S 2719 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2719
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
10066 /.1 . 6-f- 3
O LB'S NAME: PHONE': COj�TRA GK'S NAME, LIC NO:
v- /(t /{ aolgii- fix ^ G NIC CONTROL Of
' ARCHI .CTENGINEER: LIC NO: AD BBE.S,S� // •��� ❑
CONTACT: PHONE: /`YJ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BI❑DC ELECT PLUMB MEEC14 -
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hemby ofnrm that I en licensed ander provisions of chapter 9(councilman, JOB DESCRIPTION
wo,"Z th Section 9010)of Division 3ofthe Business and Professions Code,and my license is RESIDENTIAL:
F ne full forcerne eft PERMIT ISSUANCE r
4UZU License Clan. Lic.N 0� DSFDWL [I KITCHEN REMODEL
y6W Date— Commenr APPLIANCES-RESIDENTIAI. El ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLA2 TION DMUI.TI-UNIT DSTRUCTURAL
F+�N PANELS
z l understand my plansxhall he used as public records MODIFICATION
Oz"—Q UP TO 200 AMPS E]INTERIOR ❑CHIMNEY REPAIR
; Licensed Professional 201-1000 AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION
a� a OVER I"MAMPS D BATH REMODEUREPAIR ❑DEMOLITION
C Q I hereby affirm on I am exempt from the Professions
Contractor's License city
o prime
3 W F which following tors,a(Section]03 1 onstr Business and.se.ac lack Calc:Any oily or county SIGNS ELECTRICAL ❑OTHER
y which rcgoires a permit to eomwd,mita,improve,demolish,nr repair cony rwdure
��Q prior he is issuanm,elan rer ines the applleant forsach permit to f le a signed statement SPECIAL CIRCUFUMISC.
..-1 that he is licensed pursuanuo the pe),oica—rthecoal..err Licence Law(Chapter 9
0n (commencing with Section 7000)(if Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
0.p� e' that he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION D DEMOLITION
W^y Section 90315 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
y
not more than five hundred dollars(8510).. IMPROVEMENT
�sdn ❑ Las owner othe propenynrmyemployees mbdurwith
lord fosaltheir(Swc.compensation,Bratlnn, SWIMMING POOL ELECTRIC
F
will dothewon,ande he Gammon's kens nr a.does
apply ,,aowalne,cs ❑OTHER
m and Professions Cede.The rues name Lind w Luo does nm apply nt if owner of OUThP.TS-SWITCHES-PIXTURBS
property who builds or provided
t s tbsuch i and who doer such work bed or or through
his own employees,pnwideJ that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ Pr.
sale,If.however,the building or improvement it sold within one yearofmmpletion,theFT.FLOOR AREA $/SQ.FT.
ownerbmider will have the burden of proving that he did net build or improve for pur-
to cot soled.
D I,as owner of the property,am exclusively contracting with licensed contractors at 9'O'f 0 A
construct the project(See.9044,Business and Processions Code:)The Contmmar's Li-
unieLawdoesnotapplytoanownerofpropedywhobuildsorimprovesthereon,and QTY. PLUMBING PERMIT FEE
who cantmets for such prolmts with a li numeon,)licensed pumuom m the Commoners
License Law. PERMIT ISSUANCE
D 1 am exempt of Sec. ,B&P C Inches reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) / VAL TION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 6
I hereby zfOrtn under penalty of perjury one of the following dmlvmuons:
❑ Ihaveand will moinminaCertificate of Cnnsennnself-iroure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CDN 5 R TYPR CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Cade,forthe perfonmmec of the
work for which this permit is issued. FIXTURES-PER TRAP - (S
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3000ar the labor Chile,for the performance of the work for which this pencil is issued. GAS-EA.S YSTEM-I INC. 6WLETS OCC.GROUP APN
MyWorJJVfyy's�D}}�p;ll�ttintJJ lneurr��-c��ecame,and Policy n�9�hd ) 1I
Curiem(,dr/�' RTI ' Policy No.' IgER G-7G GAS-EA.SYSTEM-OVER ( ) 1 5 19
CERI'Imc ATL OP .XEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WAST TERCEPTDk
(This,uormin need not becompleed ifthe tenni,is far one hundred dollars($100) BUILDING DIVISION FEES _
ar less.) GREASE TRAP CHECKFEE
I certify that in the performance mile,work fmrwhicb this permit is issued,I shall SEWER-SANITARY-STO
not employ any pemoe in any manner m as to become s.hjce,to the WorkersCompen- ENERGY FEE
,Z sation Laws of California.Date WATER HEATLR WNENT/LL[ClB
O O Applican, ) GRADING FEE
r�N-e NOTICE TO APPLICANT:If,after making this Ceni)cam of Exemption,you should WATER SYSTEMOKEATING SOILS FEE
bemme.cubjecbto the Worker's Compensation provisions or the Labor Code, on meat
WA forthwith comply with such previsions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM R. SQ.FT. PAID
U Q Iherehy a[flnn that them isunmswmion lending agency nnheperformanceof to Recciptp
W F the work for which this permit is issued(Sec.'3090.Civ.C)
O C) Lender's Name TOTAL:
W Lenders Address TOTAL:
I comfy that 1 have read this application and state thaube have information is BUILDI PEE
fail correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building eradication,andhereby authorize representmivesoRhis city elimination the SEISMIC E
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree eco serve,indemnify and keep harmless the City of Cupertino ugainse ELECTRIC r
habilines,judgmenes,casts and expenses which may in any any acme against said City ALTER OR ADDTO MECH.
in consequence of the gmaminflof this permit. PLUMBING FE
APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI F(TO 10,o00CFM) O
MECHANICAL FEE
SOURCEREGULA
AIR HANDLING UNIT(OVER Forma)CFM) CONSTRUCTION TAX
ighadmiII17Appoicantafformorchor I Dote EXHAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the..pfrom,orounce building occupant store ur handle hazardous material HEATING UNIT(TO 100,000 BTU)
its defined by the Conscious Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Sermon 25532(a)'I / HEATING UNIT(OVER 100,000 BTU)
D —Yes MPrr VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt K
Will the applicant orfmure building by the Buse aAir Quordevices which BOILER-COMP(3HP OR 1(X1,000 BTU)
go emit hazardous air contaminants as defined by the Buy Area Air Quality Management TOTA
UistricB
E]Yes esQ/ BOILER-COMP(OVER 100,0001117
AIR CONDITIONER
I tropical]the hmmrdous undecials mqulrementc under Chapter 6,95 of the Cali- ISSUANCE DATE
forma Health for Safety Code,Sections 255(15,25533 and 2.5534.1 understand that Fthe NEW RESIDENTIAL MECH. SQ.Fr.
building does not currently haven,, ,be fit is m'responsibility to notify the occupant
n t pC✓�F J
riffle reluncranis - riorm lssnanceofa CenifcmeoyDea er, -
7 ill
IF Owner or auN tad agent m T ISSUED RY:
OFFICE `