S0001 B0330 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT 1'LU.\IIIINCAIF.C11,1NICAi. SOOOI 90330
IIUII,DING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANHARY NO, API-I.ICAI'IONSUliM]I'IALDAI'I!
OWNER'S AME. PHONE: CONTRALTO '.'NAMIi LICNO:
-7 LG / Z we CON rleol.x
ANCHII iC'1'IY. GINIHiR: / LIC NO. AUDRI;'S � (i(/ ❑
1Y
CONTACT: PHONE DU ILDING PERMIT INFO
��f4 �yNM e ❑ Consultant Fccs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONI'RACI'OR:S DECLARATION QTY ELECTRIC PERMIT [ZEE
1 hereby affirm that 1 am Incensed under provisions of chapter 9 Rommy,tcavi JOB DESCRIPTION
Cf�Z with Seninn](XXD of Uivisinn7,fthc Business mA P tfesxiom.0 dmylicerecis RESIDENTIAL'
W p PERMIT ISSUANCE
�Iy� in lull force and elFcd. ,� ❑ShDWI. [I KITCHEN REh10DE1.
QUV l.iwrw Class Lich AI'i'LIANCCS-HESIDLM'IAI. ❑ADDITION ❑PLUMBING RE-PIPE
yGd 11011 CO°1°10°' - ❑MULTI,UNfT [I STRUM URAL
HI'I ECI"S DECLAI A9 N PANELS
Io-z f under. and s plans%hall M used a.%public records h10UlI T:Y RE N
ZO w... GP TO2(XIAMPS F1 INTERIOR ❑CHIMNIiY REPAIR
OZ-p
F-��t+2 Licensed Pndessionul 201-1000AMPS IMPROVEMENT E]SWIMMINGPOOLS
OWNIiR BUILDi-R DF.ChARATION OVER I000AMPS ❑BATH RF.MODEVREPAIR C1 DEMOLITION
y�16 1 hereby affirm that I am exempt from the Contractor'.%License Law for the
1m Iti U fidlrwing mess.....(Section 7031.5,Resines,and Pmce,notax Code Any city nr county SIGNS ELECTRICAL ❑OTHIiR
I+l a a which requir,s a permit at construct.alter,improve,dmmnlixh,or repair any urvnurc
,1"„x'0il
¢ prim) I ..also re,unne,the pplicntf h varrafto fl 8edsmumont SPECIAL CIRCUI'FMISC.
marl d,msa I Bhe p '. nn:aftlo,Contractor's LLaw(Chapter9 COMMERCIAL
WC 0 Isom g th Seco ]qp) fD' 'sir 3 fth I ess JV fissions Code) '1I:SIP.METER OR ' ST.
c.4 e�d thin he is exempt themumn and the basis Rbr the alleged excm,dram Any violation-
❑NEW BLDG/ADUIq ION ❑DEMOLITION
Xm1+ lection 7031.5 by any applicant for a permit subjects the aPPhcanrin a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
m urn more than Eve hundmJ dollars(SSWI. IMPROVEMENT
2Z0 ❑1.anvare,nf he pmpfty.a,n1,mnployce,with wagas as their.cnle compenutloo• SWIMMING I'OOLELE RIC
d l.. will do the work.and the structure is not intimated oroRered for ure(See 7044.Business ❑OTHIiR
Wce and Pndcssiana Gale:The Contractor',Uwase Inw does nor apply to an owner of OUTLETS-SWITCHES- RES
�• property who builds ar improves thereon,end who does tech work him.adf or through
qI
his own employees,provided that such impmvcments art not intended or offered for NEW RESIDFMIAL LLF.CTR SQ IrF.
sate.11,however.the building orimprovenmot is said witbinowe yenrol no,irtion,FIT SQ.FT.ItOOH AREA S/SQ.II'.
