AIR HANDLING UNI'1'(OVER IggIII CFM) CUNS'THWTION TAX
SignaircnfnpplistanA.mracmr Data EXHAUST HOOD(NMUCT) HOUSING MITIGATION THE
HAZARDOUS MATERIALS DISCLOSURE:
Will the applicam orfrem,building eecupantsmrenr hoadlchuardous material HEATING UNIT(TO I(N)JU)BTU)
as defined by the Cupci ino Municipal Calc.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)^ 1 HEATING UNH'(OVER LOT"BTU)
E]Yes No PAID
VENTILATION PAN(SINGLE RFSID) Data Receipt X
Will the applicant ar to are wilding occupant use aeutpmei nr Jcviees which BOILER-COMP(3HP OR 1 00,000 BU)
T
mit hazardous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
D11111a9 ROII.ER-COMP OVER 100,WNI B OJ)
❑Yes
atiiA thchw nateriulsre Is ands,Chaser 695 oI he Calm AL R CONDI'I ONCR ISSUANCE DATE .
umna,
fen ,& SidetY Cld S tone 2551152 I2-55171 I sra_mm Teas NHW HESIDIHN'1'IA1,MIiCH. SQ.FI'. - /1
h I' gJ t' tlyh .d t t Y RmdM1I'tyt 'Lee« pact W
tIt net t faCntat '(X11 c
nen am sized em at TOTAL: ISSUED BY: \VI
OFFICE