S 2744 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH.DINC.ELECTRIC]. PERMIT NO.
BUILDING DIVISION APPLICA7'ION/PERMIT PING FROG"nF IDENPHAC S 2744
I nuu.msc rl:oaLtc'r IDENrHTCAIIOh
BUILDING ADDRESS. r SANI'IARYNG. API'LICATIONSUBMI'I'I•AI.DA'l'E
712 Z7 s11—�q-Fiy
OWNER'S NA h PHONE: !� NTRACIO AML: / �LCN /�
lG /Kr_J NIC CONTHOLa
ARCHITECT/IiNGINEF: L Nf x'. ADDRH i_/ ❑
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CONTACT: PHONE BUILDING PERMIT INFO
❑ CIns illant Fees Paid by Applicant(Initial) BLDG ELIiC1' PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S UHCLARAHON QTY. ELECTRIC PERMIT PEE
1 herehy infirm that I and licensed under provisions of chapter o(cem ncraing JOB DIISCRIVTION
Q=Z
nlmemr
' 3RESIDENTIAL
WO PERMIT ISSUANCE � ❑SDW.
❑KIrC11NRG0UEL11= fallunnIT
XULcene�ad - V Lic.pY/ZZ^7 APPLIANCES-RESIDENT ❑AUDI'170N ❑PLUMtING RE-PIPEQU lJ
QLDam Coh
AIiCI Ii"1'ECTS DECLAItA I ION ❑MLLI[-UNIT El STRUCTURAL
'D o,y I nrvmnJ m tuns he xhu l used av public recants PANELS MODIFICATION
OZ14p� ndeYp r UP 10 11(10 AMPS �3- [-]INTERIOR ❑CHIMNEY REPAIR
I Mlzw Licensed Pme,ional 211I-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
W44 OWNER-BUILDER UECIARATION OVER Hard AMPS
❑HATH RIiMODIiI/RIiPA1R ❑DIiMD1.ITIGN
I herehy affirm Nun I:on exempt from the Contractor's License Law for the
p W U ❑OTI II:R
L following rcnsen.(Section 7031.5,Business and I'mI...if ns Crule:Any city or cmtnlY SIGNS IBXCIRICAL
'3 LL y which tego'e,a Permit to crnutmal,:drr,impnwe,denmlis'h,ur repair any mnmutre — /300.tC.
��pgno,To if,issuance,alsorequlrullic.,licam fo,.ueh petminn fila axignedetmomcm SPECIAL CIRCUIT/MISC.
} that he is licensed pursutnuothe provisions e1 the Comment's License Lose(Chapter 9
W{Yp0 (commanding with Section70SB of Division 3 of the Business and professions CMe)or TEMP.METER OR POLE INS'R C.QMMERCIAL'
L q e C but he Is exempt therefrom and the had,for the alleged exemption.Any violadon of ❑NEW BLDG/ADDIT'ION El DEMOLITION
W y IVH. Semina 70315 by any applicant for a Permit nupjeck the applicant In a civil Penalty of POWER DEVICES ❑'TENANT ❑FOOD SERVICE
1� amore(ban His hundreddollam(3500). IMPROVEMENT
C O ❑
T.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL IiLIiC'I'RIC
p., willdmhewnrk,andthe strvcotre knot intended ornlfered Cnsole(Sec.91NJ.Business Off[1117R
W.
ao and Professions Code:The Connactoes License Law does am apply to an owner of OUTLET S-SWITCHES-FIXTURES IF
Property who builds or improve,Thereon,and who does such wvmk himulf or through at
his own ennplayces,provided that such improvements are not omcadetl or offered for NEW RESIDENTIAL EIAiLTR SV FT.
mde.If,howc...lit,building nr inmtniverol is sold within one yc:uaf completion,the Nt 17..FLOOR AREA E/SQ.Er.
