S 2655 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUIL4.ELEC�RICAL PERMIT NO.
TY OF G DIVISION APPLICATION/PRRMIT PLumN9CC S 2 6 5 5 '
IIUIIDING TIFICATIONBUILDING ADDRESS: EIARYO. APPLICATIONSUBMITTAL DATI
D Nth G D —0.19 (�IISYNbR'S NAME' O.^ 1'Hli: CON' HACTOR'S NAME' LIC NO: gq C(INTROL NARCIIIII'IECTT/ENGINEER: V LIC NO ADDREu R
CONTACT PHONE: -^! BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLDMB MECD
LICENSED CONTRACTORS DECLARATIONQTY. ELECTRIC PERMIT FEE
m
I hereby uffuthat Pum licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QWZ with Section 7000)nf Dlvmon3 ofthe Rminessand Profexlnns Code,and my lirer.ae is RESIDENTIAL,
in lull farce:std cFue PERMITISSUANCE
�U~ Licca,Class Lic.p ❑SFDWL ❑KITCHEN REMODEL
6 sj APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
vFi<i Doc EnntmcC
As shall1heuse DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
f,.pm PANIiLS MODIFICATION
20 ,7j Irndcnand my plaxshallMrsW as public mwNs
OZ�+n UPTO200AMPS [I INTERIOR [I CHIMNEY REPAIR
[F 4F'BI Licensed Prolessimal 201-101DAMPS IMPROVEMENT C]SWIMMING POOLS
a 4 OWNER-BUTLDER DECLARATION OVER IfI(I(IAMPS LI BATH RIiMODEIBSPyR ❑DEhID1.ITIGN
M hereby arrdm mal 1 arm snoop,tram me Contract.,
omm rocs License Law for me ❑o' ITR /A LATE!( Lj ATfR
3
,U
following reason.(Section 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL L�� �
V.,n which rninirns a perana m conswn,one,improve,demolish,annelid,repair wy mmeare �aM1
m6..4 pdurbs its issuance,also as, me upPlicam far inch porn Ito file asignedona, em SPECIAL CIRCUIT/MISC.
pr thio he is licassW purtu.nuothe pmvisioa of the Contractors Limmse Low Whrpr,r 9 COMMERCIAL
� aC (commencing with Section 9000)ofDivision3oftheltosinessandProfessionsCale)or TEMP.M=,RORPOLEBST.
a o C that he is ceemq therefrom and the dais lit,Ibe alleged.storms .,Any violation of ❑NEW BLDG/ADDRION ❑DEMOLITION
Y• Scctinn70315 by any applicant torr period abject,meapplicarom arivil paddyof POWER DEVICIS El TENANT ❑FOOD SERVICE
not marc Nun live hundred dallarI 5500), IMPROVEMENT
�ZQ 1,'v nwnerolrhe ,,arm In ees with wa esmtheir vs le cam nation, SWIMMING POOL ELECTRIC
paper l yore Y g .
5a'P, awillnd dotbewok,ande The Contractors
Licentended se
Lowdlfursale(Sly1.im awatess ❑O"fHIiR
ly"m and I'rnfessions Code The Comments License Law Jr¢s nm apply m an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or Impmves thereon,and who does such walk himself or through NEW RESIDENTIAL IiLECTR SQ ITT.
his own employees,provided that such impmms at
vees e not intended or offered fur SQ,FT.FLOOR AREA g/SQ.FE
sale.If,however.The building or improvement is sold within one year of completion,the t
owner-builder will have The burden nT proving That he did not build or improve for pair,pose of al
❑ 1.as owner nT the property,am exclusively contracting with licensed commucons to TOTAL:
msrmer the prated(Sec.7041.Bneines,and Prnfessinna Cade)The Contractors Li-
srL.awd,w,nmrpplym an owner Infproperty who builds a,improves the.., ad QTY. PLUMBING PERMIT F
who enmricss for such Projects with a cuntmctood licensed pursuant m The Contmanrs
license Luw. PERMIT ISSUANCE:
❑I am camp,under Sec. .11&P C far this reason
ALTER (EA) � VAWAI'ION
Owner Dole .�
WORKER'SCOMPENSATI(IN DECLARATION BACK FLOW PROTECT.DEVICE � OOyQT
I hereby affirm under penally of perjuryane of Ibe fallowing declamti aw: VV
..r ❑Ilmveandwillmainminu Certiricmeof C..nsennaself-inarefor Workers Compen- DRAINS—FLOOR.ROOF.AREA,COND. STORIES TYPE CONSTRUCT 101
adnq es provided l..r by S ninn l7IXl of Lha Lnda CWe,fa,the performrnce nr the
work for which mi,permit is issued, FIXTURES—E'ER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
.300 ofthe Latin Code,for the performance of the work for which This femur is Issued. GAS—ISA.SYSTEM-I INC.4 OUTLETS OCC.GROUP
My Wod�(jC -. 'MIptuyyc camerrndlIcibe,Y4plYlM�OIOIg GAS—FA.SYSTEMOVP.R 4 UTA) v
Camcr.`- IIVILL Policy No.:F�L�^K �1`
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFiA51➢INDUS'1'RL WASTE INITiRCEYfY7R
COMPENSATION INSURANCE BUILDING DIVISION PEES
(Thiswetantmodmahe....offered ifthre mollis foronchrndreddollam DI001 GREASETRAP
nr PLANCHECK FEE
less r
I.edify mal in the perform:mec nRhe work f..rwhich this Tenni,is iswed.I shallSEWER—SANITARY—Sr FORM F.A.21X1 F1'.
