S 2469 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BU I[,[)IN(;-ELECTRIC.I. PERMIT NO.
CAL
BUILDING DIVISION APPLICKIIONIPF,RMIT PING PROJEBINGCT MENTIFIC S 2469
BUILDING 1'RDJI!C'F IDN.N'ITFICATION
II UILDINGADDRGSS: SANITARY NO. APPLICA)'I(1N SUBMITTAL DATI
tea+'
OWN R'SNAMIT' PHONE: CUNTR .fU 'S NAME: LIC NO:
C Y, 491 T
N/C CON'IROLa
CIIITECI'/ENGINEER: LIC NO'. ADDRESS
: ❑
'ONTACI': PHONE: BUILDING PERMIT INFO
�� - �5 ❑ Cunsullanl Pccs Paid by Applicant(Initial) BLD ELI❑'.Cr I'LIl❑MH MI'❑Ct1
LICENSED CGS rRACfOR'S DECLARATION QTY IiLECFRIC PERMIT FE[': JOB OESCR IPTI ON
1 hcrcny alEnn m;n I am liceroal under pnrvisions nl CLapter 9(commencing
�Z i1h SemonW )0)cI Dlvldmt 4or Etc Busmouaar;d ' .fixsinn.Crdn,and rnyllmnmix RFSIDFNTIAL
WO0 w; I'IiRMI'I'ISSUANCIi
CWF- mfull force un cRat. ❑SFDWI, ❑KITCHEN REMODEL
=WP Licelne lass Lica APPLIANCES-RES]DENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F Z W Umu Cnmmmor
cep Q'p ❑MULTFIINIT ❑STRUCff1RAL
r kCHITI?GI'S DF,CLARA PANELS
F AZ Iunderstand rayplunnshall be used as public records M(ODII ICAI'ION
----L UPTO2UUAMPS El INTERIOR []CHIMNEY REPAIR
Licensed Professional 201-1001 INIPROVEMENT 0SWIMMING PCOIS
OWNER-BUII.Id:R DECLARATION OVER I000AMPS - ❑BATH REMODELIREPAIR ❑DEMOLITION
a C Q 1 Lcmhy ufGnn that 1 ant ucntpt Frere the Cnntraclor's l iccmac 1.11,for me
OCw
t CIT U following maroon.(Section 70315.Business and Profession+Cade:Any city or county SIGNS ELECTRICAL ❑(YfHI? 1
m which requires a permit to construct,Direr,improve.demolish,or repair any Thacian --\/�1-QT T
o,T,; prop I also y the applicant fM1p.noril Inlife 6 Lt-mnemt SPECIAL CIRCUIT/MISC.
be,lie Ip Oa'he p D C t' lor,U,enor l' ((I'ptarr COMMERCIAL:
WCCSO (commencing with Section"RNID) fD a J ITh R :- dl I Cdc)or 1'I:MP.MI:FIik OR Pi INS'1'.
a a.c C that he is exempt Iheretmm and the basis for the alleged exemption.Any violation Of ❑NEW BLDG/ADDI'I ION C]DEMOLITION
kmLL Section]031.5 by jury applicant for a permit subject,the applicannna civil penalty of MOWER DEVICES ❑"NAME' ❑FOODSERVICE
W h aI nmre Than Evc handfed dollars 18500).
.r.=6 Ljun owncrnf the n SWIMMING POOL 1, IT MPROVIiMENT
G pn'pe r.ornry entpinyces with sergcemthcirsnlc nmtpaoaJn"' o'rHER
p.. will do the work.andthe.ary m.is rot intended or nflead bustle(See.]IHJ.noxious
m and Professions Code:"The Contractor's Licen,law does not apply O)an Owner of GETr1.FT5-SWITCHES-FIXTURES
TO
3 I ly wire builds or Intprovcs Ihcmnn,and who docs such work h mcult ,,,hmugh
his own employees,provided that such imp rvemenls am not intended or ohcmd for NEW RESIDENTIAL PUT= SQ PI'.
sale.ILhomewe the buildingor mapmvententosold within true yearofemnpletion.the IIGR ARBA SISQ.Irl'.
evear.builder will have the burden Of proving that he did not build or improve for par- /
O1,.-e
Lassloo ax,of the property,ant cedu+iccly contracting with Receded ucumcmrx to TOTAL:
m+wct the project(Sec.TOLL Business and Pernewions Cade:)The Counacmr'.s Li- ` 7
ceme Law Jams nor apply to an owner of progeny who builds or improve,themor.and QTY, PLUMBING PERMIT FEE
who contracts Gtr such projects with a ccrrmctm(x)licensed pursuant Io the CommemLs
Lire—Law. VERMI'IISSUANCE
(]1 am exempt rather See. .B&Is C for his reason
ACrER-DRAIN d VENT'-WATER(12A) VN,UAnON
Owner Date
WOR KIR'S COM Ill NSA'IION DECi A RAI ION IIACK FIS PROTECT.
