S0001 B0408G
NTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
'CUPERTINO
QTY IiLE(-RIC PERMIT
BUILDING - ELECTRICAL
LS-RESIDI'NTIAL
;APPLIANCLS
PERMIT NO.
�G DIVISION
APPLICATIONIPERMIT
PLUMBING -MECHANICAL '
BUILDING YROJEC1IIDEN1IFICG1ION
50001
160408
`
POWER DEVICES
SWIMMING POOL ELECTRIC
N not more than five hundred dollar (5510).
E=G ❑ Lmownerol he property, or try emplayces with weges vs theiu:ole umapen.sation,
F will do the workand tbesaanum is nm inendeJo mEb,d for smle(Sec. 76i4, Business
not Prnfesaimas Curb, The Contramor'v license Low Jails ran apply to an ownar of
6 3 propcny who builds or improves thereon. and who doe, such work himsdr nr through
lois own empinyces, provided Than such impmvemcnts are not intended or offered fm
sale. If, however, the building or impmvcmcm is sold within one year nlcoinf lation, the
cr-builder will have the burden of proving that he did not build or improve for pur-
SANITARY NO.
NEW RESIDFNHAL M ECTR SQ PT
I
AI'PLICADONON SUIIMI'1'1'AL UAf
1UDBESS:
posepf xale.).
owmar of the prniu.ny, am exclusively contracting with licensed contracmrs to
construct the project (Sec.LW4, Business and Professions CwIC:)The I-marner %Li-
a,c Law doe.nor'npply nh an owner of property who builds or Improves thereon. it
who contracts far such projects with a commctm(s) licensed pursuant o the Conunaor's
Liam, Law.
Ilam ex tam cr Sec. . I3 Ai P C tunhb rmavn
QTY. PLUMBING PERN7IT
/ ANCE
ALTERIN & VENT- WATER (IIA)
EBACK�OW
O nil Date
3 STANrVA-0
PLAC�E
PROTECT. DEVICE
OOR. ROOF, AREA, C.
101 ...S-PER'TRAI' a
2- P
AMii
PHUNI!:
COVIRACTOR'SNAM@ LIC NO:
NIC
COKIROI.a
(�Jn.`
^-' $Z0611161014
AM [�
49 •i1W61�
6-15+0
❑
Z
DENOUNCER. LIC NO:
ADDRESS:
❑ Consultant Fees Paid by Applicant (Initial)
LICENS12D CONTRACTOR'S DI:CLARATION
1 hereby anima ow I if. licensed nada pmvisions of Chapter 9 (a,mmendng
'co with Sation'lgNq of Division tel aM1C Businesr tend Professions Code. and my llcen.se is
� in lull force and offelo
QUU License Class Lie.
D.mc CommcmrARCHITECTS DECFARAI'[ONOZNZ I underatand my plans shall be used as public recordsMP5
QTY IiLE(-RIC PERMIT
/ UANCF
/
LS-RESIDI'NTIAL
;APPLIANCLS
1P-.4tW Licensed Professional
a4 OWNHWItU11.DGR OFCLARA'I'ION
hereby afliarn aha I am exempt from the Co rbour or's License law for theW followig reason. (Section 911]1.5. Business and Prnlessions Code: Any cityos county
which requires a prook to construct, abcr, improve, demolish, or repair any structure
0 prior to I '1.so rectums the applicant t'hpor fit, filea,bredaaemenl
f i3 T that fie is licensed pua a the previsions f the C w a 's l La (Chapter 9
ty�p0 (ecmmcnciagw'1h Sntion71,00)ol'D'v-m 3ofthe Bus'u.', uaJP f.! sCode)or
d e fY that he is exempt therefrom and the bruise far the alleged cocand m. Any violation al
Section 7031.5 by any applicant Ian. wourn oubjecu Ibe applicant to a civil penalty of
PS.14
AMPS1
CfRICAI,
SPECIAL CIRCUIVMISC.
TEMP MEI'I!R ON POLI!1NS'r.
`
POWER DEVICES
SWIMMING POOL ELECTRIC
N not more than five hundred dollar (5510).
E=G ❑ Lmownerol he property, or try emplayces with weges vs theiu:ole umapen.sation,
F will do the workand tbesaanum is nm inendeJo mEb,d for smle(Sec. 76i4, Business
not Prnfesaimas Curb, The Contramor'v license Low Jails ran apply to an ownar of
6 3 propcny who builds or improves thereon. and who doe, such work himsdr nr through
lois own empinyces, provided Than such impmvemcnts are not intended or offered fm
sale. If, however, the building or impmvcmcm is sold within one year nlcoinf lation, the
cr-builder will have the burden of proving that he did not build or improve for pur-
OUTLISfS-SWITCHES-FI%TUR1S
NEW RESIDFNHAL M ECTR SQ PT
❑OTHER
TOI'
posepf xale.).
owmar of the prniu.ny, am exclusively contracting with licensed contracmrs to
construct the project (Sec.LW4, Business and Professions CwIC:)The I-marner %Li-
a,c Law doe.nor'npply nh an owner of property who builds or Improves thereon. it
who contracts far such projects with a commctm(s) licensed pursuant o the Conunaor's
Liam, Law.
Ilam ex tam cr Sec. . I3 Ai P C tunhb rmavn
QTY. PLUMBING PERN7IT
/ ANCE
ALTERIN & VENT- WATER (IIA)
EBACK�OW
O nil Date
C'HON'IAX
WORKS 'S COMPENSATION DECLARATION
I hereby infirm under pen0',nfp jury one ofthe following dadmarom,l have and will maintain a Certificate of Consentto self-inum for Workers Compen-
PROTECT. DEVICE
OOR. ROOF, AREA, C.
