S 2819 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PIiNMI'f NO.
BUILDING DIVISION APPLICATION/PIERMIT PLUMBING-MECHANICAL. S 2819
BUILDING.PROJECT IDF.NI'IFIGTION
BGII-DING ADDR[SS: SANITARY NO. APPLICAI ION SUBMITTAL DATI
(IWNON MG: O PI ONF;� CO R, NAME: LIC N(1: —6 —1
I N s NIC C(lNl'ROI.a
`ARC 'IECTd? OINEF.R: L 'h API3ItGS5: ❑
/ n
CON'I'AC"1': PHONE: v BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) HLDG ELECT PLUMB MECH
Q. Mol ZQ El ElL!Y ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm mat 1 am beenxN ander pmeismms mf chapter 9(ciamentdng JOB DESCRIPTION
CA with Sation](X)(1)uf Divisionlof the Hueincxsu JNnfes'ons Cud e.anJ mylicense is RESIDENTIAL,
O PERMIT ISSUANCE
Fes_ fin full force andyfRlLQ / / ❑SFDWL ❑KIT NREMODEL
aUU L¢ensc Class-C.i'-(f—Lina APPLIANCES-RESIDENT]AL ❑ADDITION .UMBING RE-PIPE
Fs:a a Dane c.+mmadT
EARCH[FECPS DECARN'ION ❑MULTI-UNIT []STRUCTURAL
ori
Z O m Z I and a
undcrslmy planhall be used na public rem
ede PANELS MODIFICATION
O Z-C UP TO 200 AMPS
_ ❑INTERIOR ❑CHIMNEY RI;
F41❑z-' hiacnsnl Ptoresionul 201-InWAMPS IMPROVEMENT' GSWIMMING POOLS
CY C� OWNER-BIIILDIIR DECLARATION OVER IB(m AMPS ❑BATH REMODEUREPAIR C]DEMOLITION
C C ae 1 hereby affirm that I am esentpt from The Commcom's License Law fpr In. —
.1 d U fnllowin,ncaum.(Section]831.5,B.,incxs and Profesvion.r CWc:An t OOH HER
�( y y eftyo,or coon y SIGNS ELECTRICAL.
Iv131+ so which inquires a permit m conswat,uler.improve,demolish.or repair any.amarum
prior to its issuance.also requires me applicant for such permitto file a signed statement SPECIAL CIRCUIT/M ISC.
feg thaheis0cemedporsmamtothepmvision..of rhe Comracmts Liceme LawtChapter9
It 00 (connnencingwim Section](XA))of Division3ofthe Buainessnod Rmfessions GNe)ur TEMP.METERORPOLEINST. COMMERCIAL:
a a c�y that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
Xm4 Section by any applicant for a penmitsubjecu the applicant a civil penalty of POWER DEVICES
ul.-y GTENANT FOOD SERVICE
t more than five hundred dollars($51X11.
F Z i IMP OVF.MFNT
XQ 01,us owner of the propenyl or my anpinycee with wages as Meir sole compenm.inn. SWIMMING POOL ELECT RIC 7�iI
Eb,G will dolimixak,midda,mucam,is not intend.m olcred fmsale(Sec.]M4.fiminess ER
3 m and Professions Code:The Contractor's Uccnnc Law does out apply to in Atter of OUTLETS-SWI'TCIIIis-FI%'NRRS
pw aroy who builds or tmpnrves mention,and who dues such work ldra,df or through
his own crideycev,provided that such improvemems at not intended rn nfl4rN Ila NEW RESIUIiNfIAL ELT:C'Rt SQ FT.
sale.ILhowever,the building or impmvementi,ssoldwithinone ycmrxcunmplmi.. me SQ.IT,FLOOR AREA $/SQ.ET.
owner builder will have the burden at proving Ihat he did no build or improve for pur-
Issse of sale).
