S 2752 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELDC'IAICAL PERMIT NO.
BUILDING DIVISION APPLICATION[PERMIT PLUMBING-MECHANICAL 2752
S
RUILDINGI'ROJP,C'r IDLNTIF'ICNFION tJ
BUILDING ADDRESS: SANI'I'ARYNU. APPLICAI'IONSUBMUTALDAI
z �, a2A I' 3 -z3
OWNER'S NjIME: PHONE: CONTRACIOR'S NAME: LIC NO:
V I' d C ci . a e 6S-/S Ac t W1JZAj 3aHsJ�/ El c°"T'R°L"
ARCIII'I IiC'1'/13 IINI?Iilt: LIC NO: ADDRESS: �/ /
CONTACT: n PHONE: HU 11-DING PERMIT INFO
yr O ❑ Consultant Fees Paid by Applicant(Initial) BERG ELECT PLUMB MECH
V (P ( O Y ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy alerm tint I:tat licensed andel Pm dah,ns of Chapter v(enmmeneing JOB DESCRIPTION
Doo with Samioa70MEH.1Ditisiim 3ofllc Bu,it„ end Pro ms,lon,Code,amlmy Erenw RESIDENTIAL:
FOO
in fall farce and effect PERMIT ISSUANCE J
aUU hiccnnc Clan a -/A ❑SFUWL ❑KI'fCHIiN REMODEL
Lic” APPLIANCES-RESIDENTIAL ❑ADDITION ❑I'hUMH INC RE I'IPF.
Naw Dam Contra ao
ARCHII17 I';SDECLARA ON ❑MULTI-UNIT ❑STRUCTURAL
Z OZ Iundernandmy plansshall hetsesi ,lublic records YANLLS MODIFICATION
--z4-� UP To 200 AMPS ❑INTIik10R ❑CHIMNEY REPAIR
F��W Lacus,-d Pifl-onal 201-IWUAMPS IMPkOVI?HENT �SWIMAtING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH RIiMODE11RIiPAIR 11DHMOLIFION
C R Q I herehy affirm Thal I um m exempt frothe Contractor'.License Law far Thu
3 i U following reason.(Section 703 1.5,Business and Professions Cale:Any city or count' SIGNS ELECTRICAL ❑OTI IIiR
y which I..... a.coni, ,,., ,brad,alter,improve,damolisb,or repair any,nuctim (J
IL< prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCOIT/RISC.
that he is hcemulgums...,to The.......tinsel he Comma-',License Law(Chapmr9
1y�p0 (commencing with Section700(hof Division J of the Basi nes,and Pofcssionn Cale)ar TEMP.MFI]"R OR POLE INST R IAT:
Q.e C 'bat be is wimp,direct nn and the hosis far the a11cgN exemption.Any vioMtum of ❑NEW RLDC/ADDITION ❑DEMOLITION
Xnu. Sedan 7031.5 by any applicant for a pcono subjects The applicantma civil penalty If POWER DEVICES
W^m ❑TENANT ❑FOOD SERVICE
F. rn man than live hamdred dollars($500),
SAO Las nwncrnf the.ropeny.army cmpl^Yves with wage.as their nolo aonq,cnsutinn, SWIMMING POOL ELECT RIC IMPROVEMENT
F will Jo the work.and thestrunure is not intended oroRcrnl for mile Nec.70IT Business ❑OTHER
s W 3 at and Prom,sia I,Code 'rhe Cnnmmmis L iwmc Law does nut apply lu ua owner of �s OU I LAITS-SWE FCIIES-FIXTURES O
L progeny who builds or improves thereon,and who Juts such work himnclf or through If
h1...wn antplayre..Provided ma,such improvenrvms are not inamded ar offered 1'or NEW RESIDENTIAL ELEC'IR SQ FF
side.If.however.no building..r improvement is sold within one year ofcompletioq the SQ.IT,FLOOR AREA S/SQ.IT..
owimi-bodder will have The burden or proving that he did not build or improve for pur-
now ofsale).
