S 2882 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPI:RTINO BUILDING-ELECI'RICA]. PERMI F No.
ROILDING DIVISION APPLICATION4aERD7aT r1.UnunNG.MECHANICAL
tlUILDING PROJECIf IDENTIF'ICATIO, 882
BUILDING ADDRESS: �� I ,-r SANITARY NO. APPLICATION SUBMITTAL DATE
/0 `Z#0 !3�/i3�3 IZ,,Ai> /JAr�I// �' /�..-�h
�\WNEIl5L R: N'� AZ PHONE: C[)IRACTDR'g NAME: OI C� '.JS NO
1IVVll N NIC COM'HOL#
Sl v GIN'ER/,' LUL Gi792o 3i5H0e,LEJJ w g,:4 � � Z
CONTACT. PHONE: BUILDING PERMIT INFO
toI ^-LVAolxi �/�( � _/2�I ❑ Cons'ultant Fees Paid by Applicant(Initial) BLDG ELEEcr PLumn htecH
LICENSED CLINT RACTOR:S DECLARATION QT'Y. FLFCFRIC PERMIT FEE
I hereby aMo.that 1 am licensed ander provisions of chapter 4(Commendag JOB DESCRIPTION
O=Z with Section 9g0Bol'Division Joffe Businexa and l'rorC,,mr,Crxlc,and mylicensels RESIDENTIAL,
111 O PERMIT ISSUANCE
a,� in full Interlard effect. [I SPENT, O KITCHEN REMODEL.
aUZU Licence Cl ss Lla.# APPLIANCES-RISIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE.
vFiQ1 D:ne T'S D17 L ❑MULTI-UNIT []STRUCTURAL
FOy AR'HITI[CI'S DIiCLARATION PANELS MODIFICATION
z O y ZI understunJ ntY Plans shall M uxeJ s.v public records
Oz=q UP1020IAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F 4FW Licenud Professisnal 211-10C(1AMPS IMPROVEMENT [J SWIMMING POOIS
OWNER-BUILDER DECLARATION
6 I hereby offirin that 1 am exempt from the Cantracmr'e License Law for the OVER IqO AMPS ❑BAT"REM00131JRIiPAIR DEMOLITION
�°(• a U following reason(Scctinn 7()31.5,Busincss and Professions Cade:Any city orco.ty SIGNS ELECTRICAL ❑OTHER111 k3.LLp N
which req Permit t t t alar P demolish,mP y structure
pro tt)its Issuance,sl.o req the ppl' wf r suchp a rile a signedsttament SPECIAL CIRCUITIMISC.
p.
I
hat lie is licensedPu.0 rn to the provisions fthe Cormuctor's License In (Chuptcr9 OOMMFRCI AI
laommenengw'th SecinoWNE(fllvs'rot 3 oflhe Buxnsoi,i Prf..'rs Code)nr TEMP.M1,7ER OR POLE INST.
0.y o that he is exempt therdmm and the basis for the alleged exemption.Any violation of 1 [I NEW BLDG/ADDITION [I DEMOLITION
Wim Seceon1131.5 by any applicant for o permit.subjects me applicant o a civil penalty of POWERDEVICES 45(HA�$rFA(JTENANT [I FOOD SERVICE
F- not more than five hundred dollars($50 ). MPROVEMENI'
XOO Lasownerofthepmfcny,nr my employeeswithwa6esusmcirsolecmnpem;nlnn SWIMMINGP'OOLELECIRIC
will do the work,and the ameatme is not intended oroffered fnraale(See.7044,Business ❑OTHIiR
W m end Rochester,Code:The Cmdracsex License law does net apply In an owner of25 OU'FILL'TS-SWITCHUS-FIST ORES -
�'a` property who builds or Improves thereon,and who does such work himself our through
his own employees,provided that such improvements are not intended or offered for NEW Rli. )EN PIAL ELECTR SQ FT.
