S 2480 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING-F,LRQ'RICM, PI,RMI'1'60.
IsUILu1NG DI VISION APPLICA'f10N/I'ERMIT rLuwlwc-5fecxnNla#1- C� A O 0 O
BUILDING PROJECO'IADENTIFICATION X1
RUILUING AD I)R ISS, r^ �^/ SANITARY NO. APPLICNI-IONSUIIMITTAL DA'D
ITV. _ A -ZZ �
OV'WrAMr;: /B I AC (
j 1S
NIC CONTROL#
A IITF'/EN NE' /CLIC NO'. r\UURPSS ❑
COMPACT: PHONE: BUILDING P RMIT[NIF0
❑ CnnsDltant Fces Paid by Applicant(Initial) BLDG/• ELECTS PLUMB ME❑CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FFF
1 he ch,alum that;am licensed under Provision..of Chapmr 9¢otntnen.ing JOB DESCRIPTION
WOZ wim Section 7000).1 Division3onne Badnessand Pmfce,ion.Cost,v.emy lice...is -3 RESIDENTIAL:
ulOp PERMIT ISSUANCE J
Fm� it.0tlucfa-c and effect.�x �` Y ❑SF WL ❑KITCHEN BE MODEL
<UU Mare 1 c# /1=� �:�/apC� � ppt LANCES-RESIUCNI'IAL DITIDN ❑PLUMBING RF,-PIPE
yC l- Dmc Commuua
F>,� ARCHITF.CI'S DIiCLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O N Z 1 understand my plans slmll be used as public records MODIFICATION
C,Z-�0 UP TD 201AMI5 C3 INTERIOR 71 CHIMNEY REPAIR
C��W Li.arccd Poetereinnal 2d1-1010AMPS IMPROV17,MEN'f 0SWIMMING POOLS
ayE� OWNER-BUILDER DLCLARAI'ION OVER 10010 AMPS ❑BATH RI?MODzJREPAIR EJ DEMOLITION
C)W a I hereby affirm mm I on,cxmnpl 1}om the C(Emco ',Lkcn,c Law to,the
IKy•:=U following reason.(Section 90315.Begin...%and Pmfe\,io is Cuda.Any ciy m county SIGNS ELECTRICAL ❑OTUER
40N which requires a permit m comn.G,offer,impmvc,demolish,or repair any soman..
F'mNJ prior to its issuance.also requires the applicant for such psmatto file a signed slmcmenf SI'IiCIAL CIRCUIT/h11SC.
uumn,ir,,i1 parsuanllo the pmvi.....m 3.f u Ba,mbrzs dPmfi W...Coi nn 9
�a0a G0ykle
(dot he isexempt
xempt tSulinn91#X1)rle busis tohall,idnes.andon.Any stolatitin
GWd ur (LMP.MITEROR IK)L61NS . COMMERCIAL:
d y m C that he is exenlplIM1ercfrum and the M1ush Fir the ullcgctl exemption.Any vinlmimf.I' ❑NEW W I4LUG/AUDI'fION ❑OHMOLI'I'ION
W^4y. Section 9031,5 by any applicant for a pent subject,the applicant to o civil usually al POWER DEVICIS ❑TENANT ❑FOOD$IikVICE
mores than Bva bondmJ dollars(SSB.).
IMI'ROVEMISN'I'
F�a Lmne wink,lbepmpmyar mYcmpinyccs with wageso,ale(selcenmpenwrion, SWIMMING POOL EIJiCI'
ar ldolhewnr,anda Ilia Curcisnot, Arced or uttered doe orot.,IySee to; ,Business ❑OTHER
63 m anal Prnl'cssinne Coda'I'M1c Cntnrvemh Liantt law doss not upplY to an owner of OUTLETS-SWITCHES-FI%TUR;.
pmpeny who build,or improve.Ihcra,n,and who Anes such work himself er Through
his own enlployea,,pnwimul Ihaf such imprnvenlems urs ne, On ud I..r olLril for NEW BIiSIDEN"11, r:LECTR S t .
,ala.IL howcvea be huildingor lmpontmocnl i,suld w0hinnnc yen ofnttry,l.finn,the -( SQ.PC FLOOR AREA SISQ.TT.
