S 2899 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELF.CI'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMP NG-MECUAN1CAL
BUILDING PROJECT IDENI'IF'ICA'110IN qq
OUILUINC )DLESS: � SANITARY NO. tPLICATION SUBMITTAL ATF.
OWN". " / CONTRACTOR'S NAM!;: _ LIC NO: C
' '-//11��AAOO CONTNOLp
1POtCIFIFECI'IIINGINIER: LICNO: ADDRESS: ❑
CON'fAC'I': PHONE: BUILDING PERMIT INFO
A '��'X(� ElConsultant Fees Paid by Applicant(Initial) BI.DG ELECT PLUMB
MECH
/7 vAs� El EJL� ❑
LICENSED CONTRACTORS DFCLARNPON QTY ELECTRIC P17RMIT FEE
I hereby affirm liar I an,licensed made,pmviebm of chapter 9lcamm..ring JOB DESCRIPTION
�aZ wihsocllmn IlXXBefDeWou 30,hc Businesailnd Prafessi...sCade.andmy Blease is RESIDENTIAL,
OO PERMIT ISSUANCE
UlU mfense Class
c0un. ❑SIUWL ❑KITCHIiN REMODEL
EUU License Clms LIaA APPLIANCI3S-RPSIDENI'IAL ❑ADD]TION ❑PLUMBING Rf P1I'II
E-Z 1 Dole—GnnlDECL
Q¢ AIiCHI'IP,CI'S DF.CI,ARA'I'ION ❑MULTI-UNIT! ❑STRUCTURAL
[-D N PANELS
Z Oval l undcmand.11...shall he..it as public recoNs
O
Z�`� UP'02XIAMPS ❑INTIkIOR ❑CHIMNiY REPAIR
r L4t:w Lovscd Prnfessl...I 201-1000AMPS IMPNOVEMENT EJ SWIMMING POOIS
OWNER-❑IIILDIiR DECLARATION OVER INXIAMPS ❑HATI I REMODEIIREPAIR El DEMOLITION
a LLa Q I hereby affirm hal I am c.aempt from he Contractor's License Law far he
aC,U I"ollowing revs....(Section 7031 5,liminess and Pmfcssions Cale:Any city nr county SIGNS Fa.CCfI21CA1. ❑OTHER
ul a h which requires a Permit to construct.alter,impmve,demolish,or repair any swclure asQ / 6
Q 'mono its issuance,also requires the applicant lar such permit it)file a signed statement SPECIALCIRCUIT/MISC.
and he is licensed purstrand to the provisions of the Contractor's license law(Chapter 9
W Q� (amm�encing with SeminaRXX))ml Divisian3 mf the llusinas anJ Rnfessions GMel ter TEME METER OR POLE INS'T COMMERCIAL:
a0 1 hat he is exempt therefrom and the basis far he alleged exemption,Any violation at NEW BLDMADDITION ❑DEMOLITION
'a(�a• Section 70315 by any upplicam far v permit subjects he applicant ton civil Penalty of POWER DEVICES
W�r� mm�...cman five hundreddolhus(5500). TENANT ❑FOODSERVICE
IMPROVEMENT
=Q [ I,,,it,wowner kf the property, ry mann ended with wages edfor sale IS ,compemmtinn, SWIMMING POOL F.IJICI'RIC
6q
a�
wdl da he work,and lheauunurc man imondeJ or it l'ur solo(Su.]n44.Ilusinuas ❑OTHER
W and Profusions Calc iise Committees 1.icenx Low does non apply m an nm of OUTLETS-SWITC1113-ITXTUR[S
pmpwty who bmdds m impmvflu macs..,n.d woo hta.au"h ware h ed m o,mroogn
I own owevecarrdo,vi,me taildo d hon such..in., old am not intended nr o0cml for NEW RESIDENTIAL IiLGCI'R SQ F.
cele.IL however,the huilding nrlvy+nrvmn,m is snlJ whhin ane yntrnfunnpletlap the SQ.1'11 FLOOR AREA $/SQ.FI'.
s owner-bra er will have the burden of Proving that he did not builA nr improve for pur-
c.