❑ I,as owner of the property,am exclusively contracting with licensed contractors to O'D
instruct The project(Sec.70,14,Business and Professions Co f,)'ITe Contractors L!-
ne,Law Eees not apply to an owncrot progeny who builds or imptoves memor.and QTY, PLUMBING PERMIT FEE
who comma,forsuch porects witha c au,acmdO limn,,d.nouannn me Contnmm's
License Law. l iRMff ISSUANCE
❑ I um cxciam under Sea ,If X P C l it this reason
Owner Data
ALTER-DRAIN&VHist-WATER(EA) VALUATION
WORKERrr,COMPENSATION DECLARATION SACK MOW 1'I<fll IiCI'.DEVICE
I hereby uflinn taint Cen ific of fCmn enc..f the following W..ker,Co
❑Ihave andillfar by eCen 3700 of the Labor
Code,for the,dorm'G^mlrcm- DRAINS-FLOOR,RUOIr.AREA.GOND. crOIf[ }yPE CONSTRUCTED
whoa, r which
fpr by Ss issued
7700 of the LaMa G,tic.for alis performance of IM1e % s
ark farwhich Thi, mama is i.. kd. FIX'T'ORES-PER TRAP
I have and will...I,Far Workers adme of he
Insurance,as required a it Section
My ofthe Laborpenaionhsurance career a me w..ck numbs mi,.cnnit is lsand, GAS-EA.SYS'IP,M IINCJ OUTLETS OCC.GROUP AP@
My Worker's Compensation Insurance careerandNo:
number are: 3(1?Cnnicr: Policy Nu: GAS-EA.SYS'll!M-OVEK y IRA)
CERTIFICATE:OF EXEMPTION MOM WORKERS' 3 O
COMPENSATION INSUkANCF. GREASEYINDUS'IRE.WAS TE IN'FERCEMON
FROk,cettin need not Mcnmglmeviifahc pemTil is lie one hundred Jolla..($1Ad BUILDING DI VISION IyiES
ur les) GREASH I RAP
I¢nify that in The pertonnanec of the work firt wbicM1 thi.v permit is isrtmd lsh�ll PLANCHECK 19iE C
not employ any person is any mennerw as ti secure wbcam the Workers'Cum SEWER-SAN[ ARY-STORM EA.200 IT.
1 M1^' ENERGY PEE
zy mian law�sX of
WATER HEATER wNENIIFLECtK
zQApplicantNOTICE O� � IL;dtc^.v CiFm ,yGRADING Bi
hoidd
WAFER SYSTF,AVfRIiATING
a ? beamm whject m the Worker,Compensation provision.offish Lahr Code,you must SOILS FEE
forthwith comply with such prmtisin I,,,,This path..,shall be deemed rOokod WATER SERVICE
Uj
a0
oz CONS]RUCI ION LENDING AGENCY NEW RESIDENT IAL FLUB. SQ,IT PAID
V Thereby affinn thin them is connmaion lending agency for the perfrnmmnce of Receipts
F the work for which this permit is issued(Sec.7097.Ci,C.)
ULender's Namc
W Lender's Address TOT),h: TOTAL:
a 1 eenify dao 1 M1avc rad this application and ams that The th..tc inmfmntian is BUILDIN'F e 3
h nrtmeL lugrcemeumply with tll coy ane county oNinances unJ,mm laws relating to QTY. MECHANICAL PERMIT FEE
Uz hualdingeonsTfnmion,and he,chyamhoriec rcpnsenmtivesnf thiscitymenmrupm the SEISMIC F17 O
above-metnioneJ proparty for inspection pnrpnws. PERMI'I'ISSUANCE
(Wc1 agree m sate,Inde n sly and keep hamdes,the City of C.,Uino against ELECT ItE
Iiabiluics,luJgmcmz,emsand cxpcves whichnray in fifty wvyaccmc againi,aid City ACI'IeR OR ADD'IY)A1liCH.
in n,c,wo,col'the granting of this permit. w PLUMBING M.
APPLICANT UNDI:RSTANDS AND WILT,COMPLY WITH A1.1.NON-1'(IIN'IAIR HANDLING EST(TO 10.00pCEM)
SOURCE REGULATIONS. MECHANICALE
AIR HANDLING UNIT OVER 11.00f)CI
AO CONSTRUCTION TAX
ignuturc nfApplicaMContmcm. Uma EXHAUST'I IOOD(W/DUCT) HOUSING MITIGATION FEE
MATIiRIAL.S DISCLOSURE
Will lic applicant or future building oecupunl sane or handle M1aeaNpus nmtenal 1112NI ING UNIT(IO 101.000 RTU)
as defined by me Cupenin^Municipal Cole,Chapter 9.12 and the Ileuph and Safety
Co c.Sari 25532m? HEATING UNIT(OVER 100,1100 BTU)
Yes [�Ya
VENTILATION FAN(SINGLE RISIU) PAID
Will the applicanl or future building necepart use e(Impmhm or devices which Dam Receipt"
D..tit arders air ctmmminam nu defined by the Bay Arca Air Quality Management BOILER-COME(3HP OR 1(0.11011 BTU)
iaridRetp T� T(YI
❑yes LTvO BOILER-COME(OVER 100.000 BTU)
I have read me hvarJous Tm,mdals reyuimnents under Chapmr fi.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
Imrnin IlcahhSafety Cala cli imps 25511.5,8513 an([25570,1 undcrvtwU mw if the NEW RESIDENTIAL MRCH. SQ.ET.
building Jm......ammly have t m..ant,thus iT is nay nstif.Ctiity m nndfy,'r,on..pant .JJ
d the mmr�T�whic� t L cane ifs Cenifcam nf(Rculynry.
Owner ramhineed agent Daae—
ISSUED BY:�
OFFICE