S 2300 APPLICANTTO FILL IN INFORMATION WITHINRED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECIRICAL PERMIT No,
BUILDING DIVISION AI'1'LICATION/PERMITPLUMBING-MECHANICAL S n 3 O O
BUILDING PROJECT'IDENTIFICATION L
BIJUDui6,AW DDRF_SS: r ,, SANITARY NO. APPLICATION SUBMITTAL DATE
e, kar
OWN NA E. PHONE: CONT ACTORS N99ME: LION `� /
Mr N/C CONTROL so
3RCIUTECT/1?NGINEER LIC NO. ADDRESS ❑ j
CON'T'ACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ 2e�
LICENSED CONTRACTOR'S DECLARATION QTY ETEC"I'kIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing C JOB DESCRIPTION
�ap0 with Settlon7000),a Divicl.n 3oflhe Hain.,,and l'n�kre+i Code,and my license is PERMIT ISSUANCE �S RESIDENTIAL:
in fnlll'orcuandefecl_ L(-77 A)I ❑SFDWI. ❑KITCH17N REMODEL
GZV Lkcrtse Clots_ _ Lie.M T M f(�f.wP APPLIANCES-kP_ti1DENf1Al. ❑ADDITION 0 PLUMBING BEPIPH
I-d 6 Date ConlRe +
y.Om AItC ITELTS DIiChARA'1'ION § PANT?I8 ❑MULTI-UNIT ❑STRUM TURAL.
Z O y Z u dersmnA - all hu useA na public records MODIFICATION
UP'10 21X)AMP$
O ZNC ❑INTERIOR 0CHIh1NF:Y REPAIR
F.-1jel Liven
ie a Ptufessionvl 201-100BAMPS IMPROVEMENT OSWIMMING POOLS
CYE; OWNER-BUILDI?R DECLARATION OVEk little AMPS ❑BATH NEMODEIIRFa'Allt [3 DEMOLITION
0.' d I hereby ulErm(hit 1 um exempt Irom the Conlon, n's L Ic:nxe Law fnr the
LiyS O W O following reason.(Section 7031 5,Business and Professions Cade:Any city or countySICNS I!LF.CfRICAI. ElOTHE
t+t 3 LL y which requires a permit to cnnswn,alcor,iisprmm,Jcmnlivh,or repoir any sweture
F�O� Her to its i....nee,olso requires the applicant for such .it no Rlev signed statement SPECIAL.CIRCUI BNI1SC Z,r $`Q D
thot ha is licenxeJ pursuant to the Provisions n(the Conm¢mr's hiecnxO Lvw(Cblpmr9
d� 0.vnnnencingwllh tieClinn 91X1(bnlplvisiul13 of the ltmintss and l'rnfessionx CnAe7 or 'TBMP.ME 117R ON POLE(NST. COMMERCIAL:
Il e C that he is controls therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m Section 9031.5 by any applicant for a lemon smorsos the applicant n a CIVIL penalty of POWER DEVICES11TENANT ❑FOOD SERVICE
nm mors than Five hu.mol dollun($500). IMPROVEMENT
=�d D l,ax owner nl'I he pra,vdy,mm ttlu Ih wa'exnstheir sole eommlwaliuu, SWIMMING 110 -F-EC'fRIC
OOOXGGG SS yell intended
m b I
(..0 will Jo the wnrk,;nW the xtmcmrc is not intenJeJ or.ffercJ Vsmle(SecACW4,Business ❑OTHEk
63 m anA I'n,fe"now CMe:The Contractor's Licence law does not apply to an owner of OUII.ETS-SN'ITCHPS-FIX 6
property who built,or improves thereon,and who Joe.,such work himself or thamgh
his own earl provided ohm such intprovomano nn:not inlnund nr offered for NEW RESIDENTIAL ISL.EG SQ
w1a 11.however,the building or llnprovcraai is sold withionne year of completion,the SQ.17L FLOOR AREA s/SQ.E1'.
mer-builder will have me burden of proving that he did or build or improve fnr pur-
i po,e ofaole.).
I,its owner of me Sce.704,con exclusivrly and Poll
with b I linCil cnnmtemn J- 1i •(JJ /
......mM Thor(of the
(pro 7044,nu,iness only contracting
C.te:)Tho Cumnemr's Lo
cent,Law does notapply to an ow net of property who build.,orimprnve,mtmm,and QTY. PLUMBING PERMIT FEE
who constraints for such prejeca with o comractorts)licensed pursuant at the Connector%
License law. PERMIT ISSUANCE
✓ E] Ilan exempt ander Sa. .B&P C for don,masnn
�1 ALTER-BRAIN&V1?N'T-WAI'Ek WA) VALUATION
Owner Dec
O
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby d into under penalty of perjury one of the following declamuione:
❑ Ihuve ant will lnaimeina Ccnipcam of Coreenuoeel f-il,ure for Worker's Cntnlmn- DRAINS-I1.001t,ROORAREA,COND. S'TORIPS TYPE CONSTRUCTION
cation,its provided for by Section 3900 of the Labor Cole,for the performance of the
work for which this permit is isned. FIXTURF9-PER*1'RAI'
❑I have and will mail Workers Corgcnmion Insurance,as mi,imed by Section
3700„Ithe Lal rCodc,far IDoporfarmnnccol oho work nor w hick this punnit is issued. GAS-EA.SYSTEM.I I NC,4 OLH1.Eq'S OCC.CROUP MIN
My War 's oad,nxmlrn Irl ce e, ivr and PoJ,y nnm re:.
