S 2280 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PEtITNO. 2280 28O
BUILDING DIV ISION APPLICATION/PERMIT PLUMBING-MECIIANICAI, l`
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION�N�TI%rV DA'fF.
1&4 -
OWNFTS /'—/ .-g�r J'H/E:? ^� CONTRACTOR'S NAh�IEF/y L1C�Pw NIC CON'1'HOLN
see
�ARCIi �N 1A �/ O-�6�3 J ADI�)HE54ti:� C/0 A/
CONTACT: BUILDING PERMIT INTO
�/ PHONE:
,T6iFi1/ N� �• �ry �p�-260 ❑ Consultant Fees Paid by Applicant(Initial) BECr PLUMB ME
,/ CH
ifs Da,-LDG ❑
LICENSED CONTRACIOR'S DECLARATIONQTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm Thal 1 am licensed under pmvisinne of Chapter 9(commencing
{O{YyZ with Setion]0pfofDivisinnlo(Ne Business and llnfcssinnscWe, nd my liccvorts RESIDENTIAL
Fp�Wo in full force and effect I? PERMIT ISSUANCE ❑SFUWL ❑KITCHEN REMODEL
QF.UzU 1,iccnse Class LION— (� AIIPLIANC17S-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
N6Y Do, �'���r—Conwc ', ❑M CfURAI.
FOy ARCHITE RAT, PANELS 1 DIFIC T
ZO Z linde d y,Iamm fi, uNs
OZ—C _ ,/lL UPT02MAMPS oil R ❑ NINE IR
r4FLL Livenxed Profession �U 201-IIXx1AMP5 I ( BMENT �SWIMMI LS
W '� OWNER-BUILDER DECLARATION µ �
Ly'� .J OVER IINMIAMI'S EIB M IiP IR 1 f
LLfLLL6 crehy affnn Ilial I ten exempt from the Commcru's License 1.uw fnr the ❑
xx O Y U f
ug mason.ISami"a]03 LS,Business and Pmfessinns CWc:Any city ter county SIGNS ELECTRICAL
W LL Fa' which requires a wourn ,,conswet,alter,improve,demolish,or repair any suucwre
F .] prior to its issuance,also requires the applicant for such pennitto file a signed statement SPECIALCIRCUIT/MISC.
yIlial he is licensed pursuant.the pmvisiens of the Cnmmcums License face lChupmr9
W p0 (utmntunuingwith Section7nut Iof Diskinn 3nftha Binmc,,and Professions Calc)nf TEME MRfHR OR POLE INST 1
dqi5 C that he is exempt therefrom and the basis fur the alleged exemption.Any violation of ❑NIT OLITION
Wim
Section 7031.5 by any applicant file a pi subject the applicant to a civil Penalty of POWER DEVICES - ANT ❑FOOD SERVICE
^=Onot more than five hundred dollars(SSW). IMPROVEMENT
❑I,ox owner of the ProPeny,or my employees with wages as their sole nnmpcnsmion, SWIMMING P RIC El OTHER _
CCCC2 I"' willdo the ,,,it,and thustractem is not intended or offered for sale(Sec.JM4,Business
end Professions Codm'rbe Convenor,License Law docs tul apply to un owner of Oil I LETS-SwpklIES '1'l3RE
publicly who hulldn or Improves theater,and who doe,such work himself rr Ihroagh
his can employees.provided Nat such improvements arc not intended or offered for NEW RESIDENTIAL WrE IT.
sale.If,hnwever,the building or improvement is sold within one year aRnmPldinq the SQ.FT.FLOOR AREA 5/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose rr salc).
