S 2128 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PESIT NO. /� /N
BUILDING DIVISION APPWCATION/PERMIT PLUMBING-MECHANICAL PES
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BUILDING PROJECT IDENTIFICATION
BUILDINGAI)D F,SS: SANITARY NO. APPC A NSUBMITTAL DATE
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OWNER'S N ti' E: CO TRA Z'S NAME: LIC NO:
YAWUPT9 �O (� /,f,/-S /./!LL C NIC [� CON'1'ROLH
ARCHI EC TIENOINEEIL CI' : ADDRESS: ❑ J( I�
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C ACT: t PI N' BUILDING PERMIT INFO
111-111 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
T- �- ®-
ucENS D ) RACTf 'S DELI RATION 4QTY. ELECTRIC PERMIT FEE
1hemny0)ar the(]ma lie ensedunderprovisionsof Chapter 9Imn1,cc.,is JOB DESCRIPTION
��Z w1.shoroc IDIX1)ecD;aisinn3nnne mathwsane erofossions coax,and n,y ndensa;° RESIDENTIAL;
F in full tome ant effect. pp p PERMIT ISSUANCE O
aUV I,iaenw Class �'..) Lica ���u ❑SFUWI. ❑KITCHEN REMODEL
F+�u1 Dme Cnmrvynr M/J/+OH/) APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
22 ARCHIT'F.CTS DF;CLARATION� [_1 MULTI-UNIT [I STRUCTURAL
Z O r-Z I wide amad my pinnsshvll be used us itin le records PANELS MODIFICATION
'OZ^0 uPT02110AMP5 El INTERIOR El CHIMNEY REPAIR
1�i.F"W Licensed Par(csjoint 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION E]SWIMMING POOLS
0 W I hereby afOmt Ihat I mo exempt from the Cnntruetn,',Llccnse Law for the OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
ae.U following Rasing(Section 9031.5,Boehm,,and Profassidns Cole,Any Cry or merry SIGNS FILECTRICAL ❑OIHER
:W h which requires.permit m canswm,ager,improve,demolish,or repair ant strumure
F�O; prior In in,isomme,.Iso requires me applicant for such permit n file to signed_stutement SPECIAL CIRCUI"I'/MISC. v
o' Wel he is licensedpm,mmttothr,owr,mh,,fJg Ch......sLiwnee Luw lChapter9
p0 (commencing with Section 7")of Division 3 hfthe Business and Profecsidns CWe)m 'TEMP.MB TERGRPOLEINST COMMERCIAL'
w d c C
flat he is exempt therefrom and the basis for We alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^LL• Section 7031.5 by any upplicam far u permit subjects the applicam m a civil penally of POWER DEVICES
❑TENANT ❑FOOD SERVICE
oat mare Ihan food hundred dollars(5300). IMPROVEMENT
GI Q I]I,as owner of the pmped,or my employees with wages asdub...to annpervvalinn, SWIMMING POOL IT FCT'RIC
wdldu the wark,hndthesmmmre is amimlmdnloroffced Far side(See 9044.Business OTHER
1 a m and Professions Code:The Conamnor's License Law dew not apply to on owner of OUTLETS-SWITCHES-FIXTURES
prnpcny who builds n.intpmves thereon,mW who dos such work himmlf or through
his own employees,provided that such improvements arc not intended or offnvol Por NEW RESIDENTIAL GLECTR SQ 17.
sale.If,however.the building or improvemnn lcsold within one ywrafcampledor.the SQ.FT.FLOOR AREA $/SQ.Pf.
r-builder will have the burden of proving that he did not build orimprove fimpur- Q V-7 X2S7
pure°af sale.,.
