S 2657 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL INT PEN ONLY
CITY OF CUPERTINO HNLDING ELECI'RICAI, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL /rat/a
IIUILDING PROJECT IDRN1'IF'1CATION L FVa
OUILUING AUURESS: SANITARY NO. APPLICATION SURNIFFLAL D !?
57
►� AT.2g _q
OWNIiR'S NAME:
LIMPHONE; CONakACTOk:S NAMIi: LI
N/C CONTROL#
ARCHITECTIENGIN TR: 1.1-1— ADDRESS: ❑
c
CONTACT: PHONE: aMONAL
BUILDING PERMIT INFO
kIll ❑ Consultant Fees Paid by APPlicant(Initial) BI.DG ELECT PLUMB MECH
0 / ❑ ❑
LICENSED CONTRACTOR'S DECLARATION ❑
I herebyQTY, ELECTRIC PERMIT'
imF70 D)Fd mm I con feca,ed nttder pmvish,nd OI C rude. 9 ta,mmem:mg PEI: JOB DESCRIPTION
FSBI-W. th Seorreande ofDivision3of the BminessanJProfs.+stoneGrle,nnJ mylicenveis
ntfull force sand en PERMIT ISSUANCE RESIDENTIAL
�UU License Class Lie.# ❑SFDWL
HZS Dme_ � Co free, APPLIANCES-RESIDENT JAL ❑KITCIIEN RF,MODF;I.
[]ADDITION ❑PLUMBING RE-PIPE
I_Ow ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
ZO2n7, Itmderwand my plans shall he used as public records MODIFICATION
ul'T02(N1AMI•S 11 INTERIOR ❑CHIMNEY REPAIR
F-.'.-F LL�I I.wen+cd Po(csstonW NI TO 0AMPS
M OWNER-BUILDER DECLARATION IMPROVEMENT
C'� ❑SWIMMING MNIPOOLS
y tL I hereby,(lion that I a.1 exempt form the ession%Co License Law cu the OVER I(Xm AMPS ❑BATII REMODEURIiPAIR ❑DEMOLITION
x 3 LL F rnnmvmg ream,.(Smdon 7111.1.Ruxit ess and improve,
de ions Code:Any dry or cnanry SIGNS ELECTRICAL ❑
F`O r5 which requires a permit reconstruct,alcor,improve,demolish,or repair any structure
fitmJa' Primal ill issuunac,ale requires ibc applicunl for such permit to fileaslgned stulement SPECIAL CIRCUIT/MISC
m mat he isliren Jprsuanutheprovt����sofheContmnorsl.iauclaw(Chaptere) �E�C *Ldl.OKIllill—
Ty)�q0 !commencing with Section]000)of Division ldithe Buourni,and ProfessionsCod0or TEMP.METER OR FELL!NST. COMMERCIAL:
tL Ind he is exempt therefrom and the ball.,tiro the alleged escngdion.Any vinhnion at
,_, Section 7031.5 by any applicant fora pemtit subjects the applicant loo civil penally of POWER DEVICES El NEW BLDG/ADDITION ❑DEMOLITION
y�
tax morethanFive hundred doll.,(Scion. TENANT ❑FOODSERVICE
SC I]1.axnwner tattle pmpeny,nrnty employees with wages a.s mcir sole compen,mian, SWIMMING POOL ELECI'ItIC IMPROVEMENT
y1. will Jo the work,and the sunclore isnot intended contorted for late(Sec.](M4,Business ❑OTHER
4 3 and Professions Code:The Commaorn License Ire does not apply m an at, if OUTLETS-SWITCHES-19XTURIS
property who builds or improve,mere.m,and who does such work himself nr through
his own employees,pmviJal Nat such improvements are nm imm�deit or offered far NEW RESIDF.NT'IAI.BLBCTR SQ
.vle.IL hawcvcq the builJing orimprovemem is cold within one year ofaompletion.the SQ.FT.FLOOR AREA USE.FT.
nerbuilder will have the harden of proving that he did not Build or improve for por-
lo of colt -
❑L as Owner of the Propel an,exclusively contracting with licensed contractors It TOTAL:
construct the project(Sea.7014,Holiness and Pmfes,ions Cale:)The Ca imam's Li-
cense Law does maapply tnunOwner ofjol who builds nr improves thereon,and QTY. PLUMBING PERMIT FEE
who conual for such pajents with IF crammoam)licensed pursuant n the Contractors
License Law.
