S 2133 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PI STIN°. n 13 3
BUILDING DIVISION APPLICATIONTERMIT PLIIMIIING-MECHANICAL, v` L
BUILDING.F'ROJEC'P IDENTIFICATION
BUILDING ADDRESS: PPLICXGON SUBMITTAL DNI
015.4'* VILLA MAe)A -r . d-
OWNIiH:SNAME: PH(1NIi: CX��'1RACTOR'S NAME: LIC NO:
Aa-moa- woo N� 481 ' ���'3 NA2'6v-o oC /�OkD16kU CAL
NIC CHINA ROE.
lI ARCHITEC I]NGINEER: LIC NO ADDRE!E3: ❑
a'19 Oso OuAar eo. 0 2%
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB Exi
EiZI6 Go-DHAM [&50)593-45o0 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELLCTRIC PERMIT FEE
1 herehy anirm mal I ant licensed miner provision,aI Chapter 9 anmmnaeing JOB DESCRIPTION
q�Z with Section700duf Division 3ofthc Business amIPowc,.,mna Gnle,and my license is RESIDENTIAL:
1x100 wI PERMII'ISSUANCIi
CSF Litin from and effeaN �2/sr, ❑SPDWI. El KITCHEN REMODEL
U License C v Lic.p •/IPIO
bZZW Dae $d Contmcmr kC Al [ AI'I'LIANCES-HESIDIiNI'IAI. ❑ADDITION [I PLUMBING RE-PIPE
ASCII I FUI S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
b-pm I'ANF.I ti MODIFICATION
z O n z I understand my pions shall be used as public recalls
MODIFICATION
0z-0 N'TO200AMPS [I INTERIOR El CHIMNEY REPAIR
F 4IrW Liccnud PnticW....al 2014000AMPS IMPROVEMENT E]SWIMMING POOLS
ail��d00.0 fallowing rensan.Section 03I�S�BusiDER DECLARATION C.s License Law lot:he OVER I(MAMIS ❑HATH RF:MOULLREI'AIR ❑DEMD1.l'I'IDN
,C W 1 herehy n131mt that I our cic,nn tram the Conractul
iqp5 Code:Any city or county SIGNS ELECTRICALCY
❑(Yf111iR
Yl'3 0.F which requites a Permit n)construct,alter,improve.denmllsh,or repair any slrumure
FSO prierm its i... ulw rnptires thenpplicaen for such permit to file a signet statement SPECIAL CIRCUIT/MISS.
} That he is license)pursuant to the provisions ofthe Conaaroea License law(Chapter 9 a
00 (eu tonneau, ith Section 7000]of Division 3ofthc Business unJPmfcasinnsCndeksr TEMP.MP.I'IiROR IKIL9INST. /rl/, �
0.p, q thin he is exempt therefrom and the basis for the alleged exemption.Any violation of EW 9LDGIADDI'I 0 '�I)EMO.O O
)C a.
Section 7031.5 by any applicant for a perm,subjects me appliwnl m acivll pento,of POWIR DEVICIiS TENANT ❑FOODSERVICE
nal nate lo,r five hundred dollars 15500).
H Z i' IMPROVEMENT
❑ Lasowner of the property,or my entpbryecs with sages a'their rule rnmpensminn, SWIMMING POOL ELECTRIC
Wp¢.O and dmhewons Core- he antra Cols License
a Law dos not apply to
Boniness El OTHER
6 3� and Professions Code:The Contractor's License law dues not apply m an owner of OUTLETS-SWII'CIIIS-FIX'1'URES
progeny who builds or improves thereon,and who Jots such wink himself or lhruuah
his own employees,provided thin such impmvemunts are not intended or offered(or NEW RESIDENTIAL ELEOTR SQ FT.
side.If.lowever,me building or improvement is sold within one year of cor,dolon,the SQ.F.FLOOR AREA $/SQ.Fir
ownerhuilder will hove Thu burden of proving that he Jit not built]or Improve for pur-
pose of sola.).
❑L as owner of the property,am exclusively contracting with Liccoed contractor,In TOTAL:
instruct the project(Sec.7044.Business and Professions Gxle:)Into Conrean%Li-
Ovule Lowdoesnot apply t.an awnnnf pmpery he builds..improves lhereun,and QTY. PLUMBING PERMIT FEE
whocontracts for such projects withacnnme (a)l maned porsuma to he Canlruclur's
License Law. PERMIT ISSUANCE
Ivor exempt under SO,. ,B ax P C for this tern.
