S 2778 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERT[NO BUIUDING-ELECI'RICAI. P[RMI'I'NO. 2778
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BUILDING DIVISION APPLICATION/PERMIT I'LUMHING MN:CIIANICAI. S 2 7 7 8
BUILDING PROJECT IDENI'IPICATION V L �J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAMB
f33 IfZ 02 Gnuoanz � - °
WN. '. NAME: �y� PHONE: COM'RACTOE'I NAMIi: LIC
,� �?1ppW5 F2ig#M NIC CONT
ARCHITE11?CT/ENG NEER: LIC NU: ADD +SS: ❑
- CONTACT: PH NE: BUILDING PERMIT INFO
/��/ Se S�tfto rtZ'c 79S-�JS d7o9
❑
Consultant Fees Paid by Applicant(Initial) BLDGELECT PLUMB MECH
eaetowlG7y 411,?f7o(4 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
• 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
WOO
Wwith Section 700B.f Division 334the Business unit Profession.Codc.and my license is PERMIT ISSUANCE RESIDENTIAL'
FSin full force unA effect. t ❑SFOWL ``````�❑��� KITCHEN REMODEL
QL.UFU License ClassLIc.N APPLIANCES—RESIDENTIAL []ADDITION UMBING RF.-PIPE
NGi Date Cmancasr ❑MULTI-UNIT []STRUCTURAL
ARCHn ECTS DECLARTIONA
F O rn PANELS MODIFICATION
Z O n Z I undeamnd my plans shall M used a puM1lic recnrdv ...///
OZ—M UP TU NN)AMPS I�IINTERIOR 11 CHIMNEY REPAIR
r�E-W Licensed Frdexslo;al 201-1000AMPS "aIMPROVEMENT []SWIMMING POOLS
�; OWNER BUILDER DECLARATION OVER I(g0AMPg .Ys BATF(RF.MODEIIRF.PAIR ❑DEMOLITION
C Q 1 herchy uflirm that 1 am caempt from the Contractor's Litems Law ht the ❑OTHER
L U following restart.(Section 7031.5,Business and Professions Code:Any city or county SIGNS[LECTRICAL
al?+0 ye which requims a permit m constancy.alter,improve,demolish,or repair any swclure
I�'u•O.] prion,,its issuance,also requires the applicant for such permit file a signed statement SPECIAL CIRCUIT/MISC.
yNm he is liceredparsuommthe provisionsofNe Contmnor's License Low(Chupter9 COMMFR I
WOC (commencing with See onTWO of Division 3 ofthe Business and Professions Code)or TE MP.M ETER OR POLE INS'('.
ay m K that he is exempt fliomf in and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
YXI Y. Section]031.S by anY applint calinapermit-hi npam toociv
plicit penaltyof POWER DEVICE [I TENANT ❑FOOD SERVICE,
m m more than five hundred dollars Epitaph. !'1 IMP VEMENT
=Q nbus owner of the proTeny,lir my emFlnyccs with wages us their sole campcnsmion, SWIMMING POOL ELECTRIC V
p., wAldothework,and the smmtme is ant intended.roffered for ano(Seo.7Wq Businass ER
L 3 m uad Praress,nns Cede:The Cantreemrs License Law does not apFty to an,,Dune,of OUTLETS—SWITCHI3—hIXTUR65
progeny who builds or improves thereon,and who does such work himself or through
his own nnployees,provided that such improvements are not intended or offered for NEW RESIDIiNT1AL FLECfR SQ FT.
ns sale.IL however,ihebuilding orimprovemem issold within one yearnfcompletion,the .FT.FL LA T
er-builder will have the burden of proving that he did not build ser improve for pur- D D
sale.).