Ons asowta T'O'TAL: ��
of the property,am exclusively contracting wih licensed contractors In
ceroil Ili,project(Sec]Ilan,Bn imus and Ihmfexsimts Code:1'11te Comrunmr's hi-
nwLawsaesnotapplymono ter nl',..play who build..or itnprms hereon,amu QTY. PLUMBING PERMIT FEF, FD
whncnmructs tpmjuas toil tv mw,om( licensed pumuunttothe Cnmmctor's 4 99
License l.uw. PERMIT ISSUANCE 3 APR 1 1
❑Ism 'A Sec .B&PC ter lli' rcmon
All1'17R-GRAIN&MINT-WATIiR(IIA) 'X�It VALUATION
Owner Datn
ORKE MPENSA'1'ION DECLARA'f1U HACK FLOW PROTECT!.DEVICE
1 hereby affirm under penally of Perjury ane ofthe fallowing decluratiom: B
I haveund will muinminu Cenillcem ofConsenuo xelf-insure lar Worker's Canal DRAINS-11OOR,ROOR,AREA,CON 1). '1'YPECONSTRUCfION
ration,as provided for by Section 3700 of nM Labs Calc,for Ibc performance of the
work for which this Perot lis iswn1d. FIXTURES-PER TRAP
EI I have and will maintain Workefs Compensation Insurance,as required by Section
371111 of the Labor Coda formeperformnuccol""the work far which this perothis issued. GAS-EA.SYS"IT F.M.I INC.4 OUTIS OCC.GROUP A p
My Wa,wr`,Compenmtion Insurance carie,and Policy number are: V
Car,ar: Policy Nn: GAS-F.A.SYSTEM-OVER 4(EA) /
CERTIFICATE OIs EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
('Ihis.,mn need nal be completed if the permit in formic hundred dollars(S 100) GREASETRAP � - — --�
or Iess.7 PLANCHECK PEE
I cenily that in he performance of he work lin which ibis permit is issued,l shall SEWER-SANITARY-STORM PA.21X1 FT.
not employ any person in any manner so us m raccoon,subject it)the Workers'Compen- ENERGYFI
Z sari....LOW.,of California.Date WATER 11E 11311 W/VIiNT'/ELECFR
7�Q Applicant GRADING FEE
.^. rj) NOTICE TO MTLICANT:If,cher making this Centurion,of laemption,you should WAFER SYSTEM/TREATING
F became subject to the Workers Cpe
omnsation provisions of the Labor Code,you must SOILS ITE
tiforthwith comply with such provisions or this shall he deemed revoked. WA'T17R SL'RVICE
Q Q
U O CONSare kitcmis LF.NDINGAGI cant' NEW RESIDENTIAL I'I,MiI. SU Frf, PAID I e Rent iplp
1 hot which
lite hem iso,d(Ser.30 lending agency far tM1c perrtmtuna of
Ibc work for which this permit is issueA 15w.Jtlq],Civ.C.)
Lender's Name TOTAL:
Lende,Address
a 1 unify Ilial 1 have read This applicmion and su¢Ihm the above infnnnaninn is BUILDING tHE
tF-t f/J "once,I agree tocmnply with all city and Oi uynnlinarre,O d stem laws rcla ing m QTY MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives of this city to enter upon the SEISMIC '.E
aMwe-tae Maned pmixny tin'inxpcetinn pupnaea' PliIi MIT ISSUANCE
( agrcemuvc,' oily unitkn•P harmless the City of C.,mrat.,mast CLEC TNTC
Iiahlllliu.udgmen,,casts ndexpemes which mayi..anyway accmeti,timt said City g1;1'F:R Oft ADD TO MECII. O
in curtsey sof the......f this permit PLUMBING P'F,
APPLIG.T UNDIiRSL )S AND 11.1.COMPLY Wilt ALI NON- DINT AIR HANDLING UNIT(0IB,(XX)CFM)
SOURCIi .'UL 4T O' MECHANICAL ai
AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCT ION TAX
Slgn,arc of moor D a E%IIAUST HOODIW/DUCT)
IfAZARUGHS MN'ERIALS DISCLOSURC HOUSING MITIGATION FEE
t theapplicant or home building occuprm store or handle hazardous refumml HEATING UNIT(TO]BLOW Bill)
as defined by the Cupertino Municipal GMs,Chapter 9.12,and the lieanh and Safety
Cale,Section 25532(a)'! HEATING UNIT(OVER 100,000 ETU)
❑Yes VEN'I'ILADON FAN(SING LE RESID) PAID
Dane Reca p
Will the oppliwm car fmnm building aceupanl use equipment or devices which BOILER-COMP(31{p OR 100,(NIO BTU)nit namrdous air contaminants as dl by he Bay Area Air Quality Management TO
DISH 1
❑Yes BOILER-COMP(OVER 100,0(al BTU)
AIR CONDITIONER
I
has ad the he7do nmaials uiremen(s under Chapter 6.95 of the Cali- ` ISSUANCE:DATE
fnmin i:ca t S,Rf,Calc, r s 2550 25533 tmd 25534.1 ua I•.In n I that if Ibc NIIW RL'SIDENTIAL MECII. SQ,FP.
onfic,gd sr maily se u' mymspnnsibirty m r 'fypth��e cups.., I
nl'Ibc ret en t w & not it t ammo 1vCenil r� l +
Owner Ihnri- 1tgenl Date
TOTAL: ISSUED BY: s7_
OFFICE