S 2484 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL [N /N L aI
4
BUILDING PROJECT IDENTIFICATION J VX
RUII.DINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
z 185-6
z 3
OWNF,R'S NAyF:� PHONE: CONTR T(JNAME: 1,'C NO:
� ll//.."///A1��. A N/C CONTRDLk
1ARC1I1 ECT/HNGINhFIE LIC NO: ADDRESS: ❑
CONTACT:h �} PHONED 0�7 BUILDING PERMIT INFO
?Roox,T C\f D-} ^ ' [:] Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
q8�
!^ ❑ 0 ❑ LL}�
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OWDOZ wuh Svcsr700 .fDi,Wo.3ofthe Busineasvnd Prof esions Codgand my license i. TITMFT ISSIIq E RESIDENTIAL
F in full force ffrc�
�UZU Licenseuve� `� Lie l(- L ❑SFDWL ❑KITCHEN REMODEL
Nd4 Date Can ES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
x OiseARCHITECT'S F.CLA 'PION PANELS El MULTI-UNIT []STRUCTURAL
w z I uadersmnd my plana shall he aced ns publi tecnrds
Z"�Q IIP TO 200 AMPS MODIFICATION
F,41 w LscnsW ProtrsSumal []INTERIOR El CHIMNEY REPAIR
y O 'a OWNER-BUILDER DECLARATION 201-Ia)AMPS IMPROVEMENT E]SWIMMING POOLS
W U 1 hereby affirm that 1 am exempt from the Conuacmr'c License Law for the OVER 1000AMPS ❑BATH REMODEL/RF.PAIR ❑DEMOLITION
k d following doomn.(Section 70315,Business and Profeccions Code'Any city or county
W 3 W F SIGNS ELECTRICAL El OTHER
0 which requires a permit ar conffrud alter,improve,demolish,or repair any structure
rn 5 prior 10 its issuance,a Lo requires the applicants tm,drh permitm fleaslgnW stannum SPECIAL CIRCUIT/MISC.
y that be is licensed porsuain m the provisions of the Contractor's Licence Law(Chapter 9
Iy 00 (enmmencing with Sermon 110(h of Division aid 11a Busing and Professional Cackler TEMP.METER OR POLE INST.. COMMERCIAL
t1 W o C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�iy Section 90315 by any applicant fur apeman subjects the applicant to t civil penalty or POWER DEVICES
y�y, not more than five hundred delta, ❑TENANT ❑FOOD SERVICE
F 6 ❑1,as owner ofihe pm IMPROVEMENT
Ork, struchme or isomanoytecwithwagesasthciNvrn 044. dsamr,. SWIMMING POOL ELECTRIC
F will dothewon%ande:The Contractors
ont isoats License Law does of apply to an Business ❑O'CHHR
6'3 m and property
who
Code:The Cos'here c License Law rise not apply s an owner of OUTLETS-SWITCHES-FIXTURLS
his own
who build,or improves t a thereon,and who does such wink himself or through
his awn employeese provided that such mentis old within are not iyarO[ nr pletio ,roe NEW RHSIIlHNT1AL HL' Q PF.'`
m ner,e. lu saveven the ane th b or en )I Fomont is at heidon build or improve
the SQ.F I'.FLOOR AREA SISQ.FT
aw tor-builder will have the burden uF proving ptvt he did not build or improve fur pur-
pose of Sala.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to _ 'f L
eomnon the pajaal(Sec.AN4,Business and Professions Code)The Contractors
cense Law does not apply to an owner of property who builds or intpnrvwe there T BIN F. IT PEE
who rentmcts for such projects with a combecmr(s)licensed personal to she CnnO
License Law.
❑ lamexee,ardder .Sec ,B&PCfor this re r PE
Owner + A R- 1 &VENT-WATER(EAJ
Date - VALUATION
WORKERScee,family
a ilyof COMPENSATION DECLARATION ACK FLOW PROJECT.DEVICE.