4uilder will have the burden of proving mut he did not build m improve for pur-
pocol' salc.). TOTAL. /
(,,%owner of the property.am exclusively contracting with licemed contractors In `
construct the project(Sec.7044.Business and Professions CoxR)The Commcmrs Li-
,caw law
i-
c wlaw Joe,nolapPly m an nsvncr of property who buldcmimprove, bererm,and Q'TY. PLUMBING PERMIT W. /'+\ /
who contracts f,rsuch projects with acommemds)licensed pur,uamuo the Coal—'-'s Pit
Liccrsc Law. PERMIT ISSUANCE ` MAY 1
1 am exempt under Sec. .B&PC for mi.,meson !f
ALTER-DRAIN&VENT-N'ATIiR(EA7 VALUATION
Owner Dam ( Uv
WORKERS
odh I of Nrimy on DECLARATION BACK FLOW PROTECT.DEVICE l�
wand yul maiunder penalty of p jury rd to llm if-moureior declaraWorker s ae "
n Ibeveam,fded oily, dor37amm Consehm Cnad jercforW orae Carrier- DRAINS-II.00R,ROOF.AREA,COND. STGR11i$ ^' q' Ii CONS"1'ItU.PION
smirk,ac provided for m Section 37W rf the Lubar Code,for rhe performance of the
work lot which tela permit is issued. PI%TURES-PER TRAP
El 1 have and will ods.loo Worker's nnowa fm rkfor ce.In as his Per by Section
37(Nl of the Lubar Colo tiro the perinrm,rncc of rhe work for Inch this permit is is,ual, GAS EA.SYSTEM-1 INC.4OUT'LEfS OCC.GROUP APN
My Worker,�}Co��mp��ensati�n lnsumncec ' and Policy number are GAS''-EA.SYSTEMOVERJ(EAI
�� f�CCVV11 JC TE Pe (L'MI'TION FROM WORKERS
'
COMPENSATION INSURANCE GREASF/INDUSTRI.WAST(?I4TIiRCEIT(1N 1{UILIIING UIVISIIIN Plili4
O-b,N.umncednul Mcompinml if'he p,obll i,for one hundred dollar,g 100) GREASE TRAP
i'LANCI IIiCK hili
rotas.)
Ioy nyrPer in me anymatnero the workas to
for whisubject To
..it is ker,Cl.lsh a- SF.WHR-SANITARY-STORM E.A.21X1Fp.
not employ any Person in any manner so a%m M1ecrmc chject to the Warkeri C,mtpcn- ENERGY FEE
'mion I % f California.Dam WATER HEATER N'/VENDELECfR GRADING FITH
Z Z
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYS'I EM REATING SOILS THE
a � heroine snbjut to me Wnrlab,Cnmpen.minor provisiaa,of the Lebon Code,you muco
Qforthwith comply withsueh ximim.bor this perm,shall M JeemeArevokcl. WA'll?R SERVICE
� Z CONSTRUCTION LENDING AGENCY NEW RESIDI'NT1A1,PLMB, SQ.FT. YAIU
I hereby affirm that rm rhahen is a conemcuon lending ageacy panic perfummam.1' Dwc Rccciptp
ilia work ibr which this punoti,ix lrmcd(Sec.3097.Co.C.1 T,
\I
Q U Lenders Name TOTAL:
r W Lcnder's Addm11 BUILDING FEE
Oo 1 verify that I have read this application and state[hit(the above information is
.f. In corer.]agree to comply with all city and county ordinances and state laws mlaring to QTY, MECHANICAL PERMIT FEE SEISMIC PEE; Ll
LI Z building caaammion.and hereby adlimicc mpmwn dive%ofmi,city no ewer upon the
short-merommal property for inspection purpose, pERMI p ISSUANCE ELECTRIC IIiI?
Ow)agree to.cave.Indemnify and keep hamdecs he Cit,of Cupertino against
liabditieajudgram s,costs and expenses which may in any way accmc agaiot said City ALTER OR ADD TO MF.CIL PLUMBING FEE v
in consequence of the granting of this permit.
APPLICANTUNDERSTANDS AND WILL COMPLY WI AhI,NON-POINT AIR HANDLING UNIT(TO 10.00007M) MIiCHANICALFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.00a CFM) CONSTRUCTION TAX
Signal..of Applica,90stere Dam EXHAUST HOOD(W/UUCP) HOUSING MIT IGATION THE
HA 1 RDODS MATERIALS DISCLOSURE
Will Ne applicant or future building mcupent store or handle harurdou,Ractor I IEATI NO UNIT(TO 11X.00011 rU)
Its defined by he Caperton,Municipal Code Chapter 9.12,and the health and Safety HEATING UNIT(OVER 1110.1011 BTII)
Code.Section 25572(u)F
C)Ye, ales VENTILATION FANS[RULE RESID) (•AID
Date Racipt x
Will the applicant or future Wilding occupant use equipment or des im,which BOILER-COMP pHPOR I1p.WO tlTU)
emit hattra nus air umuknlnmms as defined by the Buy Arco Air Quality Management TOTAL:
Waorta^ BOILER-COMP(OVER IIIB.(XXI BTU)
Ldtxs�t
3
AIR CONilll'IONER ISSUANCE DATE
mad me hmardoux mmerialx pa,manne d,umla Chaper fi.95 of he Cali- /'�
Safety Cou.Seot.Ws 25505,25573 and 25574.1 unJersmM mut dim NEW RESIDENTIAL MI!CH. SQ.FI'. 9 _ 9 Y
building ot curtenit It aIcr nt.that it is my mspon,iilrymnolify the rccupam ( 2enw svldrJTtru+rf he met poi missutrrtsre aro carttfL'°reef(kcupvncyaritt�lal9cccru `,y�`r{/�`/--' Dam TOTAL: ISSUED BY.
OFFICE