S 1317 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.CTRICAI. PE18IT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. V 1317
BUILDING PROJECT IIIFNT'1FICSTION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
1 C) 57C L,nf.f 2
OW :R'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
e, NIC COM'ROLp
,q„1� a 2S 3 2 9 7 1
ARCHITECUENGINEER: LIC NO: ADDRESS: n'/]� ❑
21,15
1 �S 1s1.
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
91 ❑ ❑ ❑
LICENSED CONTNACfOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provision of Chapter 9(commencing JOB DESCRIPTION
OWZ with Section 7")ofDivision 3 office Business and Profession+Cade,and mylicense is RESIDENTIAL
LV O O PERMIT ISSUANCE
F d in foil force and I �e ❑SFDWI. ❑KITCHEN RF.MOI3EL
a U LicenseC ^ Lic.p V 1 APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
E G W Date Contracturawio
ARCHITECTS DECLARATION ❑MULTFUNIT KSTRUCTURAL
PANELS MODIFICATION
0 Z p y.Z 1 understand my plans shall be used as puhlic records
O � UPT02(I(IAMI'S ❑INTERIOR [I CHIMNEY REPAIR
r91ly Licence Professional 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
A
License Law f
Thal I ahe'a OWNER-BUILDER DECLARATION OVIiR IBIN)AMPS ❑HATH Rf:MOJyi[JtE�jR 0DEMOLITION
following re
T+ ifrn am exempt from he Contractors or t (�. [s+
x�x O 1 hereby w
L V reason.(Seaton]03L5,Business and L'ndessinns Core:Any city or county ❑OTHER SIGNS ELECTRICAL _�y
W 3 W aI which retinas,a permit to crosmo,1,alter,improve,demolish,or repair any structure _
1q'��g prior to it,issuanee,alsom,mmstheapplicam 5nsuch permit n file aligned statement SPECIAL CIRCUIT'/MISC.
2 N fenhe is licensedpursuantaidu provisionseflhe Commdors License law lClm m,9
^OQ (commencing with Section 700(hof Division3ofthe Businessand Rofessione CnJc)nr TEMP.METER OR PULE INST. OOMMEERC— �
d n eG 'bat he is exempt therefrom and the basis for the alleged emaimism Any Ananias of E] G/A9DIT1CId� F:fdO1 MNEW HLDDON
+ may Section 71131.5 hyany,applicant for a permitomjemn meapplicant to.civil penaltyof POWER DEVICES []TENANT ❑FOOD SERVICE
FZ_
not mom than five hundred dollars.(S50o). IMPRO` WATI Q ❑las menc,ifthe pmpcny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will0,the work,and the suucmre isnot Intended.....itched to sale(Say.]044,Bmimss ❑OTHER
and Professions Core:The Contractors License Law does not apply m an owner of DID LETS-SWU'CHES-FIXTURES
property who builds or impmvn themon,and who does such work himself or through f
his own employees,provided that such impreventenls am not intended ar offered for NEW RESIDENTIAL ELECTR SO FT.
FEB 26 AMR
sale.If,however,the building or improvement is sold within one year nl'cnmpI Iiun,the CITY
IT FLODRARF.A 5/SQ.FT.
ownenbuildef will have the burden of proving that he did not build or improve ka Par- C�1 1 UI' (iUf Ctt l IIYU
pose of sola).
D 1,as owner ol'the prnlwny,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec 7044.Business and Prolissions Core:)'IBc Cmnmetnr's Li-
emeel.awdoes ma apply ,,anowncrofpmprny who builds or irmhowsthcays,and QTY, PLU LNG PERMIT FEE
who contracts for such projects with a conuacfdp)licensed pursuant to the Comm hors,
License law. PERMIT ISS
I am exempt under Sec. .B&PC for this moon
Owner Date AEFER- AIN&VI• - ATER IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACKFLOW FROTECE A lt6eC;
• 1 hereby affirm under penalty of perjury one of the following destinations: V—
❑I have and will maintain a Cenifrcate of Consent to self-insure for Workers Camper- DRAINS-P ,R ,AR"INOD.. STOMPS; TYPECONSTRUCDON
wean,as provided for by Section 970()of the LnMr Care,for the lxrrfnnneacc of the
work far which this .it is issued. FIXTURES-PER ' '
D I have and will maintain Wark es Compensation Imumnce,as required by Section
37(oofthe Labor Cade,for the performance ofthe work for which Nispermit is issued. GAS-EA.SVSTEMI INC tT5 OCC GROUP APN
My Workers Compensation Insurance canter and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(E,O
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFJINUUSTRL WASTE INTERC R
G, COMPENSATION INSURANCE BUILDING DIVISION .FS
('Itis seaionnced mol becomplmedif Ne permit in forme hundreddollun($IIX) GR17ASETRAP
m lesv.) PLANCHECK FEE
I certify that in the Performance ofthe work for which this permit is issued.lshall SEWER-SANITARY-STORM EA.200 L,
.