❑ 1,ma owner of the pnipeny,ten exelnxively mntriating wish licensed conlocmrs to LAI'
emataxi the project(Seo.7044.Business and Profe,sinns Cillo:)TheCotinuou's Li-
craw law driem Peny s not apply an ownerof,mwho builds or improves thereon.and QTY. PLU 70 PERMIT FEE
who contracts for such project with acnmractond licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑ I ate exempt under Sec:. ,B&PC I'nr this reason
ACTER-DRAIN&VENT- (P.A) ALUATION
Owner - Date
WORKER'S COMPENSATION DECLARATION BACK 11-OW PROTECT.D-V-1C H 000
1 hereby affirm under Penally of perjury one of the following declarations
❑IM1uvc and will mainainaCenificate of Consent to self-insure fnr Wnrkerk Camper- DRAINS-I1.00R,ROOF.ARRA, STORIES TYPE CO UCf10N
codon,as provided for by Seeuoo 370,al the Latter Code,lira the IKrfnnnance of the /
work for which this Pinnal is issued. FIXTURES-PER'I'RAP
❑ 1 have and will mainluin Worker's Conpensalion Insurance,as required by Section
3700 of the Labor Code,for the Performance of the work for which this potent is issued GAS-EA.SYS TEM-I INC.4(t OCC.GROUP APN
My W la.uC oe u. Insurance canner and Policy atLrq�l
Carrier: �'^ Policy No. rye✓TMIOEZ- GAS-EA.SYSTEM OVER"(
CERTIFICATE OF EXEMPTION FROM WORKERS' <;HIiASPIINDIISTRL WAS .INfERCEPTGH
COMPENSATION INSURANCE BUILDING DIVISION FEES
T m—ccfion need not lwc articatlifthepermil is Eanne hundred dollars(SBan GREASETRAP or less) PLANCI BECK FEE
I cenify that in the permrmanreof the work for whichthis permit is amed.I shall SEWER-SANT Y-STORM EA.2W FT. . 7A
not employ any person in any manner xn as In become subject to the Workers'Compel- ENERGY FEE /may
Z .tion laws of California.Dote WATER HE BR W/VP,NT/IILF.CTR
z Q Applicant GRADING FEE
FN-t
NOTICE TO APPLICANT:IL into making this Cenif¢mc of Exemption,you.should WAT SYSTI;M/fREVHNG SOILS FEE
h hecome subject 19 the Worker's Compensation provisions of the Labor CrA you must
forthwith comply with such provisions.this permitshall be recall revnkW. ATER SERVICE.
d Q
CONSTRUCTION LENDING AOIiNCY NEW RESIDENTIAL PLMD. SQ14. PAID
l bmebyvffinn last there i,a eonstratiun loading agency far the perhor Bance of Dam ReceiptX
� ,�+ the work for which this permit is issued(Ser.3097.Civ.C.) TOTAL:
C)U Treece'.,Name
kl lenders Address TOTAL'
C6 1 comity that I have read this application and stem tam the above inhvnmtion is BUILDING FEE
H N cut I agree to comply with all city and county ordinances and state laws rclating m QTY. MECHANICAL PERMIT FEE SEISMIC 17EE
U Z building connmation,and hereby authorize reprewinativesai'this city to enmrupun the
above-mentioned property for inspection purposes. PERMIT ISSUANCE 4O
(We)agree m save,indemnify and keep harmless the City of Cupertino against LI[LTNIC FEE
fiabilities,judgment.cost and expenses which may in any way same against said City ALTER OR ADD TO MECIL PLUMBING FEE
in ueamuence of the grunting of this patent
APPLICANT UNDERSTANDS AND 004,COMPLY FH ALL NON-POINT AIR HANDLING UNIT(10 Billow,CFM) MECHANICAL FEE
SOURCE RF,f A"ION'
AIR HANDLING UNIT(OVER ILL(010CFM) CONSTRUCTION TAX
Signature ofApplicalmCcorlifiraverow Date EXHAUST HOOD(W/DUCPI *PAID
It IZARDOUS MATER, S DISCLOSURE
WIII Ihem,fleanl...future buildi.mo,,uplato err handle hamrdnux material HEATING ON]'f(TO 1gt0lo0 BTU)
Code.ijus the
Catarina Municipal Code,Chvpar 9.12,main,Ha ldi n a1 Safely
HEATING ON1'f(OVER 100.000 BTU)
❑Yes ON. VENTILATION BAN(SINGLE RESIDI �O -,abhmll e it coumorfumre definedding vacby the mumea AilQmlity or Mna wMch BOILER-COMP(JHPOR 10,,010BTU)emit huznnlnus air amuuin;mts as dclincA by the Bay Arca Air Quality Mnnugemcnt AL.Dimrirt' BOILER-COMP(OVER 100.1100BTU)
❑Yee ❑No
I have read the l .rdom materials requirements under Chapter 695 of the Cali- AIR CONDITIONER TE.forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand tam if the NEW RESIDENTIAL MUCH. SQ.FT.building docs net currently havea Iemal.Nm it is my nesponshi fly Ia notify the oocupvnt
ofthe requirement which ma.be met print m issuance ofo Cenificme or Occupancy.
JOwner or authorized agent Date TOTAL:
OFFICE