S 2788 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
TY9F CUPERTINO BUILDING-ELEC`T'RICAL PERMONO.
BUII,UING DIVISION APPLICATION/PERMIT PLUMPING-NIECIIANICAL S 2 7 8 8
NUILDING PROJECT IDFNI'IF'ICATION
BUII,DING ADDRESS: p SANITARY NO. APPLICA'iTON tiUBMITTAI.DATE
1 6 C
OWN, 'S NA E: PHONE. CON FRACIOR:S NAME: LIC NO:
- � N/C CONTR(1LN
.RCHIT'ECT/ENGINEE LICNO: ADDRESS. ❑
s Sa.iak
CONTACT: PHONE'. BUILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) BLDG IiLECT PLUMB M,CH
C`3— 0i Ws�'
LICENSED CONTRACTOR'S DECLARA'T'ION QTY ELECTRIC PERMIT FEE
1 hereby affirm Nat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
pC)Z TL Section of Division 3 oflhe lousiness and Professions Code.and my license is �l R SID NTIAL:
alOp wt PERMIT ISSUANCE. J
F n lull force anA ellen. [ �y ❑SPDWL EI KITCHEN REMODEL
b,z License Clas Lich—1 -W APPLIANCE'S-RMIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
F Z W Date I�7(6 Contme f P-yRj�—
m6m ---�`T� ❑MULTLUNIT ❑STRUCTURAL
Dn ARCHITECTS DECLARATION PANELS
F`oZ I understand my plans shall be used as public records MODIFICATION
Oz UP TO 2M AMPS C1 INTERIOR ❑CHIMNEY REPAIR
f..cr) Wj Licensed l'mfesional 201-I0IXIAMPS IMPROVEMENT C]SWIMMING POOLS
SY2;
OWNER-BUILDER DECLARATION OVER 10(X)AMPS IaBRTH REMODEUREPAIR ❑DEMOLITION
LL G'a 6 I hereby of Grm that I am exempt from the Comruaor's License Law for the
following reason.(Section]031.5.Business and Professions Code:Any city or county SIGNS FLEICAL ❑OTHER
u13 LL h C IRwhich requires a Permit to construct,aper,improve,demolish,or repair any stmcture
F.WpN` prior to its issuance,also requires theappllc.nt for such peron,,,file a signed statement SPECIAL CIRCUIT/M ISC.
�Y that he leliccns«I purnunnuo the provisinm of the Contractor',Liunse Law(CM1apmr9
�a OC (commencing with Section 7(X101 of Division 3 ofthe Business and Professions Code)or TEMP.MCI ER OR POLE INST'.
W m Nat he is exempt therefrom and The mule for the alleged exemption.Any violation o1' .W BLDG/ADDITION ❑DEMOLITION
",� Section 9011more loan
by any applicant for lnrmit subjects the applicant tau civil perratynf POWER DEVICES p ❑FOODSERVICE
Z y not on five hundred dollars($50X1). I EMENT
4o ❑I,as owner ofthe pm ny,ormycmployees with wvgcs as theirxolecnmp nsmion, SWIMMING 11001.BLECTRIC
will clothe work,and the structure is not intended oroffered forsale(Sec.704,L If siness O ER
G 3 and Professions Cale:The Contractor's Licence Law does not apply Ina.mvner id OUI'LETS-SWITCHES-FIXTURES O
property who builds er improvne thereon,and whn does such work himself or through
his an employees.provided not such improvements are not intended m offered far NEW RESIDENTIAL HLEM R SQ 14.
on,If,Mrweven the huikim,.r improvement is sold withmmic year ofenmplown,The SQ.FT.FLOOR AREA LSQ.IT.
owner-Wilder will have the burden of proving that ho did not build or improve for put-
p..se of sole.).