I bruchy ulBrnt under betrayer IerPtD nuc of the lidlowing dedurntionc
I have and will maintain a Cenificam of Corwinto.self-imam lot WorkcBs Compcn- DRAINS I 1 R. CON S'IORIVS TYPES CONS'IRUCTIOS
m s powked far by Section 3700 of the Labor Coals.far the performance of the I y
'rd Orr which this pennl is issued. FI%TUR �PERTRAP J //\Y/
❑ I have and will maintain Wada',C(...urn-lion houmnce,nx mgoircJ by Section - II--
J1004thelabrCode,lit he lerfnmmnceof the work for which this permit n issued GAS- .ESYSr MNdN-. 'LI�9 (ICC.OR
APN
My Werkcr's Compemmion Insurance carie,rad Policy n andel um: w 3 5TQ3�5
Onncr: Policy Novo GAS-EA.
SYSTEM OVIiH J TEA)
CFRTIIBCATEGI'EXEMPTION I ROM WORKERS' '�
COMPENSAHONINSURANCIi GRIT\SPJINI�I15'1'kl,WA51'E IN'1IiRU'PIOR B ILDINGDIVISIONPEFS
(This xeaion maul nm bucompleted if Ne pcnnit i+(nrwwhundrJdollaa(SIND GREASE TRAP
I'LANCHIiCR FE[
or x-1
Iccrily lLatinmc purlrean,, of he war h 'hicb tltis lncrmitls issued,rConaten- SI1WIiR-SANI'I'AItV-STORM IIA.2U11 PC
employ any person it tiny moaner�+y rob npy,(w[,y� Ire Workers'Campers- 17 TROY FIE
O ,'� nation laws of Ca Lira. trc /c- —�i--J— WAFER HIiAIF.R W/VIiNT/F,LECIB GRADING IIiE
0 Applicrm^
'�'r NOI'ICE'I ON'P-L1r7('N'I If, imnnakingthis Cerificaterf Exemption,you should WATER SYSTEM/I'BETA[ING
SOILS ITili
a ;
became subject m the Worker',Compema inn prnvisinns of the labor Code. -into
04 Ibrhwith comply wabmch p-L....or this penni,,h.il he deemmd revoked. WATER SERVICEUJ M
PAID t-
7 z CONSTRUC'T'ION LENDING AGIiNCY NEW RESIDENTIAL PLMB. SV IT. tc Receipt M
U O I hereby affirm That there Is n canomclinn Imtding agency fur the pert rrnnncc nl
U.
- thcwnrkfnrwhichmispermit is i....it(Sec.$IMI].Civ.C.) TOTAL:
Q :wLvdrA Nan¢
U Lcndcr's AJArcw+ 'T(ITAL:
rN IL I eerily that 1 have read This appllca(on and rate Ihw the abnvc I;J'ormullmt Ix BUILDING P
F' EG correct.l agree to comply with all city and county ordinances and state lawsreWeng to QTY. MECHANICAL PERMIT FEE SEISMIC TRE
U building coronation.and hereby anthmiss mprc,entativcs of this city to enter Open the
uMwonanBnned pmp L fur no,eetion puHnoel. PERMIT ISSUANCE ELECTRIC FE
(We)ugn'c art save,indermiI,end keep Lennlna are Co, d Calcium,on......
limniliiics.judgnum,,cost'and expenseswhahntey in any wayacceieagainsloud City AITEROEEADDTOMECH. PLUMBING FEE
in cerscrNcnce ofthe granting of This cmil.
A VPLICANT UNDERS FAN AN D WE LL CONI PLX WITH ALL NON-POINT At R HANDLE NG IISEFTO I ROM CTIA) MECHANICAL ME
$till ?RhGULAI IONS, /1 / A
Olt - U •^(jaj, AIR HANDLING UNI'I'l(1VHR IILINIII CITU CONS'IRl1CUON']AN
SiS�Iure of Applacan brnme(br '� arm EXHAUST HOOD(W/DUCr) HOUSING LED IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building aeeuprnl neem or handle Inu ndom'material I IEA'I'ING UNIT('H)IINI.INID BTU)
us defined by the Caprnin,Municipal Cade.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 ETU)
Cade.Section 255J2(a)'I
(]Vex Fl NO VIiSEDLXHON FAN(SINGLERIiS1U) PAID
Dam Receipt p
\Vitt the applieanl n,future hoilding arcapant use equipment or devices which IyO1LER-GGMP(}IIPIIR Ig1.gX1 ETU)
r buaurpous air c:m aimart,us defined by the Bay Area Air Quality Management 'I' 0
tlfitIf IFF
.00GHTID
E]Yr, ❑NO
I have mad the hRnoteasnwtedals is un&r Chapter 695 of the Cali- ISSUANCE DATE
equimmen
fitmiu Health&Salcty Cade.Sections 255115,25533 and!25534.1 unJemm�J ram it he NEW . S0.ITT.
hnildtng Jue.v rereurrcnly burs Wnunl lh:n it le n,y nnibililrmnmt if c,Or /
of lhv l.a.Q I.ms T.'lliclt ,ari a.incl n,A i+n+u�tc(dfa Ccnit Idin
Vwnerngcnt +b V6.•lY/ T e(Qt—�41 TOTAL: ISSUED IIY:
OFFICE