S 2033 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL rel TT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �J 2033
'BUILDING PROJECT IDENT'IF'ICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL ONE
/0/05 PE %✓Zt} $LVP
- JOWfN,E,(k�S NAME
pv.,R p6/ p�I-) N/C
kOl.pCONTRACT L: LIC NO:
• FtTSAj .LR
LI1824Z DDRii.
i,L.w -FSA. en. I Ia
CONTACT: PHONE: BUIL C PERMIT INTO
)Zr Fj-rSeI e7j C,115) 777- -WO o HaitF Paid b' :cool(Initial) BLDG I.EC'Y PLUMB MECH
t-%'1/�f r I D LTTE�
LICENSEDCONEIRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby alrr that 1 am licensed ander prnvi.dons ar Chapter (commencing JOB DESCRIPTION
O TLZ with Section 7000)of Division 3 of the Business and Professions Gale.urdinyli....t is :NTIAL:
I-I00 PEItMI'1'ISSUANCIi
F,WC
in full fnrcu onA eB"m I. +DWI. ❑KI'fCITEN REMOIIEI.
U' License Cwss Lim.p
Q U pPl'LLWCIS-kFSIDCNI'IAL ADDITION ❑PLUMBING RE PIPE
N60. Dale Contractor
ARCllll'ECT. NE:CLARADON ❑MULTI-0Nll' El STRUCTURAL
PANELS
mZ IunJersw sans sh pu Is MODIFICATION
OZ=q / UPTO20OAME'S ❑INTERIOR ❑CHIMNEY REPAIR
F4L�,W Liccawd Prnlgwl 201-1000AMPS IMPROVEMENT E]SWIMMING POO
$''...1 14NER"BUILDER DF.CLARAI'ION OVER IFIX)AMPS ❑HATH RRMOIlE1JREl'AIR ❑DI+ fOLI'I' )N
Q I hereby affirm[flat 1 am exempt from the CommCtaEs License Law for the
ig(O L U fallowing reason(Scetiva"10]1.5.Business unit Profession,,Calc:Any city or courtly SIGNS[ELECTRICAL ❑ HER
1+13 W y which reyafres a pcmtit m emi'mu,cher,improve,demolish,nr repair any"I mure
Oe prior toil,issuance,also reyuirc.0 We applicam for such ry:rmil to tileuxi6m'J sidle+nont SPFC1AL CIRCLE I'IMISC.
in - el thin bels llmenscd pursuanuo the poi,owns althe Cnmrumors Liceroc Law(Chme,c)
HG0 (commencing with Section 90IXB of Division Sof[lie Businessand Pmfesior,CWMP.e)or TEMEI'ER ORPOLL INS'll I
a C x drat he is exempt therefrom and we basis hu ohm allcgeA exemption.Any violainn of ❑NI7W ITION [I DEMOLITION
0
Suction 7031.5 by anyapplieotn for a armil subjects the applicant n a civil Family of POWER DEVICES
W^h :NANT ❑FOOD SERVICE
^ZDnot marc than five ft hundred dollars y cinpl.
❑Lasowner of shit property, emfWf,]c with wages mlhci GPOOI.F.LI:CIRIC OTHHR IMPROVEMENT
will dalhcwark,Cde:The Contratoti Licensoraw dos sale _ ❑0'fHIiR —
and I`rnfeasinns Gde:The Qmrmcmrs License Ww rices nal apply m an oPar of OUTLETS-SWI'ff.IlliS-I+I 131:5
Amps"who builds or Improves demon,and who docs such wnlWA1yyIyy,vqr I�I��gqhyyllIgg
his own employees,provided that such improvements am not int is'"d G r 1(' NIIW RESIDENTIALcEp a IUnsQ FI'.
sale If,hnwo'er,the buildingor improvement mond vadamone ye SQ.FT FLOOR AREA E/SQ.FT,
er-bolder will have the burden of proving that he did not bund,S�lt'iAvor arm",
t .cep cowem
ryrs1,a, lc'. ' tesptinSik�il ''> r: I;'%. Ions; e e
❑ T,if.nvner of the propenY.am cedusively cmbueting with Le ' 1 t' ' f- IOTA L;�I
msmrel the prnjucl Neu.I(A4,Businessland 'mfessions Cndu)T�yg[�IpHyµyjj. p� -
cenw:Ww Joas not applymvn uwnu of propeatY who builds or in LUrv�IING PERMIT FEE
who contracts forsucb pmjal,wilhacminacmr(e)licensed pursumlyIDt1 B11(L+1
Limbou Law. 4YII IF/IGIGU �Ilu PI: 11
ANCF,
E] 1 am cxengn under Sc,. ,B 16114t I
Owner Uum�p-)^ " W - VALUATION
WORK[:R'SCOMPIiNSATIONIIECLARAI'[O f[ R� AC I'R(4ACI. :V
I hereby affirm ander perral of peflury one of the rmlawin�foMans: 8
❑[have and will maintain a CenificmeofConcennn sell'-insure lin Worker itpvo _ ARBA.GOND. S"TORIES TVPIi CONSTRUCTION
nlalim,us provided for by Section 3900 of the LaborCode,for the perform dal oho
work for which this pcmtil is issued. (��Ngn�yFq P I
❑I have and will maintain WakeLs Compensation Insurance,usle��d
3700 of the Labor Code,for We permrnarnse of the work for which this ls' GAS EA.SY T'M-I NC.40IfTLETS
My Worker's Compensation Insurance carrier and Policy number I 1 OCC GROUP AI'N
Cameo Policy No.: -E S OVHR4(EA)
Cliff IFICATI:OI+EXEMPT ON FROM WORKERS' Da}e
till X
COMPENSATION INSURANCE ll GREASE]INDUS'I'RI,WAS TEE IN I'ERCEPI'OR
Gla-.1lon need Bol hecontplered low pontis is furore hu dddhrla(Y1007 BUILDING DIVISION
or lens.) GREASE TRAP PLANCHECK ITE
T eeniry that in the perfornnce of the work far which this rmit.macil lshall SEWER-SANITARY-STORM LA.2BOPT.
