S 2330 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL YERMI'I'NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL (N Q
BUILDING Y OJECT{DE.NTIF'IL'A'1'ION J J
BUILDING AUDIiG55: SANITARY NO. APPLICATION SUBMITTAL DATE
a2io�o me aoL dr ung f o, R •
OWN61YgNpWE: gtlPl{Opp._—/ O C t ,�(IR'S N^1�� I.IC N� Y
/oM 'F1Y (�fJVY/ j//ll( /'lFJ/1 g., !S NIC CONTROL#
ARCHITIiC'UENCINEER: LIC NO, ADDRISS: ❑
CONTACT: � PHONE: BUILDING PERMIT INFO
nNE/ /,O ❑ Consultant Fecs Pail by Applicant(Initial) BO Eu{cT Pul❑MB MF®/
LICENSED CONTRACTORI'SS DDUCCIA/RA`I]ON(' r QTY ELECFRIC PfiRMrr FEE
1 hereby mrrm that I am lieenaed under provisions of'hamm 9(commencing - JOB DESCRIPTION
QaZ with Section900),d Divisien3orhe Bmine.avand Profession,Cale.and my license is J� /Y REQIDENTIAL:
wOO in PERMIT ISSUANCE /
C full force /� Ql ❑SPDWL ❑KITCHEN REMODEL
aUU License Cla. Lick APPLIANCIS-RISIUENTIAL ❑ADDITION El PLUMBING RE-PIPE
z W Data nmuucvn
4°' ARCHITECPS DEC[. 1 ❑MULTI-UNIT (:I STRUCTURAL
F'D m PANELS MODIFICATION
z O y Z I and esund my plans shall by used as public exa ob,
OZ.N-G UP10200AMPS ❑INTERIOR Ll CHIMNEY REPAIR
F:.y'F'W Licensed Professional 201.1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNIiR-BUILDER DECLARATION OVER 1000AMPS ❑BATH RFMODEUREPAIR El DEMOLITION
y6 I hereby affirm Ihm I am csen:pt from the Contmanr's License law Botha
❑OD{ER
S O i U fnllnwing tension.(Section 9031 s,Business and Professions Cade:Any city or county SIGNS ELECTRICAL.
0g
W'3 fi y which reyuia,a permit to container,other,improve,demolish,m repair any tartare
F u•OQ pHorm its issmnce,also outputthe...heart for such l'voiiun lileasignedmatment SPECIAL CIRCUI'I'MISC.
;!{} that be is licensed poll uanuo0te provision ofthe Commona'a License Law(Chapmr9
a�p0 (comtiencing with lection 9000)of Division 3 ofthe Business and Professions Cade)or TP.EMMETER OR POLE INST. COMMERCIAL,
ad
IL d c C that he is exempt therefrom and the hais far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION []DEMOLITION
�y Section 91131.5 by any applicant fm a permit subjects she applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FWD SERVICE
not more than five hundred dollars($500). IMPROVEMENT
C]1,asnwneroflhe Pmp,ny,ormy employees with wages as their sole compensation, SWIMMING POOL ELECTRIC []OTHER
H
will do the work,and the structurei snot intended or offered for.sele(Sec.9044,Business
and Professions heCody,Theme,the. License Law does not apply m an due of OU'I'LGI'$-SWITCHES-Il%TUKLS
�3.. property who builds or improves thereon,and who Jas such work ltimmlf nr through
his own employees,provided shat such imprmentcrta arc not intended or offered tar NEW RESIDENTIAL ELECTS SQ F1'.
sole.If,however the landingo,improvement is sold withinore yca,af cn.u,ition,the SQ.FT.—FLOOR ARHA EISQ.FT.
owtoolmilder will have the burden of proving that he did not build or improve for put-
pose or sole.).