❑1,w owner ojeth So,,7044,B e mo si and ch.vacting with licensed enntfaetmx m ,
construct oto pmjecl(sec.9fW4,Bnsinws and Pmfwsions Cheeq The Convnctnrn Li-
cruse Law Anes not apply to an owner ofproscry who builds orimpmves border,and QTY. PLUMBING PERMIT FEE
wbt cant..to Earthen nijeed,with u mmure,n s)licensed pursua h n,the Carbonic's Y
License Law, PERMIT ISSUANCE, �0
❑ I am exempt under See ,B&P C for this reduce
ALTER-DRAIN&VENT-WAT: A) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVIC �(�' x, 2
I hereby affnn under penalty df jur
paynneof the folkn ing fadmation.n J
❑I have and will maintain u Certificate of Consenrit)self-insure for Worker's Chmpon- 41UAINS-FLOOR,ROOF,AREA.CONU. STORIES TYPE CONSTRUCTION
smihn,as provided for by Section 3900 hf the Labra Code,Entire performance of the
work for which this perch is issued. IXl'URIi '�'R TRA
❑ I have and will mocanno Worker's Compensation Insurance,as required by Section
3700(if the Labor Cede,for the performance afthe work for which this permit is issued. 4AS-U�S f M-I Ist OUT E OCGGROUP APN
My Workers Compensation Insurance currier and Policy number are:
Carrier: Policy No.: G 'AySYSTEM-OVER4(EA) \
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIJINDUS L NTER R
(This.vecron need not be completed ifthc pmmn is forme hundred dollars($100) Ill INO DIVISION PEES
or less.) GREASE'I'kAP - PLANCH: FE �0
1 codify that in the porforinanee hfthe work for wnichthislwnnitistesued,I-shall ITAkY-STORM EA. N)FT.
net employ any person in any manneradas r toe ugl Imthe Workers'Compeo- ENE FP
z ,Z sand.Laws of 1,mar.Gam "l `I !WATER W/VP.N Z O
O Appliwm ' GRADI REE
ry 4 NOTICE TO A GAN'E making this CCnlfical - 'm-ytRi should Wq'fP.R SYSTP.M/1'RP.A'TING
H� bhcdntnsanpo ciIlse Worker's .nsntion pmv of We Lu nCrde,you must S FEE
L>a fdnhavah comply withsnch poweanna dr this pertl eh.11 be de, drevokW, WATER SERVICE
�
CONSTRUCTION LENDING leAGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID x" Ihemby offinn that them isawnsimction lending
ing agency Far the performance of Dale Receipt
E+ the work for which this permit is issued(Star.3099,Civ.C.) , Q
7
V.
U Leader's Nome 2�� t TOT
Leaders Address T-i: /'r
I cenify that l have read thls.ppllcaoon and mnletnal the above lnfnmmtina Is BUIL N FEE. / O
V) correct.l agree to comply with all city and county abundances and state laws rehaing to QTY. MECHANICAL PERMIT FEE
L)~ 2
z building n,and herebyaclum representatives city upon me S 1 FEB
nbnver(We) bed propend fhrlreP_yin.purposes.
We)a bee I.,dud,indecent oil harmless the Cil [Cu ninon I PERMIT ISSUANCE � , f� f .'CI IC PEE
( g hereditary an p yet po gwrts
li�bilities,judginentc,cons and expenses whmh may in any way accmc against said City ALTERORADDTOMECIL
mequence of the 6mndng hl Wit permit. U ING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Alk HANDLING UNI T'(1010,000 CFM)
SOURCE REGULATIONS E {ANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CO STRUCTION TAX
Signature ofAp,1imm Cmnmrd., Date EXHAUST HOOD(WMUCI') HOI1S 'G MITIGATION FE.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle huzardmis material HEATING UNIT(TO 100,0110 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health auto Safety
Chun,Section 25532(.)1 HEATING UNIT(OVER 100,000 BTU)
❑Yes E]No PAID
VENTILATION PAN(SINGLE RESID) Doth Receipt Is
Whims air
Its asbeading by
H u Arco
Air
Maronwhleh BOILER-COMP QHP OR 1(0,1101 R'i'U)
mit hazardous air edmumimms as defined by the Noy Area Air Quality M.nagnnenl
Dimricfl
E]Yes ❑Nn BOILER-COMP(OVP.R IOQ(NIO BTU)
AIR CONDITIONER
I hnlh&S rdyfile Cu enlws mater25505,25533 ms under Chapter 6.95 attire Cthe 1. U�VCE DB'FIE�
Fnmia Health&Safety Code,Sections 25505,25533 and 25534.I to aemmnd Ihm if the NEW RESIDENTIAL MECH. SQ.PT. r �-(
building Jrcsnot currently hove v Ionone That it is my respmsihility to notify the nmupnm
of We requirements is ichor be ,act pari tissuance of.Confiscate of Occupancy. Or
Owner nr autnorimd hgem Date ISSUED BY
OFFICE