ALTER-DRAIN&VENT-WATER(EA) VALUATION
owner Dae
WORKER nder Penalty
ofre AI IONregion,
PECe following
HACK IslpW PRO]ECT DEVICE ff--���
I hereby ll maiinar under penalty ncofCon nuc of the following Woke,declarations: 'V
❑Ihave and wi,,lfo,by Sclion 3700 of ConseiltoCode,sureie Wmmanu Compen- DRAINS-FLOOR.ROOF,AREA,GOND.
notion,ns Prnvidal for by Findon 3]00 of the[ahm Code,for the pvrfonnvnev of the Sr RIES 'TYPI!CONS'1'RUCI'10N
work for which this pemtit is turned. FIXTURE%-PER'I'RAI'
I have and will maienuin Warks's Compensation Inxunace.as rap:ired by Section
3700 afore Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM.]INC.4 091 LH I S OCC,GROUT' APN
My Wmk`els Co.,` BIityl Insurance sumer and Policy qq�{{JJwx. gg(p�,,, ,l'
Cartier: For` Policy No,OTL•Yd UhlT!M GAS-EA.SYSTCM�OVER4(F
CERA IFICATE OP RXIiMPI'ION FROM WORKERSGRF.ASFIINDU NI'ERC: R
COMPENSN"I'ION INSURANCE BUILDING DIVISIONFRIES
Onassaction need nolhccantpletod iftheparmil iefonmchundreddollam($100) CRIiASF.
or less.) kM Lit" PLANCI IECK FEE
I tell i fy t hat in lhalwRormanceofme work for whichthis permit is issued,Is hall SEWER-, 1 RY-ST( MHA.�(1
oat employ any person in any manrner no as..M<ame subject m the Wodm'Compen- ENERGY FEE
z ,Z, soden Lawsof California.Dale Wp'I'lik HE i /V :BCTR
C) Applicant GRADING ItiE
h NOTICE.TO APPLICANT:IL after making this Cenificate of Exemplar.you should WATIiR SYS]" TREATING SOILS FEE
a ? heron a suhject le the Worker's Complar ution provisions of the Latin Code,you must
W forthwith comply wim such provisinnsorIli,pernit shall he dccmed revoked. WATER SERVES
Pa z CONSTRUCTION LENDING AGENCY NEW RESIDENTA3. SQ.FI, PAID
Receipt N
L) 0 l hereby affirm Na there is a constructionlending agency for lire perfmmeme nl p
I•+
the work lira which this penult is Intal(Sec.3097,Civ.Cd
u•' I-+ LcnJels Names TOTAL:
U lenders AJJuss TOTAL:
BUILDING TF.
[-� 1 certify that A hove read this application and sine that the smwe information is
Z cuildimlagreetoromply with all city and rounry ordinances and store lows relating.. Q'fY. MIiC11ANICAI,PIiRMIT FEE
/
U ,z hnilJingiruction,and herehy aumnrize rcPrescnmtives nfmis city loenter upomhe SEISMIC BE
above-mentioned progeny for moreminn pmpnxca. PERMIT ISSUANCE
(We)agree to save,indemnify unit keep bum loss be City of Colorer)agau at RLF.CfRIC N
C
liabilities,jadgmems,ants and expenses which may in any way accrueagairulsaid City ALTER OR ADDID MECH.
in onscquence of the greening obis perni1. PLUMRINGF
APPI.IC NT UNDERS'1'A S AND WILL COMPLY WITH (X
ALL NON-POINT AIR HANDLING ONE 10, 0 CI'M)
SOU REGULATION MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
gnmore tAxpplicaMCommetor Date EXIIAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAI.S DISCLOSURE
Will the applicant random building occupanutore or handle hazandmix material HEATING UNIT('IO 100.0a III'U)
to deline4 by the Cupertino Mi nlulpad Cale,Chup¢r 9.12,and he Health and Sm@ly
Code,Section 25532(n)'1 I HEATING UNIT(OVER 1(XL0011 RTU)
El Yes El No VENTILATION PAN(SINGLE RESID) PAID
Date Receipt X
Will the applicant or furore building use eical or deviceswhich
emit hazardous air nmtaninar as defined by(lie Roy Arca Air QuJily Management
BOILER-COMP(JHP OR IBB,(DO BTU)
District)
El Yes ETN. BOILER-COMP(OVER I00.0000'NI
1 have revA the haznrJeus Inatcmais mryilnmcnt under Chapter 695 of the Cali Alit CONDT1'IONER ISSUANCE DATE
forma Health&Stilly Gale,Sections 255115,25533 and 25534.1 tarmia mad that Hit. NEW RESIDENTIAL MECH. SQ,FI'.
huikling dues urn cnrenlly M1aveulemnL that illsmyn,"o,ohilhym amifytheeceupaen
,if the requirements which muss be met poor..issuanm ofa Certificate ad Occupancy.
Owncnu authorized agent Date TOTAL: 1 ISSUED
OFFICE