Bol employ any pvrsnn in any menner.so as m become suh co Ihm Waders'Coi I,a. EN17ROY FEF.
Zz vidua Lows of C+difitrnix,Date WATER I IEA'I'HER WNENTELECTk
Q Applicant
M NOT'ICE'D)APPLICANT':IL.ImT makins[pis Cuddle e of Exemption,you nhauld WATIiR SyS'I1iMGRI:A'IING Q
become subJwl In the WnrkcrS Compensation pmvisir nfihe Labor Code,you min
forthwith comply wish such provisions onhis pcmtil all he dame)revoked. WATIiR SERVICE:
Q yy qq
z CONS'IRUCI'[ON hENII GAGENCY NEW RESIDEM'IAI.PLMBJT�VIAL:
Ikly +U a Receiptro
U I herebyaRrm that there is a consom it lendingagency fonhe pmrfntrvnce of vthe work for whichthis peril is found(Sec .09].Civ.CJ0W. '� Leners Name s., TOTAL:
V Lenders Address
0. I renify[hal l have read[his ap cation and hale that the aMrve infitrrn is BUILDING FEE d Q
fA comet.I agree at comply with all city' icounsy onlln:meos unA swill hiwsrelatatg tit QTY. MECHANICAL PERMIT ..
V Z huilAing amntmninn,unJ hereby aurM1 icrepmaenlalivus of this city m emcrupanlhc SEISMIC PIiF.
above-ntentiuneJ property forimpat mpurpoI PERMITISSUANCE
(We)agree et save,lndemnif and kap Zarnlces Ibe City of Cupcnim against ELIECfRIC PEI:
Iiabil'nics,judgm.le,I and-P scswhich may in any way accrue againn sail City ALT ER OR ADD TO MICH.
in consequence of the&rnming of d vperil. VLUMIITNG FEF.
APPLICANT UNDERSTANDS NO WILL COMPLY WII'Ii ALL NON-POINT AIR HANDLING UNI'NIO 10,N100W)
SOURCE REGULATIONS. MECHANICAL.FEE
AIR HANDLING UNIT(OVER 10,000CPM) CONSL'RUCTION TAX
Signatumnl Applicunl/Gnnlrm r Ilam [EXHAUST HOOD(W/DUCT) HOUSING MI'TIGA'TION FEE
HAZAN US MAT17RIALS DISCLOSURE
Will meapplicant ors" urcbuildlrgoccupunt.,mmarhandlehararduusntaluial ULATINCUNITTTOILY),000BTII)
vs Jefntul by Ism 6ipeninu ticipul CnJe,Chapmr 9.12,anA the Henhh unit Safety
CWe,Semon 25532(a)'t HEA'TLNG UNIT(OVER 100,000 ITTIJ)
1]YO, ❑No VENTILATION RAN(SINGLE RESID) PAID
Dale Receipt M
Will the applican r future building occupant use equipment or devices which HOILEH-COMP([IIP OR IIIO,tX10 BTU)
emit ha nodous sir coni foams as dcfinW by the Bay Arca Air Quality Management
Diusuicl^ L'
❑Yes El I3011,E11-COMP(OVEI<IOO,ONI RTU)
hove Boit a hamalnus mst,6,1s a, Bono nit under Chapter 6.95 of the Ceti- AIR CONDITIONER �1 ISSUANCE DATE
fnmia, ald ae,y Code.Sections 25505.25533 wal 25534.1 underswnJ Bim if the NEW RESIDENTIAL MUCH. SQ.FII
building docs not currently have a tenant.that it le my ms,on,ibility to notify the nec,and Imo/ 1l
of the requiruncnts which mint be mol prion ocanee of u Cenificaseof Ou:aMmcy.
l� �_
Owner or authodvcJ agcm ])am TOTAL: ISSUEiD 11 Y:� vi _-0
OFFICE