101 ...S-PER'TRAI' a
,arm. m pnrvided for by Section 3000 of nae LaMn Coal. tar the performance of the
ark for whichthin permit is iswN.
1 have and will maintain WnrkcGt Congxnsalion Insumnva, as reyuimJ by Sermon
30(1(1 of the Loon, Code, for the u fommnce of the work for which this permit is issued.
GAS -EA. SYlH EM -I INC. 40U'H,F"IS
GAS - EA. SYSTEM -OVER 4(1!A)
MyWorker's Compensation huunnce cards, and Policy numberarc:
Carrier: Policy No.:
CERTIFICATEOF ExEsiYriON FROM WORKERS
INSURANCE
COSIP'
GRI!ASFJINDUSI'Rh WAS 'lIi INTERCEPTOR
GREASE'RAP
('Diicsudnnnecd nm be oratorical the Illi, is fnronc hundred dollars(51IF)
Z
to leosl
Icreatoroyay Person in any rural the work tor which this file aiders' on,,anl
niton L.aw any person in any manner so as to Demme subject to the darken.' Campem
Lamina laws nl California. Owe
t
SF.WIiR-SANITARY-STORM 810. 21X1 FT.
WATER HEATER WNCNT/F.LECTR
zo
N
a ;
O ❑
� Z
L) 0
H. F
O U
}U
1
nF. Z)
V Z
Applicant
NUI ]CI: TO APPLICANT: It, after nuking this Certificate of Exemption, you should
become subject In the Workers Compensation provisions of the labor Cade. you must
Ibnhwida cmnply with rich pnwisinnn or this permit shall he dccmed mouled.
CONSTBl1C1'[ON LENDING AGENCY
l heebyalRrmahm there is a coordination lending agency lar Inc performance of
the work lar which this permia is issued (Si 3097. Civ. CJ
Lender's Name
WATER SYSTEMI'TREi TING
WATER SERVICE
NEW RESIUENTIAIJ'LMB. SQ. Ff.
'I( Al:
Lender's Addicts
1 cranny that I have read this application add state that the above infinflation is
larreut. I agree i. comply wish 01 city and county ordirouces and same laws relating to
building couswcaion. and hereby anihmic representatives or this city u, enter upon the
abown-vntioned pr.,oy for inspection pare nen.
(We) agrcc al, ... r. Indemnify vnd keep harmless the City of Cupertino agvi not
liabilities, iidgmerns,coxts and expenses which may in any way res. .,.in,, said City
Q"ly. MECHANICAL PERMIT
r
1 PERMIT ISSUANCE 3 l
ALTER OR ADD TO MECH.
in couscquence.1he granting of his permit.
APPI.ICAN"r UNI !RSTANUS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT TO 10,00 CI'
AIR HANDLING UNiI'(OVER IL(XXI CFM)
S( IRC I GUI. 10�_ �,��
G�� X
EKIIAUST HOOD(WMUCT)
Signature of Appli vntEmmorcer Dote
HAZARDOUS MAII!RIALS DISCLOSURE
Will tele applicum or far.. building iatienlemre is, bindle hmzadout material
as deirr d by the Cupertino Municipal Coda, Chapter 9.12, ad the 1E.Ilh and Safe',pqIT
Gde, Section 2553200?
Dyes �
TBOVYING UNIT (T011X1.(00 It' I' U)
(OVP W,(XXI BTU)
FAN(SINGLE REMDIWill
the applicant nr taw'c budding "".'son use equipment Or devices whichMP
air contaminants as defined by the Bay Area Air Quality Mmugement
PUT OR 100.000 BTU)1huardws
MP(OVER IW.(XO ETD)❑YesIONER1
lsjid9
have read pail ImOuRa s p asmals rtyuirnncm under Chapter 6.95ofthe Cali -
MECH. SQ. Er.building
none Health S, Safety Cs Sell as 255(15, 255]3 and 25534. 1 understand that if NeNIIAL
aka(snoaurrem hweatpnmit ismspmsibility n,notifytenecupanl
•d A,. nandof 1,x133 cad ino issuance ora CertificatePP_
OFFICE
r
FEE
BUILDING PERMIT INFO
LUG ELECT PLUMB
JOB DESCRIPTION
RESIDENTIAL
DSFDWL
,,.�,,//
a4d'Imila REMODEL
❑ADDITION
C1 PLUMBING RF: -PIPE
❑MU171-UNIT
❑STRUCTURAL
FEEEE1
MODIIICM'ION
D INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
[]SWIMMING POOLS
D BATH REMODEIAEPAIR
[]DEMOLITION
❑OTHER
PEE
TC
C
D DEMOLITION
❑ FOOD SERVICE
aOTHER
YJ
5/SQ.
FEE
1,
Gat UP 3
n
BUILDING UI VISION FEES
PLANCHECK FEE
1!NERGY FEE 2
GRADING FTE
SOILS ITE
PAID
Oute Rcccipt p
10`110: _
ISSUANCE, DATE'
-/2-QTS'
5j
R eipt aTOTAL:'
FEEEE1
tme
PEEG
PEE
TC
I LITE
C'HON'IAX
_
HOUSING Mll'IGATION FEII
PAID
Oute Rcccipt p
10`110: _
ISSUANCE, DATE'
-/2-QTS'
5j