S 2796 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BullDINI:-ELECTRICAL PERM]I'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBIIS;-MECHANICAL S 2796
BUILDING PROJELT IDENTIFICATION
BUILDING ADDaR&SS: SANTTARV NO. AI'PLICA'fIO/N 5DBMICI'AL DATE
�../ � V V n/iV-7� rt
OWNF. 'SA ry: PHONE: CONT tACOR:SNAME; LIC NO:
JowcS D1 VI / NIC CONTROLp
AR CHITECUENGINEER: LIC NO: ADU1 SS: ❑
.S/
CONTACT: �PHHONE: Gi t/Qyl DUILDING PGRMIT INFO
GSW ❑ Consultant Fees Paid By Applicant(Initial) BLDG ELECT PLUMB MECll
=r667 6 K K J< ❑
I-ICENS17D CONTRACTOR'S DECLARATION QTY. ELECFRIC PERMIT FEE
1 hereby,i iml that law
m licensed oer,noniom lir chapter 9(Commencing JOB DESCRIPTION
0peZ with Season 900H)nf Division 3 ofine Buaincsand Professions Cpde.md my license is RESIDENTIAL:
won p PERMIT ISSUANCE
1-�� in mlifiamandeffect. / _ ❑SFDWL KITCHEN REMODEI.
aUV Limnm Clas - r
-Li'
- APPLIANCES-RESIDHNI'JAI. ❑ADDITION ❑PLUMBINGR&PIPE
.<ta. Uatc Commcu J�
g.5h A CHITECTS DELI ATION INNIiIS ❑A1ULT1-UNIT [I STRUCTURAL
y p,rn Z I undenwn I Iny plans dicil be used ns p records MODIFICATION
till 10 211(IAMPS ❑INTERIOR [I CHIMNEY REPAIR
aFa-yt1 W Licensed Proleso oro 20WHID1AMPS IMPROVEMENT ❑SWIMMING POOLS
y.X=J OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
Q 1 hereby amrm that 1 am CXCMP'from the Contractor's License law for the
3 LLFV- following rearm,(Section]831.5.Business and Professions Code:Any city lir county SIGNS ELECTRICAL ❑OTfiER
y which require,it permit to mnstmer,anter,improve,demolish,us repair any summure
E^�Gyy a�' prioOna,issuance,od...or,mea the applicant f Oath pernam fileosignCdslalemenl ,SPECIAL CIRCUIT/MISC.
E y
ha,he is licamedpllrsmnunthe provisions nl'Ihe Contmnor'n Liwna Law(Chapler9
W..GAOa (annmercing will Section 7000)m Divisinn3 of the Nosiness and Prnrevninns Ctde)or '.IHMR MI!'I'p it OR(MILE INS'r. COMMERCIAL'
C. e LL IhCt he is exempt ln.cran and he basis far dow alleged exemption.Any vWmiun of ❑NEW BLDG/AUDITION ❑DEMOLITION
u1�m Section 9031.5 by any applicant for pemnil subjects the applicant In a civil penally of POWER DEVICES
n more than Eve hundred dollars(E51II16 0'
'III
1ENr FOOD SIiRVICFi
�=Q ❑ Las owner of the pnrpeny,or my employees with wages as lheirmle compensation, SWIMMING POOL ELECTRIC E
will do the work.and the structure is not intended or oRvied for sale(Sm.]M4.Business
Wm and Professions Cude:Tim Contractor's License Law does not apply to an owner of OUi'LITN-SWITCHES-FixTuR[S
property who Imilde lir itnpmves thereon,and who does such work himself lir through
his own employers,pru idel shut such impr mnlem,one not intended or offered for NEW RESIDENTIAL 1!LI?QTR SQ r n
rale Ii.bowevep ba buildup lir improvctncnt i—id&immo.c yearufgokiselion,the SQ rrffL 012 It1iA A/SQ.Ion
nwricr_builder will have the burden of proving that he did not build lir improve for pur-
plsc of salt L
❑1,as owner of the property,am exclusively contracting with licensed contractors to Tty AI
construct the Foci(Sec.9814,Business and Professions Code)The Contractor's Li-
nseLawdoesnotapplyloanownerofpmpenywhobuildsorimprovesthereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projeels with a enmraclor(O licemad pnrsuavfm the Conmmols
dictum Law. ( PERMH'ISSUANCE O
0li excmpl under Sec. —,B&P C lice l his rmss, r
ACFER-DRAIN&VEYI'-WATER CA) VALUATION
Owner Dnlc
WOCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
RnderpC O — 2, 000
I hereby affirm under penalty of perjury one s the fallowing declarations: t
❑Ihave and wi8mor by
ySeCion 37oe of Ce LatinCoodenforthe Wforma Cmnpen- DRAINS-FLTR)R.ROOF.AR[iA,COND. TYPE CON TRUCfION
smirk,as provided for by Sermon 31IX1 of the IaMrr Cade,for the Performance of tbG STORI'
work have
thispermitis Worker. 19JCI'URES-PER TRAP "-rs /�
❑1 have end will maintain Worker's Compusshe w Insurance, r d,minor
r i Section GR V
My orker LuborCwe,hlr lhion Carrier and Policy
inumber this permit is i,.mw. OAS-I?A.SYS'TI?M-I INCA VUPTS OCC CkOl1Y yfRli
My Worker•C'C
CERTIFICATE OF EXEMPTION Carrier Ind Polley numher are: -
Canier Insurance Policy Ne.: GA/S._IA.SYST ;QVHR4(F.