❑ Icon ex,mpt Fodor Sea. ,13&PC Far this rcvsan PERMIT ISSUANCE
CUMPENSAI'ION
Owner WORK
AUMR-DRAIN&VENT_WATER(EA) s
• Date VALUATION
-
WORKERS DIiCLAI<ATION HACK FI.()W PN(YIFF`T DIiVICE
M1emhyill maintain
rrin i thefallowingderker's ns:
❑tal anJwillmaimySerfiFiCni3700tf Ca LaIna odd, omeare Wakers Comp the DRAINS-FLOOR,ROOF AREA.COND.
walk F us pro h this
for by Section 3JBN,(the Lnbnr Cnde,for the peranrmance n1 the STORIES T'YPB CONSTRUCTION
work lie which this permit is issue]. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Inxumntt,as require]by Section
] and Policy C OftheLahorypCu e.fill'he Nrlimmuncenolhe walk par which this Word is ileac]. GAS-EA,SYSTEM.I INC.4 OUTLETS
Mymr:Wlarkc� !FW � 'n
' S OCGROUP
APN
,✓ Policy No.: a O GAS-Fill.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPL'NSATIONcN .iliNCL> GREASFIINDUSTNI.WAS'I'F?INTF.RC[PTOk
!This section nee]nm be complete)if me permit is(crone hundreJ dollars(bltXl) BUILDING DIVISION FELLS
or les.) GREASE TRAP - --� --
1 Ceni fy that In the performmnce Of the work for which this Pocono Is issued,I shallPLANCI PECK FEE
not employ any person in any manner so as m hnembe s.bjw o the Workers Cooper- SR WER-SANITARY-STORM EA.LIO FT. ENERGY FEE
O ,z salon Laws of Cali form ,Datez Applicant WATER HEATER WNENT/I!LECTR
NOTICE TO APPLICANT If,after making Nis Cendinto of lixemptinn,you shoal] GRADING FEE
WATER SYSTEM?RHATING
a ; become subject to the WmAers Cricalmatinn provisions of he lWbor Coale.you mea SOILS FEE
tr fonhwihasmply with such provisimrs a,this permit shell be deemrrevoed.
d k
a Q WAFER S1iRVICE
7z CONSTRUCTION LANDING AGENCY NEW RESIDENTIAL PLMB. S IT. 10l--
U O Ihereby affirm that there is a conswdian lending Q' vatReceipt#
Fleer work far which his permit is issued(See 3097,Cie C.�enay rat he parPormunceaf
Q Lenders Name tl
U Lender's Address TOTAL:
y1 ready that I Fivefold this application and slate that the alms,informationis TOTAL
F41 : I BUILDING PEE
correct m
lagreec�mply wim all city and county ordinances unJ%cote laws tcatingm QTY. MECHANICAL PERMIT FEE [
L) z building construction,and hereby authorize representatives of this city menterupon the SEISM CIEEI Q
above-inenduned property far inspection purposes.
We)agree to sae,indemnify add keep harmless he City Of Cu ,into ainst PERMIT ISSUANCE'
Cullman. d ELECTRIC FEE
in mens, osis and expenses which may in any way uceme against snit City
gr:ual at this omit. ALTER OR ADD TO SUCH, NO FEE
E , )$All WILL O PLY WITH ALL NON-POINT AIR HANDLING UNIT PTO IB,000 CFM)
N. MECHANICAL
` AIR HANDLING UNIT(OVER IFcOaa CFM) CONSTRUCT!
OppcnHAZAR OU Dare EXHAUST HOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE HOUSING T N PHE
Will Be applicant Or future building occupant store or handle hazardous material ITRATING UNIT PTO 1001000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Codo,Section 25532(v)p 1fEATINO UNI'((OVER 100,100 BTU)
O Vic, U�
VENTILATION FAN(SINGLE RFSID) PAID
Will the applicant cur future Building occupant use a Air
Foul which D e Receipt p
emitric'? nus air contaminants as defined by the Nay Area Air Quality Management BOILHR-COMP(AI{POR IINI,INN)N"f0)
District! T L:
❑Yes lux, BOILER-COMP(OVER I(X),(KKI B'fVl
1 have real the Bvardows materials"moments under Chapter fi 95 Of me Cali- AIR CONDI'T'IONER
fumia Health&Safety Cale,Scctinns 23505.255]3 and 25514.I understand that if the ISSUANCE DATE
mildingdnesimllian tmml atentWl�hvt It is my rusponobibly In drolly the Occupant NEWRESIDENTIAL MECII, SQ.FL J� t �J.6
of the requirements vimu. be tp roto issuance of a Cinilicam of Flournoy, —( /
OwthnnecJ age Date TQfAL: ISSUED BY:
OFFICE -