S 2063 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO
BUILDING DIVISION APPIACAPION/PFRMIT PLUMBING-MECHANICAL 2063
%IILD[N(;r IJE(T IDP.NTURCATION
BUILDING ADDRESS: SAN]"i'ARY NO. APPLICATION SUBMI'VIAL ONE
101 N • 2G -g3
h OWNERS NAME: PHONE: comrRAC]OR'S NAME: 1 ):
1 A 5knTzemorL SIC CONI'ROLp
1�rARCHITF.Cfr/'ECNGINrER LIC NO: �. ADDRESS: ❑
CONTACT: PHONEICLP E5 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG- ELECT PLUMB — MF"CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE IIr4✓' LL^Y' t_✓ h�T/
1 hereby affirm that 1 am licensed ander pnwioons.f Chrpicr 9(commencing JOB DESCRIPTION
GCO with Section l(NI(Ilof Oivision3nfthe Rosiness and Pmlessi.nx Cale, ylicen,e is r r� RESIDENTIAL:
Is10 PERMITISSUANCE I V
F-w� in full force unJ efts ❑SIUWL L1 KITCHEN RCMODEf.
EUV LlCenu Cmr API'LIANCIS-BESIDES'DAI. ❑AUDI'T'ION [I PLUMBING RE-PIPE
yQ1 Ume Contractor
RCHIIECTS DECLARATION [3 MULTI-UNIT ❑STRUCTURAL
p.O m> PANELS MODIFICATION
Z O m G I understand my pons,h ll be movers public record,
OZ�O UPT0200AMPS ❑INT'PRIOR [I CHIMNEY REPAIR
F�F-w Licensed Professional 201-I000AMPS IMPROVEMENT SWIMMING POOLS
G
C f-4 OWNER-BLULDER DECLARATION
9. OVER 1000AMPS ATI]REMODEVREPAIR ❑DEMOLITION
yy 1 hereby.(Stmt that 1 mm exempt s an the Contractors :Any c Law for he
X 010 following tcvmn.(Section 9B3 L5,Rosiness and Professions GMa Any city or county SIGNS RLI?CfRICAI. OTHER
w'3 w y which requires a permit m construct,alar,improve,demolish,or repair any structure
'i01 prim to its issuance,also requires the applicant for such porromit to file a signed statement SPECIAL CIRCUITIMISC.
rmWm' thpthe m
at he is licensed pulse.,..the mvisiersof Cmdarer's License Law
�sg
POO (commencing all Section TOB of Division 3 of the Rminessand Professions Cale)or 'TEMP.METC R OR POLE INST. COMMERCIAL,
6y oy� Nm he is exampt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W:2 Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TIiNANT ❑FWD SERVICE
W:2 not mom than the hundred collas($EN). IMPROVEMENT
�,x0 ❑I, oOha propsrtYnrm employees with wags..thersdc,omtensaton, SWIMMING POOL ELECTRIC
[]OTHER
Cho Ildodw wnrk,xadthemrenot aeknmmadedorati'eyed forsale(Sce.'RH4,Business
1 a= and Professions Gavle:The Contractors License Law does not apply to an owner OU L T. TCHIS-1>IXI USES Q
property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvemems arc not intended or offered for NEW RC :NTIA[,ELEC!R SQ Irl'
sale.IL havocom.the building or improvement is sold within one mor of completion,the SQ.ET.FLOOR AREA $/SQ.IT.
ner-builder will have die burden of proving that he did not build or improve for for,
,in of sole.).
