S 1089 (2) APPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
(.9TYOPCUPERTINO BUILDING-ELEC'I'RICAh PERMIT NO.
BUILDING DIVISION APPLICATIONJITERMIT PING RINE:"ApDIRSNIFIC S 1089
6UILDINL'PROJFCI'IDI±NI'IF'ICATIUN AP
SANITARY ND. APPLICATION SIIIIMI'I'IAI.DATE
BUILDING ADDRESS: '
2222 U c aaa:�►o cn .4Sol4 p�2 `�
OWNER'SNO E. �L:.l PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONI ROLA
;X OR ❑
CfI1TiiCTIENGINF.F.R: LIC NO ADDRIiSS:
CON'I'AC'1': PHONE: ' :BDILDING.PERMI"f INFO'.
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MEC❑
4 G- ❑ ❑ ❑
LICENSED CONTRACIO11 )FCI ARA'I'ION QTY. ,' a-ELECTRIC I ERMI'f FEE JOB DESCRIPTION
1 hvrahy infirm Ih 1 I licensed I p .f Chapter 9(common g
'Z with Section]rap of Division 3 of theB.artes,nndirfe.:uas Code and my hoca,ct ' IIx'. FgW'.NTULL'
Q'00WZ PLRMIT ISSUANCE
F W F in full force and effect. •DWI. ❑KI'fC1113N REMODEL
aFVZF` License Class Lica APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R611PH
NQi pale Cmnlmclor ❑MULTI-Oroll [I STRUCTURAL
m ARCHITECPS DECIARAI'ION PANELS
MODIFICATION
y Z~nZ l understand my plareshall be used an public records
Q UPTO2W AMPS ❑INTERIOR El CHIMNEY REPAIR
[Accused Pmfcxsi'al 201-1000AMPS IMPROVEMENT E]SWIMMING TOOLS
�d p$
OWNER-BUILDER UIiCLARATION - OVER IBIXIAMPS ;.+ El BAIT lot O IT REPAIR CDEMOLTHON
g 1' '� 1 hcrehy nffitat 1hn1 ani.xentpc Iron Ibu Coul actor's License Law for the _
OA.U toll(owing roLann.f3cecinn 7031.5.❑uxinms and I'rufae,innx Gdc:Any city or comnY SIGNS ELECTRICAL ❑(YTI IIiI
W a W y which mquires a permit t.vinic....,1.1wg Ilnprnve,dr., I xh,.,,,,air any xamclare '
"Imo,it,issuance,al y "f ipli tf Ipermtl File asitored,loarantent SPECIAL CIRCUI'UMISC.
---
but 11 ':I ed puna t1 hetp 'r1. if the Contractors License L -(Chapter9 COMMERCIAL
WE: Ic ceni6 ith Sccl ]OW7 fDivi' l fth Ii in dP fe..bns Coddor MRESIDENTTAI.
R POLE INST.
a 1 caG that he is exempt therefrom and the basis for the alleged eamnpaon.Any violation ofC NEW BLDG/ADDITIOR ❑DEMOLI'D IN
x�m Seminn]o3 L5 by anyapplivant fora pennil.subjects the applicammonvil penahy of S 0 ENANT El FOOD SERVICE
not more than five hundred d(oIWrs(551X8. IMPROVEMENT
�Sp pl,as(owner of the property,or my employees with wages as their sale compcnstinn, L ELECTRIC
S1. will Jo the work,andthestructure is not intended or offered for sale lSec.VBW,Business �011lf.k
and Profession Cade:The Comforter's Liceme Law does not apply m an owner of ITCHES-FIX1 URFS
4 3^ property who builds or improves th ircon,and who does such work himself or thrmgh
his own catployeeu,provided that such ifnprovcmems am not intended or offered for IAL ELECT R SQ FI'.
sac.Ifhowever,the building or improve(oem ix.sold within are year ufcomplenon.the CMME
PI'.
Valwill have the baNen 1.I'proving tI a he'did nil build or Improve fill pa-
ovw'W""'s'Ilack .. . .
f the property,nm exclu' ly contracting with l cen,ed eoutrmmrs to ITYIAL. 3 0 1997
construct thep 1 l(Sec ]044 .Busine d I f: Cnde')'Inor Conmmtur a I.P. OCTll
comic[.sdes not apply to an owner(fpapeny who builds or improves thereon and QTYI' ({,PLUMBINGIfRMI'I' FEE .