owner-larlder will have the linden of proving that he JW not build or improve for pur-
pose of mle.l
I,as owner of the property,um exclusively contracting with licensed contractors a 'IOTA L:
construct the project(Sec.EDT,Business and Professions Care)*Hc Conllaenls Li- 7
cense law does nal apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT EEE
who caramels for sued,proiects with a wmracions)Ievired pursounl b Lha Contractors
License Law. 1'IiRM1'1ISSUANCE
❑ l mo exempt rude,see. ,li dr P C bar this re eon
AUI ER-DRAIN&V17N'I-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARAGON HACK FLOW PROTECT.DEVICE
I heathy affirm under pvmJly ofpcipay one of the following desli m emo:
❑ I have and will maimuinul'eni0cuteaf Qnnunt m,clf-insure for Warkcrs Compcm DRAINS-FLOOR,NOORAREA,COND. ,'TORIES I'YI'I!CONSTRUCTION
,anon,as provided forhy Section 3900 of the Latin,Cade,for Ibr ordlormance of Nc
work lin which Nis permit isl,med. FIX'I'UR17S-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
(IEO(me LvMn Code,for the performanre mine work for whish this permit i,issued, GAS-IiA.SYSTEM-I INC.JOIIT S OCCGROUP APN
MY WarAyglts Inn It stvey6Fe c(rrmer one Policy n
Cvnicr: 7 JLQ�I'ma No.: CAS-IiA.SYSTEM-OVER d )
CHKIHFICA'I'If IIF EXEMPT]ON FROM WORKERS GIIHASIiIINDUSTRI.WA" :INTERCIiP'I UR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Uratection need out becompleredillhepermit isfarone hondmaldollars(311x11 GREASE TRAP
or less.) PLANCHECK FEE
I cenify that in the performarme attain work far which this permit bissued,Islmll SEWER-SANE RY-ETORM EA.201 IT
nm employ any Person in any manner so as to beunnc subject In the Worker'Compen. ENERGY THE
z smion Lnwa of Culil'nmiu.Dom WKI'EIt IIP 'ER W/VENT'/I!LEC'PR
z Applicant GRADING FEE
sz..t .~N.
NOTICE TIG APPLICANT:IT alter making this Cendicma of Exemption,you should WATE SYSTEMO RFATING SOILS Plili
F > become subject m the Workers Compensation pmvlxiae of the LnMrt Cale,you roust
forthwith comply with such provisions or,,his permit,hall M deemed revoked. W rR SERVICE
1t Q
z CONS'fRUCTION
'LENDING AGENCY
NEW tIiS1UBR1'IAL'LM111. SU -n it«ciplN
UO Inmm,y affirm mm mora is neonswndooat ,g agency rat the paTomana ar
U. the work for which this pemnit is issued(sec 3097,Civ.C.)
Lenders Name TOl'A L:
QLeonine,Address 1 Ann-
Rt 1 aemd,That I have rend this application and staid Ihm Nc above information is r h,M, BDILDING Il
tF-tN camcctJ agnctucomply whitnll cityandcounty ordinances and s,.ad lues,oduCalnn QTY. MECHANICAL PERM I PI' .
U z build ingda...beef nn.and herehy au0ori7a mprecentatives obthis city la enter upon the SEIh MI Pli
above-maatienul properly lbr inspection purPosay. PERMITISSUANCE HL!C'TRIC
(We)agree To save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments costs and expenses which may in any way accord against said City AITEB OR ADD TO M ECIi.
in mscqucnce&1,.&raring of This penniI. UM111tING PE
APPLICANT' DERSTANUS AND -LI ) PLY WITH ALL NONPOINTAIR HANDLING IINI'I'('IY)I(1,10U ChA11
SOURCE ULA'IION' MECIIAN F.
3 AIR HANDLING UNI I(OVER 10,01 'PMI CONSTRUC ION'TAX
Nigro of Applivms1C rsmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PTE
HA KDOUS MATERIA(S DISCLOSURE
Will The applicant or future building occupant store or handle humrdous material HEATING UNIT LTO 1110,( BTU)
as defined by the Cupertino Municipal Calc,Closer 9.12.and the Health and Safety
Crile,Scotian 25532D)7 / JA""I'l
A'I INC.UNIT(OV' B)OIxxI RTU)
yes YIN, PAID
///___ N'1'ILA9'[ON F (SINGLE REST[)) /� ReL.c�ptp
Will the applicant or fours,building occupant use equipment or devices which
emit lama doe air ronmminems as definM by the Bay Area Air Quality ManagementILER-C P(31411 OR 100.007 WITH TOTAL!
Dimond? ll, COMP(OVER 100,000BTU)
❑Yvx IN./ I)NUITIONERI hove rue the hoodoo,materiels rcquiremmnu under Chapmr 6.95 al We coli- ISSUANCE DATfomia I1call hsafetyCx.Je.lection25505 ' 33 and 2551J.I nnJcmane Nm if TheiW RESIDENTIAL MIiCH. ��
buil'a"d� nolcurrendy c eta rymponsibiliry mnotify dm arupam
of Ne trcn¢ns who .sal he t ranee of a Ccyi��a� txc u,
s 3 k�
0woe ran i....I ag I pyle�� 'I1y1'AL: ISSUED IIYaT�e • � '
OFFICE