not nnploy any person in any manner un as to e� rte su y'em m the Workers'Cni tpen- ENERGY FEB
70 O scam.La s offI iii _ � WATER HEATER W/VENT(ELECfR GRADING FEE
q (A% NOfICG TOM Iff r making this Certifcmc of Lxnnption,you should WATER SYSTEMOVEAI'ING
become subject the Workers Compensation provisions of the Labor Cade,you must SOILS FEE
Lak1 forthwith comply with such provisions or Phis Permit shall he created revoked. WATER SERVICE
Q
CONSTRUCI ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V 0 1 hembyaffrmthat there iso concoction lcndingugency for the perfommnce of Dae Receipt#
W F the work for which this permit is issued(Sec.3197,Civ.C.)
0Leader's Name TOTAL.
Lender's Address 'TOTAL:
'�•' I minify that I have read this application and state that the above information is BUILDING FEE
a
.F. h coming lagree to ommoliomply with all alaand coumyordinancesand stem laws rdmingtu QTY. MECHANICAL PERMIT FEE
L1 ,•7J. building a,roImminn,nnJ herehy amhnriu rcpre+emativa.nfthis city l..enmrupen the SEISMIC FEE
above-mentioned progeny for inspection pagnms. PERMIT ISSUANCE ELECTRIC F
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilitiesjudgments,costs and expenses which may in any wayacerue agma"anid City ACT ER OR ADD TO MECH. PLUMBING E
in conegoentt of the gr:mfi ng of(his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,NX)CFM) MECHANICAL .F.
SOURCE EGULATIONS.
,moi �7..�� � � y��y AIR HANDLING UNIT(OVER IO,KKICI'M) CONSTRUCTION\X
Sr n reof Applicauc Coorntmenor //(Daae EXHAUST HOOD(W/DUCT) HOUSING MITIGATI FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle huwrdnusmatefial HVATING UNIT G 0100,000 BTU)
as defined by the Cupertino Municipal Core.Chapter 9.12,and the Health and Safety
Cale.Section255J2(a)? HEATING UNIT(OVER 100,0(X1 BTU)
DYes sal Na PAID
T'� VENTILATION FAN SINGLERBSIO) Dam Ncee t
Will etc applicant m fmure building occupant use equipment m devices which =MECH. SQ.
r
mit hazardous air contaminants as defined by the Bay Area Air Quality Management {POR IIXI,IXp BTU) T 1.
District? ER IBB.IXs)BTT)
❑Yes No
I have mad the hvadous materials requirements under Chapter 695 of the Cali- ISSUANCE DATE
fomia He hh&Safely Co,e,Sections 25505,25533 and 25534.1 understand Ihat if the NEW MECH. SQ.FEbuilJingd nd currently hevealenom,that it ismy responsibility modify theec upantq s on which must be met prions issaan¢ofa Certificate ofQ<D�w � 7 P��—z0w amanumnzdl agent Dote 'TOTAL: ISSUEDBY:
OFFICE
(,�za�t ?1�xate� eoor�ucetiaa, �orc.
23099 Summit Rd
Los Gatos, CA 95033
office and fax 408 353-3686
License#B-507541
Planed eave and gable extensions for the residense of-
Diane Moore
10356 Cherry Tree Ln.
Cupertino, Ca. 95014
c p 000,ppROV�O
D4 qNH� 114-0171,
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