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S 2260 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING.ELECTRICAL PlirT NO. BUILDING DIVISION APPLICA•I'ION/PERMIT PLUMBmr.-MECHANICAL 2260 BUILDING PROJEC 1'IDEN'TIFICA'TION BUILDING ADURFSS' SANITARY NO. AP1'I.ICAI'[ON SUBMI'I'IAL DATE Lot LZ-/ '-9f DOW N E21OWNE 'SNAME: PHONE: C'ONTRACTOR'S NAMC•: Ci LIC NO. — 1Mill. NIC CONTROL If ARCHrreC9]HNOINEEK: LIC NO: ADDRESS:/•,(P4 N (o At RL, pea/ ❑ CONTACT. PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH Q oL-o o is El El ❑ LICENSED CON TRACTOR S DI!CI.ARAI']ON Q'FY. ELECTRIC PERMIT PEG I hcrchy ntham mat 1 am(teemed under pnml.dmm of Chapter 9(commencing JOB DESCRIPTION a eeZ with Section Division 3ofthe Business and Ernresslons Cole.andmylieenrcis RESIDENTIAL, eu0, wtfull tome unit PERMIT ISSUANCE W f, in, '/(SCI. /J,— 'J7 d' 9 ❑SFDWI. ❑KITCHEN REMODEL FZZU Lorena+ els s"4�1a_cwpt gppl.lANCIS-RLSIDENTIAI. ❑ADDITION ❑PLUMBING RIiPIPE pp ARCIIITIiCTS DECLARATION p.1C+, ❑hfU1.THUNIT ❑MODIFI URA(. Z Q N z 1 unJcrewnd its plane,hall he used m public am it, PANELS MOUIPICA'TI(]N OZ—, UP TO 200 AMPS ❑INTERIOR [-1CHIMNHYREPAIR F�2.~.W Licensed l'fokssional 201-10RAMI'S IMPROVEMENT E]SWIMMING POOL-s �YF,; OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLI IO tE C U I hereby aRrm that I am exempt from the Contractor's License Law for the L O L U following m (Section]1131 S,Busines and Fisheries,Cade:An I t ❑OTHER WA- M a 115 w g ream. y ci y or coon y SIGNS iil.l!CI'RICAL w 3 w t- which rcgnrcx a permit to emmiser.alte,improve.damml,h,or rcn:dr any.cwemre .RIr�-"P( b CL1H&I Z'r 0 prior mits iso mnae,al,o requires the applicant lm such pernntm filen signed natmnem SPECIAL CIRCU 1T(M ISG. LECA 64L.L_AJO C 4� n top' mat he is Iimmed puuuntto the provisions of the Camfnalm''s License Law(Chapu9 Iy<C' (commencing with Section VO(gO of Division 3 olthe Business..it Professions Code)in TEso METER OR POLE INST. that he i,exempt therefrom and the basis for the alleged eaemption.Any Imarine,of BLDGIADDITION ❑UEh10Ll'fION �m Section]031.S by any applicant for a perh msuhjectx te happlicant ,a civil Penalty or POWER DEVICES 0T, ❑FOOD SERVICE ZZy, an more thus five hundred dollars(s500). tPROVEMCNT dinwer ❑ L]1,as ncrol'the prely,many employees with wages as their compensation. SWIMMING POOL ELECT'RIC L�1J0'. r e will do the work,and the strovere s riot imomed oriented for sale(See.]IW4,Business THER 63m and Pndeasions Code:The Comramnrs License law Jens not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own empluyces,provided that such improvements som not intended or offered for NEW RESIDENTIAL F.LFCTR SQ 14. sale.If,however,the building or impmvemenn is sold within one year ofcompletinn.the SQ.PT.FLOOR AREA SISQ.Ff. owner-builder will have the burden of proving that he did not build or improve for put- pow of'sled, ❑I,as owner of the pooped,,n s creluivcly atmrening with licensed connector,to T(H'Ah: construct the project(Sec.7(W4,ater and Professions Code)The Contractors Li- nse Law dor not apply or an owner ofprolveny who builds or itnpmves thereon,.not QTY. PLUMBING PERMIT. FEE whn contracts for such projects with s cmntranon d licensed pursuanun the Contractor's Licence Law. PERMIT ISSUANCE ❑ I not exempt under See. ,B&P Cloruis reason Owner Date ALT(?R-GRAIN&VENT-WA'I'ER(EA) VALUATIDN WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE. I hctehy affirm under penalty of Perjury one of the following Je lamtiom: s Q ❑I have and will maintain a Certificate