ant employ any person in any monde'
so as m Become abject m be Workers'Co.,.. ENERGY FEE
Z satirn Laws of Califomia.Date WATER HEATER WNENT/IiLECTR
GRADING FEE
z Applicant
arra N NOTICE TO APPLICANT If,error making Nis Cemficae of Exemption,You should WATER SYS'TEMIfBISATING SOILS FEE
became subject to he Worker,Cam eadvainn provision,of me Labor Cnde,You muni
Lklforthwith comply wits such pmviamisnr this permit shall he dcenad revoked. E.
WATER SERVICE
`) z CONST RUCTION LENDING AGENCY NEW RGSIDEN'GAL PLMB. SQ. PAID
UO I hereby affir.n that there acon.swction lending agency fon he performance or Dme Reaciptp
(L
the work for which this permit is issued(Sec.7097,Cm C.)
L.
O U Lenders Name TO
U Leander,Address
1}�r W I cenify,hat 1 have read(his offlica0nn end state(hal me abbe monnoul n is BUILDING FEE
cnnect.lagree ro comply with all city and county endurances unit sate law,oclmingm QTY. MECHANICAL PERMIT FEE SEISMIC FEE
62 building construction,and hereby autheriu mpmscduahxcs offlas city m)enter upon the
above-mentioned pmperry for inspection purposes. PERMIT ISSUANCE
TWO agree To save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
luddlities,judgmenn.jp&and.xpcacswbichnmy in any way accrue.,air,,said City ALTER OR ADD TO MECT. PLUMBING FE
in consequence nf, granting of this femora
APPLICANT VIDE AND,"ILL COk)PLY WITH AL1,NON-POINT AIR HANDLING UNIT fro Black)CFM) MECHANICAL E
SOUR 2' rLATI F/�,
Cedv AIR HANDLING UNIT(OVER I(I,IXp CFM) CONSTRUCTIONTAX
ur of pPlic VC m Dwe EXHAUST HOOD(W/DUCT) HO I ING I HO' '100 FEE
HA DOUS MATERIALS DISCLOSURE
Willawapplicuntor farm building occupants¢nonr handle hamrhars material TREATING UNIT(TO 100,000 BTU)
u defined by the Cupertino Muni,Ipol Code.Chapter 9.12,and the Ilealm and Safe,y
Code.Section 25532(x)^ HE/0ING UNIT(OVER 100,00)BTU)
❑Yee ❑N� VENT(LATION PAN IS Ift RESIDE PAID "-
Dam Receipt#
. Will the applicant or future building occupant use equipment or devices which BOILER—COMPPHPOR IO ,livi '1'U)
m
emit haousloair contaminants as defined by the Bay Area Air Quallly Managentan
Disai„❑p Yes DAO.. BOILER—COMP(OVER 101.001 BTU)
I have neral the hvard..us maefim,aceparentent,under Chanerb95of the Cali- AIRCONDIIHONER ISSUANCE DATE
rami.Health&Safety Calc,Sections 25505,25533 and 25514.1 undersand thus if the NEW RESIDENTIAL MECIL SQ,Ef. I
building docsnot torten r nuns,that it is my resp'nsibili,y to daddy the tacupant � l r
al mere vents is t b_par pda to.sones Info Curificme aftX,npan y.
Owner r adhonced agents Vale TOTAL: ISSUED BY:
/ OFFICE —