owntrobtfulder will have the burden of proving that he did oaf build or impmvc forper-
0 1,ur xuwen cr onhe leol—y,am exclusively comracm,g with liao,ed contractors a, _,eek f)T / /
,num,l he pupa,(So,.moa,Benin-,and Profevion.Cedc:)'fhc Comatmtor..... 6
ciaw,law,docs not apply to anovencr-of propcny who NOUN or impnmc,mcrcun,aid QTY PLUMBING PERMIT FEE
who commas far such projects with a cone cbmr )licensed pursuunuo the Contractor's
License Use PER.M1'f ISSUANCE
[1 1 un..xcnlpl i ndcr ;P C for this reason
ACIER-DRAIN&VENT-WA'Tli ) VAI,DATIGN
O Dmc
WORKER'S 1IPiN. N.IiCI.ARNI']ON BACK PLOW PROTECT.DEVICE �� �� �
I hereby afirm under penalty of perjury one of the following dcchucto nos:
�Thave and will tnaintainu Cenillcme o[Consennn xelr-incum for Worker,Crmpcm DRAINS-FLOOR,ROOF,AREA.COND. STO IIS TYPECONS'RUCTIOI
nation,as provided far by Section 3900 of the labor Cala.I., he per marem,c of the
work for whish Ibis pcnnit in itviod. FIXTURES-PER TRAP
❑ I hmr and will mcinmie W oka,,Compcnnmion Immense,as rcgvind by Sectio
3900ofrhe l.atxa Cock.forth.psourmwmcol the wad it which miepcnnit is issued GAS-EA.SYSTCEO-I INC.i OUTLETS
MyW'urke(s Compensation hwumuce carrier and Policy numl+crom: GCC GROUP ^�AI'N
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4 TA) Y
CER'I'IIICAI It OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GR: N5\STI?INTERCEPTOR
BUILDING DIVISION FEES
or le
(IUinscctinn sad nal hcromplcwJ if the pnnit is furnncformed dollaes 1$100) GREAT AP /nV.
o,) PLANCHECK FEE
Loy any
wr im in any manner
so ustbecomesuichthis Permit iters' d,l.en- SI?WI' SANITARY-STGRMLA.2(M)F . -
not employ any penun in any manner sec as In hcomesuhjeeuo the Workers'Gmtpen- ENEHOV FEE
z Applicant
ant ofCUGf miu.Uv¢ -
Q WATIi IEATIIj'W/VENTIELIiCTRaQ
r1, 0 NOTICE
• - - GRADING FEE
wN-t Ncome subject
APP the Wore%Cormnsati this visioso of[aborom.d.,u nidd WATF YSTI?M/I'BEATING --
FKt ,
become m.eGmthe Wmhp,r,idms.rd, provisions of the Labor Code,Yuu nmxt SOILS ITL
� lanhwilh comply with such prnviciom or lhie pcnnit.hull be Accrued revoked. WATt t SERVICE
5 z CONSTRUCTION LENDINGrlend AGENCY NEW "' r6VIlAI:PLMtl._.�•._-•, I'AIU
C.7 Q k for.1reh rin this permit
e is isisurtcSee 30 l7,Cing agermylot the Performance of Uvt kreeipt#
the work for which(his pcnnit is issued(Su:.3B9).Civ.C.)
Q Isndcr,Namc TOI'A L:
G I<ndcrs AJdms, "f(YI'A1.:
0. 1 eerily that 1 have read this vpplic rtiun:mJ statc,h n the aM,ve information is BUILDII' I
lin corned.lagrec to comply with all city and county ordinances and vete laws relaing n' QTY. MECHANICAL PERMIT FEE
U z building aamv tactinn,unit ha.by.aumnrirc rcpnsentidoes.f this city msnter open the SI?IS
clowe-nmmiancd property fur imp¢aien Putlulaes.
'
(We)agree to s c,indemnify and kkeel)M1annle.n the City oI Cupertino against PERMITISSUANCE ELF C l?I?
Iiubilitin,judgmcros..ousa xpcnm,.h hmaty ins 'way uccmca• - sl said City ALTERORADDTOMECH.
in nscyurncc of me ngaf mil pcnnit. PLUh iE
APPLICANT UN .'fANI ' ')W (15 I,Y ' ALL NON-POINT AIR HANDLING UND(f010,WOCFM)
SOUR I;It 13C IION.' MECH ICAL FEE
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTR TION TAX
Signnwre n[Ap ¢'n ommcun Due EXEAUSI'HOOD(WIDUCn HOUSING MI"1'[CATION FEE
a HAZARDOUS MA ERIALS DISCLOSURE
Will the apilicam or future building occupant store or handle haemdnun material HEATING UNIT LTO IBBINN If TU)
to delincd by the C'upertinn Municipal Call,Chapter 9.12,and the Health and Safety
Code,Section 25532(u)f I IEATING UNIT(OVER 1110,010 BTU
❑Vc,
VENTILATION PAN(SINGLE RCSID) PAID
Will the applicant(it Ibwre building occupantuse equipmmfl or devises which Date Receipt 0
Ctnit hazardous air contaminants as defined by the Bay Area Air Quality Monegemcm BOILER-COMP(311P OR 100.000 BTU)
District! - / T AL:
re ❑Yea yygaO BOILER-COMP(OVER 100,000 BTU)
Ihave mad the hum Immvreds a under Chapter f.95 of the Cali- AIR CONDITIONER ISSUANCE DAL$
rc, -.
fomiu HeaW&Salef aSafio SBS,' myand 255]4, undemtanb Ilwl Iftba NEW RESIDENTIAL MSCI I. SQ.Ill O
uI the requir nn illy has nunr, nuance of a Cerifyumotifylhupied,nt
tame rcquh� :wnil _IbCm cora cenirfafa oracnpaney.
Own ntuhrr'' ,gam Dmc TOTAL: ISSUEDBYI —
OFFICE