TOT,1,as owner of the property,am"elusively contracting with licensed enmracme,In L/ V
construct the project(gee.704,1.Business and Professions Codc)The Comrnemrs Li-
came Low does not apply toanowner ofpropmy who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts tot such projechs with a amvicuv(s)licensed pursuant to the Contact rs
License Lew. P ISSIJAN
❑ lam exempt under Sm. .B&PCfor this rat
Owner Date Al I ER_ )RAIN VENT 17R(EA) VALUATION
WORKER'S COMPINSATION DECLARATION :tW,nat.L' E
I hereby affirm under penalty of Perjury one of the fnllnwing declarations:
I have and will maintain tiCerifleme of Consenun sif-insom for Worker's Co IRAINS- '1. (l .'OND. STORIES TY Pit CONSTRUCTION
stome,ns Provided for by Section 3700 of the Lathe,Cede,Pori Ilie perfonnnne. I the
Fl
1'orwhichthiep 'disi"an9d
XTURES-P[R TRAP
I have and will maintain Wmk,e,Compensation Insurance,us required by Y
9190 nfthc LnhnrCede,for the perfnnnance of the work for whi this permit is n: 'YS'I'EM-I IN04 11TL[TS OCC.CROUP APN
My Wn Co i .ti 1 su c cameroli Policy no r GAS-EA.SYSTEMAVB (FA)
Carrie Policy No.:
CERTIFICATE 01: r EMPI']ON FROM WORKERS GREASFIINDUSTRL WASTE INTERCIiFfOR
COMPENSATION INSURANCE BUILDING DIVISION RiE$
Obi,welonereh mtbcwmplc¢d if the Pcnnit is Torino,hundreddnlDrs(510111 GREASETRAP
nr tax,.) PLANCHECK FEE
I certify that in the performance claw work for which this ennit is issued,l shall SEWER-SANITARY-STORM EA.201 F.
.or employ any person in any mann,,so us m hecome subject to the Workers Corown- ENERGY FEE
O Zsntion Laws of Calilomia.Uatc WATER HEATER WN INDE:LECTR GRADING FTE
7 O Applicant
G7 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTLMTRHATING
I•' I'" become subject to the Worker's Compensation provisions of the Labor Coca.you muss SOILS FEE
forthwith comply with such provisions or Ibis pemtit shall re deemed revoked. WATIiR SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ.EL PAID
U0Thereby affirm that there is a construction lending agency for the performance of Dam ceipt#
the work for which this permit is issued(Sm.3097.Co.C.) TO TAI:
F-' Lenders Name
W Lender's Addrem, TOTAL:
�. W BUILDING FEE
1 certify that 1 have rend thisappi
and coup intestate that the above infomutinn is
.F.r raA It
mr,cr.l agree mcomply with all city and county ordinunres and nom laws relatingw QTY. MECIIANICAL.PERMIT FF.E
U building construction,and hereby authorise representatives of this city to ester upon tat SEISMIC TEF.
xbuve-mentioned property for impcuion purposes. PERMIT ISSIJANC13
(We)agree to save,indemnify and keep taintless the City of Cupertino against , Q fiLECTRIC Rif:
liabilitic 'ndgtnems,costs anile set wM1ich may in any wayoceme agaimu,nd City ALTER OR ADD TO MECH. PLUMBING FEE
AP Ju ncc of the gmntings i permit.
:A T UNDERSTAND I D WILT.COMPLY WITH ALL/AN-PO NT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE D
5 :E 'GULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA%
fou -A$,Ifis.71Mnntminr I Data EXHAUST ROD(WIDUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant urfutommilding uecupontmoreor handle laamdummmcnal HEATING UNIT(To 100.001 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Saturn 25532om? HEATING UNIT(OVER IOB000 BTU)
El Yes 0N VFiNT11,AT1(IN IAN(SINGLE.RF.SIU) PAID
)me Remipt#
Will the applicant or future htalking rceuryml use eyvip reol or devices which BOILER-COMP(3HP OR 101,0BTU)
emit huardous air contaminants as defined by[lie Bay Area Air Quality Managemmal 01 T AI:
District? BOILER-COMP(OVI?R 100.000 BTU)
❑Yet; 7N ^
I have mad the hazvdous materials"Momsents under Chapter 6.95 oftbe Cali- AIR CONDI'T'IONER v ISSUANCE DATE^ ��
Tania Heal%&Safety Carle,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH, SQ.ET. D r 2YF--
bumeardtssnm,i hichhoveaneuMhmif ismy respmsibility mnnhify the ttceupam
of the rWuiminems which most he mw prior to issuon,e of a Cenifi<me of Ocenpancy. x/
Ownermimmenmdagem Date Yi
A ISSUED BY: ' D
OFFICE