S 2339 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2339
BUILDING PROJECT IDEN'T'IFICATION
BUILDING ADDRESS', SANI 1'ARY NO. APPLICATION SUBMITTALDATE
OWNER'S NAM F: l /'� ^ PHONE/ CONTRACGTO/R�:S NAME: 0VLICNO'.
Allik
V ,1 I& / WOMO �-IN� S rCl iti(S/j NIC.
CONTROLp
'ARCHITECT/ENGINEEK LIC NO, - ADDRESS: ❑,
CONTACT: _ PHONE'. BUILDING PERMIT,INFO
J-U4/ 'F"tL&r ?2,v- 6,7D o ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED hat I o CON'TRACTOR'S DECLARATION QTY. ELF,CTRIC PERMIT FEE
1 hereby amrm coni 1 out Ransom sneer provisions.x of Chapter 9(commend,, JOB DESCRIPTION
HOZ with Seorreandon ith Divisinn3of the Business and Rofessions Cnde.and my license i.c PERMIT ISSUANCE r' RESIDENTIAL
Cy� JU Loculi farce and diem Q®' ❑SFDWL ❑KITCHEN REMODF.I.
6 V U License Cl nv' Lic p
Q,a Datc CommRnr APPLIANCES-RESIDF;N'TIAL ❑ADDITION El PLUMBING RE-PIPE
cl ^ARCUITECFS DECLA 'ION t r PANELS
❑MULTI-UNIT L1 STRUCTURAL
Z O h p I undernand my threshed locales!as public records
O.Z MODIFICATION
UP TO 200 AMPS
{W La,en.led Prnfessmml El INTERIOR C1 CHIMNEY REPAIR
a sss�'.�I OWNERBUILDERDECLARATION 201-IOW AMPS IMTUOVF,MFNT CSWIMMING POOLS
o w 6 I hereby affirm tom I ant exempt from the Contractor's License Law for the OVER AMID AMPS ®,BATH REMODEL/REPAIR C DEMOLITION
O,V following reason.(Section 7031,5,Business and Profensiens Colla:Any city or enemy ❑OTHER
W'31y,F SIGNS ELECTRICAL .
which reyuires.a permit m construct, her,improve,demolisM1,or repair any structure
rn prior to its issuenco,also reyuirexthe npplicam for such pannemfileasigned smmnsnt SPECIAL CIRCUIVIv11SC.
a;!(¢� ohm he ix liwnsal pursunmmthe provisions of the Cnnnacmr's License Luw(Cham,,9
W"00 (commencing with Section7llW)of Division3 o(am Buainexs and Pro(essioos Gde)nr TEMP.METERORPOLEINST. COMMERCIAL:
F y C that he is exempt therefrom and the bulls for the alleged exemption.Any violation of
El NEW BLDG/ADDITION C1 DEMOLITION
iuCl-,4y Smtlon 90315 by any applicum fernpermit subjects the npplicom toucivil pennlry of POWER DEVICES
thy}
all morethan five bondrel dollars 5500) ❑TENANT ❑FOOD SERVICE
❑I,as owner of theproperty,or my employees with wages as their sell,compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
[�F will do the Indicated th arsurnfe is ern ntcndedornlfered Battle(Sec.7044,Business ❑OTHER
3 end Professions Code.The Contractors License Law does nota m an owner of OUTLETS-SWITCHES apply FIXTURES
properly who boils,of impmvec thereon,and who does such work himselff through
his own employee,,provided that such inmromwt
ves are not intended or,Herod for NEW RESIDENTIAL ELECTR SQ PT.
ade.If,howcvcq the building at improvement isnold within mneyearofeompletise,the SQ. OORAREA $/SQ.PT.
owner-holder will have the hunlen of proving that he did not build or improve for pro-
is
pose or sale.).
❑1,as owner of the property,am esclusively commences with licensed contractors to TOTAL -
constmctthe'preje vAGGr414nu...�„ t' imsCode:)TheConVact...vi-
c se Law dues no l�lyman Mn�'om pmpeny bei sort rove Reason,one QTY. PLUMBING PERMIT PEE -
who contraetstoo' tIcch� lvetois s)[Insed pt� nrotheeontmems" -
License Law. �U LlPERMIT ISSUANCE O
❑I am exempt m B P C for thiv reason
ALTER-DRAIN&VENT-WA'T'ER(EA)
Owner VALUATION
n under Penalty
,A 'f BACK FLOW PROTECT.DEVICE D
I hereby t UGERSeCOMPENSAryone of the In own declarations: b
❑ Ihevcaudwil neihtain a Cenlficemof Coasent m self-ireure0. Workars Compos- DRAINS-FLOOR,ROOF,AREA,COND.