wlhoot met,Coronado pntjeel.with.namsumrls)licenced pursuant to the Conlmemr. " r
License Law. PERMIT ISSUANCE BY:--
C 1 am exempt under Sec. .B&P C for This mason
f\---- ALTER-DRAIN&VIiNT-WAIF TPA) VALUATION
Owner � Dae
WQN&&t6MPENSqtr/,�)N DECIARATUTv BACK FLOW PROTECT I DEVICE D Q jo
I hereby affimt under penalty of perlTO one of the following declarations:
JIhave and will maintain a Confine no Consent 11)self-insum for Worker's Compete DRAINS-FLOOR,ROOF ARRA,CO ). STORES TYPIi CONSTRUCTION
rutin i as provided for by Section 3](X1 of the Labor Code,Re the performance of the
work fns which this permit is issued PIX'i'USES-PER TRAP
I jer,c unit ,If n t 'u Workers Cp t Mur , required bySection
-
3700 ft Labor Code,for(lie perfurin novold lk for w1oith this permil i,is eel. GAS-13A.SYSTEM-I I NC.4 Of I'11.EhS (X-C.CROUP- MIN
My W rko .C trope of I ecu 14 Icy nu -
Cunier, Policy Nn,: GAS-FLA.SYSTEM-OVER 411iA)
CERTIFICATE 01:EXEMPTION FROM WORKERSGRP.ASI%INDUSTRL WASTE IN'TERCIiPTON
COMPENSATION INSURANCE BUILDING DIVISION IT;S
Tlhineed net nenet he compincd ifthe pemtil is femme hundred dollars($10n) GRRASETRAP
or lessJ PIANCIII°CK PEI?
Icenifylhal in lheperfommnceafthe work forwhlchthispeormisissned.i shall SEWER-SANITARY-STORM EA.200 VC
not employ any Person in any ntnner so as u,become subjen a the Workers'Compete ENERGY FEE
Z Notion Laws of California.Dale WATER HEATER WNF.NT/ELECTR
zApplicant ) GRADING �.'
NOTICE TO APPLICANT:If,alter making this Cenifvae of Exemption,you idir WATER SYSTEM fREATING
ati SINS FEE
Babovisubletm the W.dedm Cnm.,o,this enwit hal n Bedeoned,Cale,you tater
Da fialhwilM1 mntplY with such provisinnn nr this permit hall Jcemed revoked WATCH SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLa111, SQ.f9'. PAID
az Ihereby afBmthat there is a conaructinn lmdn
ingagency for of we Rccciptp
U0 ,bc work for which this permit is issued(Sce.31X)7,Civ.CJ
Q Lcndeh Name TOTAL: 105NI;
ULeader'xAddree, - rOO
a 1¢nify that I have read do,application and arae that thinformation e above infoation ix ❑IJILDIN PEIi
JA n,mzLiagreemn,reply with all city and county ordinances and state laws refining to Q'I'Y. 'MECHANICAL hTRIAl r, J FEE b
U z budding construction,and hereby andomize repmmry,n
matives of this city to enter athe S[i$MIC Il'
aMwe-mentioned pmpeny far inspection lourf a ce, PERMIT ISSUANCE
(We)agsave,indemnify and keep harmless the City of Cupertino against ELIELECTRICree a FE
liabilities,judgments,cost and expenses which may in any way accrue against sial City' ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000CI'M) I CONS IRUC'I'ION TAX
Slgnaarcof AF,I conl/Councoor Dae EXHAUST HOOD(WIDUCP) HOUSING MITIGATION FEE
HAZARDOUS HINT iRIAI S DISCLOSURE
Will the applicant or future buildingdeavpae sure or handle humidous mmerial HHA'I'ING ON]F(TO 100,000 UGo
its defined by the Caperton.Municipal Code.Chapter 9.12,and the Health and Safely BEATING UNIT(OVER 100,0041 BTU)
Cure,Sectio 25532m)?
C]Yes; Chm VI:NTIIATION FAN(SINGLE RESID) PAID
Dae Receipt M
Will the applicant or future building occupant use equipment or devices which
r nal hazardous air commitment as defined by the Bay Area Air Quality Management BOILF.k-COMP(3HP OR IBB.fX1B DTD) 1 i
istrict? BOILER-COMP(OVER I00.X)I B'I'LE
C Yes - CNo ,
I have re ad the hmuNausmatenalxlrqui.mater under Chapter,6.95 of the Cali. AIR CONDITIONER ISSUANCE DATIi
Inmin Health&Safely Code,Sections 25505,25533 and 25534:[understand that if the NEW BESWENTIAL MECH. SQ.FI'.
laulding drca nil con ally have a loran.(111.1 it Ix lily,'cepnnsi11iliry to nolifY the deaipanl
of lherclairententy which maxi hate,prior to i....nnccof a Cardfictle ofoi lane,. r/I,
Owner nr authorized opera Dae
TOTAL: ISSUIiD BY K • , ^ I Y v \
OFFICE