Cartier. �I'nlicY No.: L) rv7N GAS-IA.SYSTEM-OVER4(HA) p
CI:RT[nCA'1'EOFEXE 'TIONFROMWORKERS'
C0MpENSNHnNUPSURANCF GRF,ASIJINDUSTRI.WASTE,IN's IikCE1TOk
BUILDING DIVISION FEES
(Thiscemlon neednmb+,nrtplcttd done mrH linanehundrddollars LSIIX)
or ins.) GRF.ASE'I'RAP \ ANC( EE
I cenifythat in(heperfonnanceofthe work forwhich Nispemlis isissuel,l shall SEWER-SANITARY-STORM IA.2 I'
nal employ any pmnm in anymune,s.auo hccome mhj,nmthe Wnrkerti'Cnnolem HRG 9
Z7.. talion Law.,of(',,Itrmtoo D;uc WATER IIEATER W/VINT/ELECI'R
O Applicant XT
NCH ICHTO APPLICANT.if,after making this Cerifiaaw of Eaumision,you should WATER SYSTEISIGREATING
been nne mann,1.the WmkclS Corn,mmian pmvi,inns of the lnbu Code,you mass SOILS F
Rj tonhwllh comply wish such sou,seso or This ponnil shall he deemed revoked. WATIT14 SERVICE
W
7 z CONSTRUCTION LENDING Al NEW RISIDIiNT1A1.1'LMB. PAID I n¢ kecei tp
U 0 kforw ah hi,, auhere isemd(51c 30 len ding agency fnr the performana of P
the work for which This pennil is i+vred(Sec,31X)9,Civ.C.)
U Lend.',Nance TOTAL:
r LCndcr'I Addms, TOTAL.
0. 1 certify that I have mat this application and stain that the above information is BUILDING Flili
LF. h 1.1,11.l agree to comply with al city and county ordinances and state laws relating m QTY MECHANICAL-PERMIT 17EE
U Z hudlingconsooalnn,andhc,Obyaudit mire represomai,esof'his oilymaule,L ithe SI!1SMICPEII
above-nwationed pmpeny for inspection purposes PERMIT'ISSUANCE e+ t
(We)agree m save,indemnify ant keep harmless the City of Cupertino againa / •S' ELECTRIC PI?li
IiahiBlies,jutgm,pI,, unit nshich may in anyway secure against said City AI.TERORADDTOMECH.
mequtnCt of the goal ANUdANIR
ng isPLUS1dTNG ITE
o AI'PI. .AN'I'1 DERS' ILL COMPLY WIT({DLI.NON-POINT AIR HANDLING UNIT(TO 111,1101 CPM) JyMECHANICAL MESOUL(F. .G LAl'1 i
j ` AIR HANDLING UNIT LOVER 11+00CPDD CONSTRUCT ION TAX
Sib I,v fApPlinnl/C1T.m1ao L!/ cele I EXHAUS'IHOOD(W/DUCT) HOUSING MITIGATION FEE
HALARDOIJS MATERIALS DISCLOSURE
Will the applicant or future building occupant store our handle loavarduus murarial I IEXI'INri UNIT(1'O 100.000 N'I'U)
as defined by the Cupeninu Municipal Code,Chapter 9.12,and the Health and Safely
Code,Serum.2553200 -`/ HEATING UNIT(OVHR IINI,INN1 li'I'Ij)
�Ves' L7 Ail, VENTILATION FAN(SINGLE RESI UI PAIDL 075-Z'
Will the applicant or fnmre building oecupam use equipment or devices which Dam Receipt g
moil harurdous air oomenumnnw us find by the Boy Area Air Quality Mann,narm BOILER-COMP(31111 OR 100,000 BTI) TOTALt e •yon
Dlxtncn BOILER-COME(OVER I11(1,1X0 H'1(1) JV
❑Yes
O
I have.1 the hamrdous maeoialx rce uiremClns under Chapter 6.95 of the Call-- AIR CONDITIONER ISSUANCE DATE
fnmin llcnllh&Sul' y CaIC,Scninn,2550.5,25533 unJ 25531.1 omJctxvmd Ihm if the N13W RIiSIDIiNTIAL MYCIi. SQ.I'T.
bnolJi Ices note nT have it mount,11mo i,my resmomibility u,notify the tccupanl
nldh uirellfn} hbhmuw Meir. .no' ofa Cenifem``e.f)llce cy. ��y(
�w111 a�nriecJ agent I Date TOTAL, u ISSUEDBY.
OFFICE