EJ1 as—act-)'lire Prrperty,am exclusively contracting with sensed contractors to 'OTAL: JUN 0 19
construct the project(Sec 70 4,Business and Professions Cade:)The Contractor's Li- 9
cense Law costs not apply to an owner of poTray who builds or improves Recover,and QTY. PLUMBING PERMIT FEE
whocomrmterorsuenprojenswecond nr(x Kennan)pursuant mine Cmycas s
License la PERMIT ISSUANCE 3 t 0
Inure r Wer • .Bffi PC for tnis reason
er
ALUIR—DRAIN&VENT—WATER(LA)
OwnDate t^�
W( KER'S COMPENSATION D.CLARATION BACK FLOW PROTECT DEVICE v C 0 O•�
I hereby affirm under penalty of perjury one of the following olmhoutions:
❑I have and will maintain a Cerifcate of Comm to self-invare for Workers Camps- DRAINS—FLOOR.ROOK AREA,COND. STORIES TYPE CONSTRUCTION
,onion,as provided for by Section 3710 of the lahCode,for Cofor the perm
forunce of the I
work for which this permit is issued IFIXTURES—PER'I'RAP
1 have sad will main,Workers Compensation Insurance,as required by Semina /
37W ofthe Labor Cede,ton the performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.40UTLEIS OCC.GROUP MIN
My Workers Compensation Insurance carrier and Policy number ate: GAS—EA.SYSTEM.OVER 4(EA)
Currier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissectiootalimmtne completed;Tote permits for one hundred dollars Who)) GRFASET'RAP
PLANCHGCK FF:E
or beat
Icenify that in duein perfornneeolthe work,nof,,,atm which this the W rkoo'Con,pessued,I ll SEWER—SANITARY—STURM EA.200 FT.
not ennploy any Pnann in any manner so m to become subject¢n the Workarn'Compen- ENERGY FTE
Z sationlAwsof Caldomin.Dane WATER HEATER WNENT/F.LECTR U �� GRADING FEF.
Z O Applicant
NOTICE TO APPLICAN I':If,after making this Certificate Of Exemption.you should WATER SYSTEM/1'REAT'NG SOILS FEE
became suhject ton the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such petition or this Fermat shut)he deemed revoked. WATER SERVICE 32)
DJ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT PAID
Oat Rcceiplp
I herchy Air.that them is., leadingageary for the performance of
o
U H the work for which his permit is issued see.3197,Civ.C.) TOTAL:
O lender;Name ,T L ^
{UIJ Lenders Address • 2 V BUILIOG :F,
y come that I nava read thirty and coup and s ate Nat the shove information;I)
h correat.l agrcememrtandwired)city and represounnances and hate enter
upon the QTY. MECHANICAL PERMIT FEF S IC I3
i U � building construction,and hereby uwhoriz.c repreacmaives of this citymenmr ogre the
aboveme;tinned pmpcny for inspection porpnses. PERMIT ISSUANCE -3 ELECT IC PEE Q
IWeI agree to save,indemnify and keep Insoles,the City of Cupertino against
hahilitic.s,judgments.costs and expenses which may in any way an�me against said City ALTER OR ADD TO MECH. PIA RING FEE 2 r Z,,.�
enscgaence of tote grnming of Nis permit.
APPLICANT INDERSTAND'AND WII..COMPLY ITB LL NON-POINT AIR HANDLING UNIT CFO I0,IXO CFM) MI: ANI AL .F.
SOURCE !❑LATIO S.
AIR HANDLING UNIT OVER I0.00 CFM) CONS x
UCTION TAX
:.�'.dll�'O
ffpplianVContruct 'late EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAIS Ill Rli
l Ne applicamor future building Occupant moreor handle hzz.Nousnmenal BEATING UNIT TO 100,001 BTU) / 2 2i
by Nc Cupertino Municipal Code,Chpter 9.12,and Ne Health and Safetye,Stion 25532(a)I GRATING UNIT(OVP.R 100,010 BTU)
❑Yes ❑No VENTILATION I'AN(SINGLE RFSID) PAIDDae Receipt X
II the applicant or future building ccupant use equipment or devices which BOILER—COMP(3UP OR 1000()0 BTU))
mutNous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
me,? BOILER—COMP(OVER IIX),(M BTU) O
❑Yes 0 N
I have readlhe hazardous materials regaircttems under Chapter b 9541he Cul,- AIR CONDITIONER / ISS ANCF DATE
fomiu Ileuhh&Sm2ty Gale,Sections 2550.5,25533 and 25534.I understand that dthe NEW RESIDENTIAL MECH. S
building doses not currently have a mount,that it is my re,dmsibility hs anday the recupant V —
ohe ui meat which rnuyyzLmenl Priorto;nuance ofa C�iso;_0Oceu ey.
Owner or aulnorizW em IG Ume T Lt ISSUED BY:
OFFICE