.sale.If,however,the Wildingsr improvement staid withinane y.rufcampletiTm.'hit SQ.14.FLOOR AREA $tSQ.F3',
caner-builder will homflue hurdeoof proving that he did not build or improve for pur,
False of sale.). ✓� �r�
0 I,as owder of the property,am exclusively contracting with licensed cone0cee to )
onsauct the project(Sec.701.Busincss and Professions0 The Coo—ur's I.i-
ucl.uw does nm apply mon owner efpmpery who builds or imprwex thermmand QTY, GPERMIT FEF
who corommus scratch pmjM%with a contmchand licensed putxuamuo lie Coutrnch rs
License Law, PERMIT ISSUANCE
0 larnmeradmaler SCC. ,B&PCmnhisreason
AMER-DRAIN K VIiNT-WATER(EA) VALUATION
. Owner Dam
WORKER'S COMPENSATION DECLARATION BACK PLOW PH �j rl1 �Q
I hereby affirm under penalty of perjury ane of the hallowing declarations: `•'
IKI have and will maintain a Certificate of Consent to self-insum for Wodce%Compen- UNAINS-Ir .HOOF 1NR STORIES TYPECONSTRUCTION
anion,us provided for by Scctinn 3700 01 the Labor Code,for the porfannance sI the
work for which this Permit is issued FI%TURFS- AP t 3
37 I have and will ode.fon Workde Compemution Insurance,h required by Scctinn T'�
371X1 nflhe Labor Code.for the work for whichthis Permit isissued. GAS-PA.SY 1-II ry E OCCGHOUP \�APN
My Worker's Campania lnsu and Policy num •r ��
Comer:�bg� J1��' Policy Nn.; -7(o(nhI' GPS-EA.SY. 'M-OVER4 RIA
CERTIIIL'AT tIE FEXEMPTIONFROMWORKEHS��
COMPENSATION INSURANCfi GREAS[IINDU" .WASTE INTI?RCEI'T HIIn LANG DIVISION 'S
IThiasenionneednotbecumplelW iDhe pcmitis fsrnrtchumlredtlollurs($1(01) CREASETRAP
m less,) � ^ PLANCHECK FEE ,O
I cerify that in the imfonn0necofhe work for which this Permit is issued l shall SBWER-SANITARY-STORM EA.2f0 FT, v
not employ any person in any manner so ase become subject the Workers Cnnnpen- D ENERGY PIiE
Z action Laws of California Date WATER HEATER WHEN TLF.CTR
Z APpliam GRA Ili
ti NOTICE TO APPLICANT':If, Herniating this Cenifmac of Exemption,you should WATER SYSTENUTRF,ATING
a ' become subject mo the Waders Compensation pmvi,mr,of me Labor Code.you must SOILS FE
W fonhwith smnply with such peoloonc or this#canal shall be deemed revoked. WATER SERVICE
CONSTHUCI']ON LE tike AGENCY NEW RESIDENTIAL PLMH. SQ.FT. PAI Date Receipt#
U Q Ihcrchy nlBrnl the there ix acnn4metinn lending agency far perfnnnmee of
Lw F the work for which this permit is issued(Sec.31147,Civ.CJ
Lender's Name I(YIAh.
�W lembe,Address r
Iy I Certify that 1 have read(his nppliadon and vete that the above information is BUIL. NO FEE
iF.I h erect l agree to comply with all city and county eminences and see laws relining to QTY. MECHANICAL PERMIT FEE SETS IC FEE (�O
U Z building Conswetion.and hereby au arms representatives ofthis city a enter aper me
shove-mentioned P,,,,My for inxpectina Ourlwxes. PERMIT ISSUANCE ELE RIC FEE 0
(WO agree rat save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments.casts and expenses which may in any way accrue against said City AT I;R OR ADD TO MP.CH. EMS I GFEF.
in
nmsequunee o[t e6mn' oaf this permit. '
APPIAGINTU ' R A US AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14(0(1 CFM) MECIIA IC LIFE a
SOURCEEG .AT N.H
AIR HANDLING UNIT(OVER 14100 CFM) CONSTRUCI'1 NTAX
Signa 4ApplicamorCo te
st Or EXHAUST HOOD IWIDUCII HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant share or handle hamrdous material IIHNI'ING ON I ('10 17,010 PTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety
Cade,Section 25532(0)? r BEAT INC,UNIT(OVER 100,000 BTU)
0 Ya sem' " VEM'l1ATION FAN(SINGLE RISID) b PAID pate Receipt p
Will the applicant or future building occupant use equipment()I ,1(0
r devices which BOILER-COMP UHP OR 110BTU)
emit htio adorn tr
air connninuntx os drinmil by this Bay Am!,Ail Quality Management Oil
Dinrict? 1�' BOILER-COMP(OVER 100,M)BTU)
E3 yes
I have read the facammus materielsequiremmnts under Chapter 6,95(if me Cali- AIR CONDITION ER ISSUANCE DATE
Istria HCu11h&Suit,C Me inns 25505,25533 and 25534.1 andertwW mm if the NEW RESIDENTIAL MECH. SQ.IT. It-V74
buildingdoesm currend atenani,matifismyrespmsibilitytonutifythcoecapant
of the require nos w a be inn prior of issuance of u Cerilicae of Occupanc,.
can or em owed agent AL ISSUF.DBY:
OFFICE