S 0761 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
,CITY OF CUPERTINO - - BUILDING.FLFC'rRIC-AL PHRMfr NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL S 0761 7 L+
O
BUILDING PRO,IH( IDF.MrIFICATION l�
BUILD13ZORR59', C_JWE2�^/�Q • SANITARYNO. API-I.ICA'I'IONIURMI'I'rAI,UA'fE
0 6 S"U SAn�7,q Lu C,1,4-
OWNER'SNAME PEON& CONE RAC R'S NAME: LIC NO:
7A72teK x/66 6:17 A o.v N/G m,'/(�)N'rRl1.«
AR HITECT/EN( F.F.R: LIC NO: ADDRESS: ❑ �
" E_ ttp_
CONTACT PHONE. - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) Itu)c 13LI?CI' PLUMB MSCI
LICENSED CONTRACTOR'S DECLARATION
1 hereh ilirm that 1 am Iicen.eJ uneer f Cha lar 9 QTY. ELECTRIC PERMIT EOE
ya ndPmfnsn p feentmensea _
JOB UBSCRIPTION
QWoZ with Seetinn]IICfI)nf Division3 of theBminess and Professions CnJe,and my license ix RESIDENTIAL:
tyOp PERMIT ISSUANCE )WI ❑KI'I'CIIIiN RI3MODiiI.
F . in full force and effect.
�UV License Class Lica APPLIANCES-BESIDESUAL )D TION ❑PLUMBING RIAIPE
y Q 0. Date Contractor
ARCHITECTS DECLARATION ❑MU.TI-UNIT ❑STRUM ORA].
F M y PANELS
Z p m 2 I undimmed my plans shall bo used as public records MODIFICAIION
py48 UP1'0200AMPS El INTERIOR El CHIMNEY REPAIR
F4L"Jcenseena
Lid ProfeWl 201-1010AMPS IMPROVEMIiNT (]SWIMMING POOLS
9W9,,....II OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C 6 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
6�O E U followingSeetion VN1.5.Business and Professions Cale:An t t ❑OTHER
mason.( y city or county SIGNS 13LECI'k ICAI.
3 a pFj which requires n permit re cnncwch alter,improve,demolish,fi repair any structure
^�p�' prior to ivcuance,also requires the applicant for such permit License awn statement SPECIAL CIRCUIT/MISC.
•� y thatbe encingwith
iit Section
000)of Di,aim Sof the
Com sines License Laois Code)or
Q. p 0
(commencing is axe wit therefrom
and of basis
rth theeged Business exemption.
Any
vii CDde)or TEMP.METER OR POLE INST. COMMERCIAL:
L q o e' that he is exempt therefrom and the basis fur the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^y Section 70315 byanyii,licum far a permit subjects theapplicanl In.civil penalryof POWER DEVICES []TENANT ❑FOOD SERVICE
not more than five hundred dal lira 6500).
IMI'ROVEMIiM
�5Q 0 Lothe as work, ndtheshe edy,or myemployeesater aloro acdfoages stbeir ea.701ole mpema ex.s SWIMMING POOL ELECTRIC tat. `�
f..p willdo the work,andthe structure is Dots Liverse owdoes rot apply to an owner or. ❑0TH' �_
ISA^m anJ Professions Cod e:iThe mproves
then' License Lawdoesnotapply himself
owner of (Hl'ILEIS-SWITCHES-FIXTURES
63^ his o ny who builds or vided that
thereon,and who does such n serve himself or through
his own employees.e provided Nat such improvements are not intended or offered for NEW RESIUfiN'I'IAl.F;LECIR SQ FT.