❑ L as owner of the property,am exclusively contracting with licensed contractors To T
cnnstrua the project(Sec.]DLL Basirms lad Prolassimrs Code)To,Cnmmcmr's Li-
censeLwdcsnotapplyTo anownerol'property who builds or improves thereonand QTY, PLUMBING PERMIT FEE
who contracts for such projevts with s contracmr(s)licensed pumuant m the Cnntnctots
License law, PERMIT ISSUANCE (J
I am exempt under Sec. ,B&P C Inr This reason
AI:MR-DRAIN&VENT-WATER(EA) VALUATION
Dam ///�`)
WORKER'S COMPIiNSAT10N DECLARATION BACK FLOW PH(yfliCf.DEVICE / V 1 ser (ej
I hereby affirm under penalty of pejun,one of the following dmlealionx: / Cl
I haveand will maimain a Cenifiutmf Consen wseltm...efnr Wader's Contpen- DRAINS-FLOOR,ROOF AREA,CONED, STORIES TYPE CONST UCTION
saline.as Provided for by Section 39110 mine Labor Cide,for the performance of the
work for which Nis permit is initial. FO(TURPS-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Nevion ek
IDOof Ne labra CNe,fonhe perlbnnanceofun,work forwhieh Nis permit is issued GAS-FA.SYSTEM-]INC.4 OUTLETS ()CC.GROUP APN �f
My Worker Compcnnat�xaN,�iiti'moc dl`ollcy num cru FA.SYS' -OVF A( A) �/
Carrier. S -r.-Y Policy No.:
CEHTIFICATIi OIIE%EMfT10N FROM WORKERS' NEA NDU. L WA 1 TE•RCEPFOR
COMPENSATION INSURANCE 'nI BUILDING DIVISION FEI
(This union need no,McompletW tithe lsmnil is forme hundred dollars( W ;Ii RA
or lona.) �
]� P I PIANCHI:CK FTE
Toy any
int he any mener in the Isecomewhichthis permit is issued.( it YI FSYIiR-SA TAR -S'1� EA.200 14.
not employ any permn any mantur.as asmhaome zuM1jecuo the worken'Cn ENERGY FEF
z ration laws of California.Date WAT17R HEATER WNEIsH I. LTR
z O Applicant GRAVING FEE
NOTICE TO APPLICANT:If,afar making This Certifcam of liaemption,you s of
h ; Iscome suhlenWorkers
co the CamNtrecohm Provisions of the labor Cole,you SOILS FEE
Wforthwith Comply will such provisions or this Permit shall be deemed revoked. WAFER SERVICE
z CONS"rRUCOON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT PAID
V 0 1herebyafftnn Thal Nen,is.cmlltunlon funding slimy for the perforders-of Dfft
44 s- the work for which this permit is issued(Sec.3007,Civ.C.)
TOTAL:
Q U Lenders Name
W Lender's AJdrcas
ly I certify Nat 1 have rwd This application and s a e thin the above loin minion is PUILDI
h correct I g.'e'r.ply with all city and county ordinances and state laws telling In QTY. MFCBANICAL PERMIT FEE SEISMIC
V z building construction.and hereby authorize repreasurtives afdox city tit enter upon the
alrrwe-mentionOil property for inspection purposes. PERMITISSUANCE ELEC IG PGE
(We)agree to save,indemnify and keep hannlese The City of Cupertino against
liabilities judgments.costs and expenses which may in any way acerae agai est said City AFTER OR ADD TO MECH. PIA NG FIT,
in consequence of the grunting 01 This permit.
APPLICANT'UNDERSTANDS AND WILL COMPLY NITH ALL NUN-POINT AIR HANDLING UNITQO 10,(00CFM) MEC NICAL FEE 0
SOU REGULATIO'S a
AIR HANDLING UNIT(OVER IB,TX0 CFM) CONSTR (TION TAX
Signalureof AVP InV n metal
Dom E HAUSTHOOD fWMUCT) HOUSING MITIGATION PER
HA".ARDOUS MATE ALS DISCWSURE
Will theapplwailmlacolaildl ¢iut,rasmremleocilch...alms mmerial HEATING UNIT LTO NQV0 BTU)
az defined by the Cupertinn Municipal Cale,Chapter 9.12,and the Heahh and Safety
Calc,Section 25532(.)'; A.. HEATING UNIT(OVER 10113X111 Rl U)
❑Yes PpIYo VENTILATION PAN RESID) PAID
I� Dam RcccipTN
Will site applicant or future building mcupunt use cytapmern or devices which BOILER-COMPI3IIPOR 10ry(100BILD i
,.it howNaus aic<onmminants as defined by the Bay Area Air Quality Management 'A
Lundell'❑Vcs No Bo TLI7R-COMP(OVER 1BTU/00,000 T
I havetevd Thehav ousmanerialsrequirementsunder Cbvpter695ofthCali- AIRCONDGIONER ANCF.DATE
format Health&Safely Code,Sections 25505,25533 and 255:1.1.1 understand Thal if the NEW RESIDENTIAL MECH. SQ.FF.
building docs nm ennead yhav ntenanT,Tb itismytnspoasibilitymnodyNeacmpam
of n,quire which mull be met To issuatxofo Cenilicatc nl'Occupar tt /
Owneror Ihmizedagem Dann c p ISSUED BY:
OFFICE