FROM WORKERS' GR iAS1I1ND KL WAS"TE INTERCEPT I
COMPENSATION INSURANCE 1 1 E BUILDING DIVISION FEES
(This visions need not becompleted ifthe permit is for one hundmldollars(511p) OR TRAPDD 1 �(1(�'1
or iess.) I'LANCIfECK FEE
Icenify'limiolh perfommecti workforuhichlhispennitki...ed.lahall r`s ••
pp SG E -SANITARY-STORM EA.21X1 PI'.
nut employ any person I toy m r st In necame.subjecno the Woden Conlpen- I!NI!RGY FEE
O Z sutinn La s fcalii .Des -� WA'lik IIHATF.R W/VI!N'I'/I?LIiCI'R GRAVING PF.F,
z Applicant
.N.I NOTICE P .ICAN`E ,after making this Ccnilicateof Exemption,you should WAI rµ_�S}gµfpµfVf71W
a ' become s r e to the Worker's Compenation provisions of Ne labor Cale,you must - SOUS FEE
forthwith ply with such provisions winos permit shall be deemed revoked. WATER SERVICE.
0
CONSTRUCTION LENDING AGENCY NEW kISIDPNI'IAI.1'LMB. SQ.Fr. PAID
z IhereM1 firm thouhere iso consvuminn Indio Gsnhe rfnmlunce of Dale RecetplN
UO ya y pe
(~
'lie work for which this permit is issued(Sec.3097,civ..C.)C.)
OLender's Name
U TOTAL:{LI Lender's Address OTA:
G I certify thg'I hove read this application olid ante the'he nbovc infnnsmiom is IIUILDIN F'E 2
F' Tn comet.I agree to comply with all city and county ordinances end,me laws relating In QTY. MECHANICAL PERMIT FEE
UZ building Commuion.unit hereby auNnmc representative%oflhis city to enter upon the SEIShfI
elawe-mentioned property for inspection purposes.
(We)agate hoses,indemnify and keep hannlus the City of Cuponino ogaina PERMIT ISSUANCE FLECI IC IE e Q
liabili'ieX,judgmcnln,ctnb ulW exlMn%cX which may in any way acerae stairs'said City At 17R OR ADD TO MECIi.
Iacggenccrrthe grent'Ingot this pcort. PLI1MIIi tFBP, O
APPLICANT U DERS'PANDS AND WII .COMPLY WITH ALL NON-POINTAIR HANDLING ON I'P(,to Io,noo CFM)
SOURCEREG .All NS. MLCII ICAh FEE
AIR HANDLING UNIT(OVER 10,006)CFM) CONST N
Cl[ON TAX
Signawr pplicam/Comm�or Dair EXHAUSTHOOD(W/DUCTI 11(IUSING 11TIGATIONITIi
HAZARDOUS MATERIALS DISCLOSURE
W'll the uPPlicum or(marc builJing occupantnmrem handle hvallous material HEATING UNIT(TO 10,0101 BTIO
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Death and Safety
Calf,Scclion 2553201)1 I IFA'I'INC UNIT(OVER Dg(I0 0 BTM
F-1 YC, [D N. VEN'll IATION FANS I NOLF RESIDI PAID Date Receipt Is
Will the applicant or future building mcupant use equipment or devices Which
visit hazallons air Commitment m defined by he Bay Area Air Quality Management BOILER-COMP(3HP OR 100.000 HTU) ,f A
UisuimDyes CI7,1(XLBBBBTU) ,
AIR CONDITIONER
have rend thn hvurdn a ems 2.15 5,25emelns under Chvpmr rs,w of the Cali- ISSUANCE DATE
Bmndi Heo11b&Sofey Calm,Stations 25505,25533 and 25534. undcmugW that If'ne NEW kl?SIDF.MfIAI.MECIi. SQ.19'. ��' R 7]
huilAing daxn CI Ily lluven Lenu but TIL Illy responsibililym nrtify the tMfupanl I
(,fine reign Is lith t iomp issu .Int l lmd of(k II cy.
tic mhmucd agent Das TOTAL: ISSUED BY:
OFFICE