sale.acolhower will have thebrimprovementisat he
within one yldorimrovetfor the ^fy� AREA $ISQ.PI',
er-builder will have the burden of proving that he did not build or improve for par- �]�y I"„U
pose of salon. T[ r{L(w1V�lU
❑Las owner of the properly, exclusively contracting with licensed contractors to ` V'
ansund the project(See.704,1..Business and Professions Codoi pro Convumor's Li- G`
cense Lawdoes not
uch apply taan owner efpmpees whored purrlmtdwes Carton,and QTY. PLUMBING PERMIT PEE
who contract for such projects with a commemr(s)licensed pursnvm to the Comruanr's
License Low. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this mown
Owner JCD1 1, z r C11
ALTER-GRAIN&VENT-WATER(EA) �•X VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE / 2 ["I`—�
I hereby affirm under penalty of perjury one of the following decimations: g/
❑ I have and will maintain a Cenificate ofCouseen In wItinsum for Workers Compen- DRAINS-FLOOR ROOF,AREA,COND. STORIES 'TYPE CONSTRUCI ION
sation,as provided for by Section 37M of the Labe Com,for the performance of the
work for which this permit is issued FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3000 of the Labor Code,for the performance of the work for which this permit is issued CAS-IA.SYSTEM-I INCAOUTLETS OCCGROUP N'N
My Worker's Compensation Insurance carver and Policy number are:
Cartier. Policy NA: GAS-EA.SYSTEM-OVER i(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
FUVINJ nlvl9lory Fres
(This simian Dead not be completed if permit is forme hundred Jnllum 151 W) GREASE TRAP
or less.) PIANCHHC
I codify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FL
not employ any Wrum in any manner so as to become subject to the Workers'Crmpen- ENERGY P:F.
z
action Laws of California.Date WATER HEATER W/VEM'/HLECI'B
III` OO Applicant i GRADI T.
Vl NOTICE TO APPLICANT:If,she,making this Certificate of Exemption,you should WA'T'ER SYSTEMPRE,ATING
a ; become subject to the Workers Compensation provisions of the tabor Cate,you must SCHAFF
� ..i forthwith comply with such provisions or this pormitshall he decimal revoked WATER SERVICE
0
OzCONhTRUCTLON LENDING AGENCY NEW kESIDF.NTIAI.PUSH. SQ,Up. PAID
C.)O Ihercby nation,thin asaconstmction lending agency for the performance 4)
D' e kcccipta ,
the work for which this permit is issued(Sec.3097.Civ.CJ
0 U Lenders Name TOTAL:
V Lenders Address A1.
I certify that I have mad this application and state that the a cave Information is - BUILDING fiE
rFiy correct.l agree to comply with all city and county ordimnces and state laws relatingto QTY. MECHANICAL PERMIT FEE
U z building construction.and hereby immunize representatives of this city to wee upon the SEISMIC F B D
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against IiI.E.CTRIC -3E
liabilities,judgments,cost and expenses which may in any way seems,against said Cary ALTER OR ADD'TO MECH.
an ecasquence of the granting of this perunL PLUMBING FE
APPLIC UN -RSTFDS AND WILL COMPLY WITH ALL NON-P INT AIR HANDLING UNIT(TO 10.01)CFM) Its 1
$ z2�f Q CONS I RUCTION
SOURC It N
AIR HANDLING UNIT(OVER I(I,INXI CPM) CONS"1'NUCTION I'A%
"'gratate of ApplicantlCondnnor Date EXHAUST 1400D(W/DUCT) HOUSING MITIGAGON PEC
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding overnight store or handle hazardous material HEATING UNIT(TO 100.00 BT U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)] HEATING UNIT(OVER 100,000 BTU)
El yes ❑No VENTILATION PANS INGLE RESID) PAID
Date Reeryia
Will the applicant or(sure building by the B use equipment or Management
which
it hazardous air conlaminems as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100.0011 BTU)
eB TOTAL:
Dion
❑Yes ❑No BOILER-COME(OVER IM."B'ITI
I have not the Incestuous maaidsrquirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE I NEE.
1 fania Health&Safety Cad,Seetions 25505,]5533 and 25531.1 understand that if the NEW RESIDENTIAL MECH. SQ.fT.
building does not comply have a tenant,that it is my responsibility to notifythe aecupam
AT Ne requirements which must M met prior to issuance of a Cenificate of Occupancy.
Owner or authnrizW agent Dam ISSUED BY:
OFFICE