1,m owner of the property,am exclusively contracting with licensed cumrnmors to TOTAL:
mstme,the For t Sec.71144,Business and Professions CNet The Ctim—tar s I.i-
mmeLow docsnof applymanoaner of property what builds or improves mason.and QTY. PLUMBING PERMIT FEE
who contacts for such projects with a contractors)licensed pursuant to the Contractues
License Lm¢ PERMIT ISSUANCE
0 I am exempt under Sec. .H&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUAThoN
Owner Date
WORKER'S COMPLNSADON DECLARATION HACK "LTt(I-Ili(YI'IIX-ll?VICH
I herehy affirm under penalty of,jury one M the fnllowin,1,clan diou,:
❑IM1uvcand will m.inmin uCedificrne nfCnnanrno.wlf-litsure fon Worker's Gmmer DRAIN ' OCR, ODI R'A.CO
STORIES TVPII CONS"I'RUCTION
,pion,as provided for by Section 3700 of the[,,he,Code,for the performaocc of IIIc
waae,tar which thivpermit is issued. 91FIXTII ER TRAP
1 have and wili maintain Worker's Comp tivida n Inemmruce,as required by Senim,
1]()(l of mclaMn CNe,lod me perfnn ce (the work nr itch ti's permit is issueJ, GAS- �SYS'I' M I C. OGI'LL S OCC GROUP APN
My Wnr 'omp sationl old Poli n 1/ GAS-F. YSTEM.OVF:R 4 G:A) _
Currie Policy /�
CE flCALL(,it EX' 'TION IItOMW R RS'
COMPENSATION INSURANCE GREAS 1�l9T'RI.WAS'TP
BUILDING DIVISION PEILS
('Ibissntitn neeA nm hecnmpletN iftbe permit is Lrtnnc hundred Jollan(511X11 GREASE TRAP
nr Iese.) PLANCHF.CK FEE
I ecritfy that in the performance ofthe work for which this permit is issued,l shell SEWER-SANITARY-STORM IIA.21X1 FL
not employanyperson to.nynlatmmrou as In heci icsubicam tho Wurkcoa Con+pen. ENERGY FET.
,z smion Luwsof Culifurnta Data WA'1'17R HEATER WAIN r 17HILECTIR
Q Afflict I - GRADING FEE
Uj NUDCC TO APPLICAN'C If,after making thus Cenifitu.e of Exemption,you should WATER SYSTIpvin RHAI'ING
a ; heconre whjenmthe Workers Compensation provisions of the LaMa Cade.you mus. SOILS FEE
forthwith comply with,such provisino orthls permit shall he deemed revoked. WATER SERVICC
Q. E
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIAIH. SQ.FT PAID
UO Date R. to
I hereby aflion thanhere is u construction lending a,ency far the performance of
the work for which this permit is issued(Sec.3(4],Civ.C.)
C) U Lcndcls Name TOTAL:
L) I.cadcls Address A I
I certmat 1 have resit this inn mr
if application t and state at the above information its 13UILUING FC
[.. d Y pp iter
Z muldiLlagrcemco,andwith
rebyacity and eoumynMoances and state laxer upon
gse QTY. MECHANICAL PERMIT FEE
U buildingemnvtmet mo,and herobyanthotire rcprcv'atluavesof this city[center tmnn.he SEISMIC PLG
ubnvu-(Wc)a,epmpeny linvram1y;m kv1p Ta' 1'HRMIF ISSUANCE
(Wo7 ogres m save,indemnify and Actp hannlesx tit City of Cupeninn nguinxt LLIiC'I'RIC F
Iiuhiluies,judgments,costs and expenses which may In any way accrue against said City ALTER OR ADD TC,MIiCfL PLUMBING FE
in asequence of the grating of Ibis permit.
APPLICANT UNDERSTANDS AND WILL COMPI.Y WITH ALL N( /1�01` AIR HANDLING UNIT TO IIk0(XI CFM)
SOU ;GULATIO S. MIiCHANICAI.FEE
AIR HANDLING UNIT(OVER 10,000 Craft CONS'MUCION TAX
':ignamreof pprcanV ontmcmr ata EXHAUSTHOODDVIDUCT) HOUSING MITIGATION FEE
HA9.ARDOUS MATERIALS DISCL05' R
Will the applicant or future building occupant store or handle hazandous material HEATING UNIT 00100,000 HILT
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Gac,Section 25532(.)1 HEATING UNIT(OVER 100,111X)NTH)
El Y11 El No PAID
VIeNTILATI(1N PAN(SINGI.li RI151D1 Dvtc Nrceip.p
Wilt the applicant or(inure building occupant um equipment or dmlee.X which
emit ha,ardons air contaminants us defined by.he Buy Arca Air Quality Man.getmenl BOILER-COMP(MIT OR t(X da)BTU)
Diorim] TOI'AI
[I YO, ❑No BOILER-COM P(OVIR 11X1,1)(9)If'N) 7? 0
1 have read the has imus mmedals mryiremcros under Chapter&95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety CNe,Sections 23505.25533 and 25534.I understan that if the NEW RESIDENTIAL MUCH. SQ.FT.
huildi cr ntly lave ale nL that it ismy responsibility to nazi he or pant
11 menti ict print u+lrsnance of ac id ( b /
Mer ag t Dane TOTAL: ISSUED BY:
OFFICE