❑1,as owner of ohs property,am adusively contrail,wish licensedennrtncmrs o0 Jul
construct the project(Sec.7044,Business and Professions Ctde:)The Contractor's Li-
cense Law does not apply m an owner of property who builds or improves thereon,and QTY PLUMBING P IT FEE
who controets for such projects with a contractor(&)licensed punnanf to the Can tmemr. rr��
License law. PERMIT ISSUANCE, y
C] I am exempt under Be, ,R&P C for this rcamn
Owner Date AUrFR-TRAIN&VENT'-WATER(EA) VALUATION a/1
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO]EC"L DEVICE �f/� A/\OfO��
I hereby affirm under Penalty of perjury one of the following doelmationsi G(—A,CJ��
❑ Ihmc and will maintunn Ccniravete of Consent l.self-insure for Workers Cnmpen- DRAINS-FLOOR,BOOP.AREA,GOND. STORHs_% TYPE CONSfRUC 101,
sutioa,as provided for by Section 3700 of the Labor Citic,far the performance ofthe O
work for whado his pmant is issmed FIXTURES-I'ER'BAI' SI
1 have and will maintain Workers Compensation Insurance,as required by Section
370)ofrthe
yLabor
tyCode,
{+for the Esojormance ofthe work for which this perm/it is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
M WoCarner('oL1Y_s1 NIlF 1'IAI Pocy NnPolicY�O�-- GAS-F.A.SYS'fGM OVER J(EA)
CERUPICArK OF EXEMPTION FROM WORKER:' GREASFIINDUSTRI.WASTE IN'TERCEPOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
IT hisociam recd ma be completed ifthe pernit is furore handled dollars($100) GREASETRAP
or less) YLANCHECK PEIi
Icenifytlutiamelsof...beeofthe work for whichthis permit is issued,l shall SEWER-SANITARY-STORM EA.200FT.
not employ any person in any manner so as to become subject to the Workers'Compen, IiNERGY FEE
O Z orni
stationcLa,s of Califa.().atWATER I IHATH R WIVE NEVE1.FCTR GRADING FEE
an
Appli
2w. NOTICE TO APPLICANT:If,after making this Contraction of Exemption,you should WATER SYS'TEM.T BEATING
I"t ? subject to the Workers Compensation provisions of the Labor Gate,you moil 5011.5 FEB
favorite
{aA^ forthwith comply with such provisions.,,his Ennead&hal l he deemed revoked WATER SERVICE
CONS FRICTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ.FT. PAID
D z 1.) O l farwhichfluohtunia i i,aom.mec.301 leading agency knife perfnnnuncc of en Rccetptp
(~ the work for which Nis permit is issued(Sec.3(Ni'/,Civ.C.)
QLenders Name 'fOTAI:
r LUkI I<ndcr,Address T AL. BUILDING :F. QO
ly L cemiy Nm 1 mistreat Ibis application sad spite that the ahrve information is
In correct.l agree to comply with all city and county ordinances and spate laws relating t. QTY. MECHANICAL PERMIT 1'EE
JZ bmildingamsuuction,and hereby atubounic representatives ardor.caym ererup.n the SEISMIC FF.F Z 00
abnvcmemtioned pr.peny for inspection Imposes, PERMIT ISSUANCE. 3
(We)agree m save,indenfmfy and keep harmless the City of Captain.against (� ELECTRIC :E
Iishilioies.judgments costs and expenses which may in anyway acerae against said City ALTER OR ADD TO MECH. pLUMtlI GPEH
in asequence of the gromi ng of this permit s
APPLICANT UNDERSTANDS AND WELL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'T(TD IgO(Ni CPM) MECH ]CAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRU ION TAX
Silecture of AppliranVComruena Date EXHAUST HOOD(W/DUCT) HOUSING MINQATION FEE
HAFARDOUS MAI'ERIAI S DISCLOSURE
Wit he applicamar future build'mg ecopeat more or Encircle[incautious material HEATING ON[I'(TO I00k003 BTU)
as defined by the Cupertino Municip I Cole,Chapter 9.12,and the Health and Safety
Cale,Scott..25532(x)? HFATINO UNIT(OVER 100.000 BTU)
❑Yes No VEM'ILA'I'ION PAN(SINGLE RFSIDI ( PAID
_ Date ReceiptN
Will the applicant or future building mecuponl use eyuipfrem or Devices which BOILER-COMP UHP OR 100AX)BTU)
unit hamrdo.,air contaminants as detinet by doe Bay Are.Air Quality Management L.
District, BOILER-COMP(OVER 100,000 BTU)
❑Ycs
I have read the hazaNafs materials mluiremeno under Chapter 0,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
carnia llealth&Safety Citic,Sections 25505,25533 and 25534.I undermnd that if f ie NEW RESIDENTIAL MUCH. SQ.ET.
building does not cmrfyndy um,f 'nodyreopn Abilaymnoi(yfurecalourn
,if
�t—hy1r. mire end which os1 Fe m m issuance f a Cconficmfe
Ownlr ornchotio agent •Omen &� OT ISSUED BY. IT
V too—
OFFICE