Thereby off rte Hader Calibrate
to ofCon ear ofthe lf-ire owingdorker Co
❑ual as and will maintain etion37M of the lemto sole,for the Workmence of the DRAINS-FLOOR,ROOF, GOND. STORIES TYPE CONSTRUCTION
;vtlon,an provided fur by Section 3900 of the Labte Code,for the performance of the
weak fur which this permit is issued. FIXTURE - gRTRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700of the Labor Code,far they+{farmunca ofthe work for which this permit in issued. GAS-EA. EM-1 LETS UCG GROUP APN
My Work tny;ps a IYsu =carrier and Policy rah
Carrier: V V Policy Ne, 0700 GAS-EA . 'EM-OVER :A)
CERTIFICATE OF EXEMPTION FROM WO f'3 �
COMPENSATION INSURANCE / GREASE/ USTR, E TERC
Ild
(Tbic ccetion acal nm be eontpleted ifihc ponds is[nr one hundred Jollurs($I W) BUILDING DIVISION FP-ES
or tete,) GREASE' AP
Icenif that in the JT'k5 PLANCHECK FEE
y anycreaaero as to become
subject
the Wleissaed.I;M1n- SEWER- !® ARY-STORM EA,200 FF.
sodium
any perms In any mvnnee so ue to becomt subject ro the WorkecV Grmpcn- ENERGY FEE/
O ,� muco Laws of Califonmia.Data WATER HEATER W/VENT/ELECI'R
z Q Applicant \ GRADING FEE
NOTICy
became
object
APPLICANT. r,alley making this Ccn rte,of of F;xab o d you should WATER SYS'fEM?REATING
(•^ " become eebjed to the Workers Compensation prnvisiom of the Labor Code,you must SOILS FEE
4aLI ti forthwith comply with such provisions or this permit shall he deemeA revoked. WATER SERVICE
Q
CONS rRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
I hereby affirm that is v csm1houraonn lending agency lbs the performance of Date Receipt
F be work for which this permit is issued(Sic.3091.Civ.C.)
LenddS Name
Q U MAL:
LkI
Leaders Address TOFAL 1.0
�y Iy 1 certify that 1 have reed this application and Stam that the above information is BUILDING FP.P.
VJ correct.l agree to comply with all city and climate ordinances and state lowsrelming to QTY, MECHANICAL PERMIT FEE
U building construction,and hereby authorize reprosamnriveS of this city reenter upon the BUIL SEISMIC
abuve-muchumned property for inspection purpesen r PERMIT ISSUANCE .(''
(Won)agree m save,Indemnify and keep hnrndess the City of Cupertino ngainn / O ELECTRIC PP.E
liabilitlea,judgments,costa and expeneex which, any Goyacemea,ir mid City ALTER OR ADD TO MECH.
asequence of the graining of this permit PLUMBING PEE
APPLICA T UNDERSTANDS AND WILL COM EY WITH INT AIR HANDLING UNIT(TO 1(I,IXtI CPM)
SOURC. F.G HLATI0Y5. _ MECHANICAL E f
AIR HANDLING UNIT(OVER IBM CFM) CONSTRUCTION %
7Will
liETOCon - Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARD US MATERIALS DISCLOSURE
applicant or future building occupant store or handle havardeus material HEATING UNIT(1'0 Habits)BTU)
e Cupertino Municipal Cone.Chapter 9.12,and the Health and Safety
532(4)^ HEATING UNIT(OVER la.a)BTU)
VENTILATION PAN(SINGLE.RHSID) PAID ..
_ applieam or future building occupant use equipment or devices which Date Receipt W
�erriit htrzardois air co tteminams as defined by the Bay Area Air Quality Management BOILER-COMP QHP OR 100,000 BTU)
District, T
C]yes cryo BOILER-COST. (OVER Ia,Oa BTU)
KZ 7Z,
I have read the hazubous tome'' meats un er 95oftbe Cali- AIR CONDI'I'JONER ISSUANCE DATE
hams Health&Safety CWMouw ns .. and 25534.1 under; nd that if the NEWRESIDENTHALMECH.
building de rmtcurrcn0 have tenant mat it is my msihility ton nn' theaccupant T T
of We ;t nmoi u ace civ - e� •up
ter aahoolva agent IF Uate T AL: ISSUED BY.
OFFICE