'tiom
n,as Intend 1$ Section 3700 of tiro Lahor Code.for BE performance or the STOR .S TYPE CONSTRUCTION
r which Il . FIXTURES-PER TRAP
ort hQ
wave and will maintain WorkerCompensation',Compenson n rl,ynlrcd by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-FA.SYSTEM-1 INC.4 OUTLETS ,OCO.GROUP APN
My Workers Com ens I Insurance tinnier an[put mm� /
Currier s? f' ��popcy Ne.: GAS-EA.SYSTHM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROMW .KERS'
COMPENSATION INSURANCE GRFASE/INDUSTRL WASTE.INTERCEPTOR BUILDING DIVISION FLES
'(This.cecom head not be completed It he permit is rnrone hundred doll..($IW) GREA$ETRAP
or less)
PLANCHECK FEE
Loy any petrothe Any marrnccolahev,ak far becomewubjectch to perthe Workersued.lshah SEWER-SANITARY-STORM F.A.200 FN'.
not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY PP,P.
coition Laws cd Calincr l.Date
O z WATER HEATER WNBNT/ELECTR
E - GRADING FEE
tiNOTICE
N(yI'ICTO APPLICANT:If,spelunking thio Cenitieute of Bxemplioa you mould WATER SYSTEMITREATING
Fx , become subject m the Workers Compensation previsions of the Labor Code,you mus SOILS FEE'
W forthwith comply with such provisions or this pennitehall be deemed revoked
WATER SERVICE
Q
CONSTRUCTION[.ENDING AGENCY NEW RESIDENTIAL PLMU SQ.FT. PAID
U 0 Iherby offrnthmthemis.control leading silently har the perkmarmceof Dvte aipt#
LL P the work for which this permit is issued(Sec 3097,Cid C)
OLender's Name TOTAL
{UTa Leader',Address 0TAL'.
Iy I certify that 1 have read this application and state that the above information is BUILDING FEE
y correct.)agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
building wnsmclioo,and hereby authorize epresenmtive,of this city to enter upon the - SEISMIC PEE 570
above-mentioned property for inspection purposes.
PERMIT ISSUANCE(We) to aveindemlify and keep hnnnlec,the CitynI'Cuel,nnongvias rt?
ELECTRIC EF
habil hies,judgments,costs and expehses which may in any way accme again,said City ( ALTER OR ADD TO MECH.. O PLUMBING FEE O
in censorial of the graming el this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNIT(TO IOpfN1 CFM7
SOUR�I REOG'UL�ATMIONy y p MECHANICAL FEE
AIR HANDLING UNI'1'(OVER 10,000 CFM) CONSTRUCTION TAX
Sig tIglja seufAf"`Ap'"'p"licar��i"e'"art/Cimtuou Data O EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplienmor future bulldingnccupemnomor handle haestr eneatefial HEATING UNIT(TO IOOA00 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'/ HEATING UNIT(OVER 100.000 H'1'U)
El Ye, F1 No PAID
VENTILATION FAN(SINGLE RF.SI)) Date Receipt#
Will the applicant or furore buildingby the Bt use an Air u or devices wInch
'Dist hmmdeus air comeminnnw as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,11011 BTU)
DisirinvTL.
LJ Yes �No BOILER-COME(OVER Iti11.oW BTU) I
I have road the Ismafdome coatnriuly reencochtsunde,Chapter 6,95 of the Cali- AIR CONDITIONER
4 p ISSUANCE DATE
Rome Health&Safety Coda,Seasonal1!5533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.IT. /D r 7/lam O
building does ern currently M1aveatwam,ihm it is my rosponcibilltymnotil'y the occupmn - (/
of the reyu encs which nm he met prior to issuance of v Certificate of Occupancy.
m �— Y
Owner dasizedrnagenl Date O'T c ISSUFDBY: ( l /
OFFICE