o(Comenan.self-insure for Workers Campcm DRAINS-FLOOR.ROOR AREA,COND. STORIES TYPE CONS'IRUCf1ON sabot,ax provided for by Sermon 3700 of the Labor Code,for the perlbnnnn c of the work Ibr which mix Pemtit ie ie.vaed, FIXTu RES-PERTRAP X21 have and will maintain Wurker'x Compwtmnnn Insurance,as required by Section ]W of the Luton Cale,for the performance of the wnrkfa vshichthispermitislssned. GAS-EA.SYSTEM-1 INC.4OUTLETS OCC.GROUP APN My Worker' CCn�pey�gn��1qt�nae r�♦,kic,and Policyyu�Q�j'�' Cartier. �LRIIYJsIsO[1/�] Policy N""NER1 AA IO/A GAS-EA.SYSTEM OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' GRPASPJINDUSTNL WAS 11;COMPENSATION INSURANCE BIJILUINO DIVISION p[?TiS (I'hiseaslonneeal nrnbovanpleted 11 the Permit is Loreto it Imddollurs($hg) GREASE]RAI' or less.) PIANCI II!CK PGB I certify that inure performance of the work far which this femur is issued,I shall SEWER-SANITARY-STORM EA.200 FT. not employ any pewter in any manner so a o Q`N to the Workers'Couper- ENERGY 1'1!1? Z Applicant ti ►] WATER HHA E WNENTA!LEC R ©• GRADING ITiI? sauna Law3g{�1f Calify iota Done q In became .bj,,to Wrak II;t oleo making this Ce dl..v t s ie Lab pt on,yon should Wq'fl?R Sys'll?M/TRI!A'IING SOILS FEE abecome scomp to the Worker's Cnm rs.,this provisions of the Lnedr Code,you mm't {✓a forthwith comply with such Pnwisiom visitors., Permit drill be Deemed revoked WATER SERVICE 0. UO that aTIONLF.NDINGng agent NEW RESIDENTIAL PLMII. SQ.IT. PAID Dam Rctti 1hcrchyichthitont there issconstruction(Sec.30lending agency for the perfnnnance of L-+ me work for which this permit is issued(See.3a)],Civ.C.) D" F+ banana's Name 'I OTAL : If � G Lender's Address BUILDING Is13F 1 certify than 1 have rand this application and.state than the above information is f-' N reamed.l agree to comply with all city and sorely entrances sortrme laws relating to tool Y. MECHAI LPERA FGF V z building conswcninq and hereby aumorim representatives ofthis city w enter open the SEI5MICFEE above-mentioned pmpedy for in.apemion purpuc`' PERMi r ISSUANCE (Wc)agree to save,in burnify and keep I......lcss the City no Cupertino against I!LECENIC IAB tiobilitie,,judgnscm ts' cxPcnses wh0ronq many way name,r,drrl said City ALTEROICADD'TO 0 F in cnnseyuence of f n�A [. J PLUMBING PI!li APPLICANT 1'/F 5 )S C .(PLY WITH Ah1,NO AIR HANDLING UNI O 10,000 CFM) OURCE F I 1 MECHANICAL FEE n AIR HANDLING ON OVER 10,000 CIM) CONSTRUCTION TAX Sigdoli Tut Appli or/C allaoso ,ate BXHAIJS'f IIOOU( N HOUSINGMITONHONFHE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or Future building occupredorc or handle hnunnus material HEAT ENG U NIT TO 10i BTU) as definal by the Cupertino Municipal Cute,Clear 9.12,and the Ilealm and Safety Cush,Section 25532ho? HEATING UNIT(OVER 100.0110 BTU) ❑Yes E]No PAID VFNTIIATICJN PAN(SINGLE ITESID) IAnc Receipt 11 • Will the applicant or Loan,hullding u'cupunl use equipment or devices toducll emit hazardous air contaminants as defined by the Bay Ate.Air Quality Management BOILER-COMPCHPOR 1(M.0011TU) Tf District^ BOILER-COME(OVER 100,000(ITU) ❑Yen ET No I have read the hmmdonsntneduls reyaimtfrom andel Chupwr,695 of the Cali- AIR CONDITIONER ISSUANCE:DATE forma Hwhh&Satiny Gde,Scenics 25505,25533 and 25534.1 un lmood barb the NEW BESIDES FAL MUCH SQ.IFI'. / 2� // building Aces not currently have a tenant,mat it is my msPnn,ilid"y m nmil y the occupant t T (f of me rommentents which must be tut prior to issuance of a Certificate of Occupancy. Ownermmalu "dagcm Dote 'TOTAL: ISSUED BY: � OFFICE