S 2760 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL C� nG�� o
BUILDING PROJECT IDENT'IF'ICATION SJ
BUILDINGADDRESS: '^ 0 { SANITARY NO. APPLICATION SUBMITTAL DATE
�3s �Lac%lwoo� �(
01-Per-11f i 2_ -,� 3
PHONE: CO 'IR
OWNER'S NAME: ACOR'SNAMI� , EJC NO:
/v/&5.ok N/C CONTROL#
ARCH]'1'EC VENCINBER: LIC NO'. A DRESS: [ ❑
qE i sGua t V,/ w Xt
CONTACT: PHONE: BUILDING PERMIT INFO
3 r F-1ConsultantFees Paid by Applic4nt(Initial) BLD- ELECT PLUMB MECCH
El
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE lriJ/
1 hereby arern that 1 am Iimn.Gm
l under pr.visn.or mme.c
Chapter 9laning JOB DESCRIPTION
wI]t4X pt Senian anoo)af Division 3anhe Bouressand Pro fusions Code,and my lken,i. RESIDENTIAL
00 tau PERMIT ISSUANCE '
a]N m full tome and e vt. C SFDWL C KITCHEN REMODEL
�UU License lana Q to z
APPLIANCES-RESIDENTIAL CADDITTON C1 PLUMBING RE-PIPE Dasa Commemr _
ARCHITECTS DECLi O fANF:LS ❑MULTI-UNIT CSTRUCTURAI.
X O rn zj I mtecrswne my.lens shell be used os puD- S,-.MODIFICATION
oz—, UP'I'0200 AMPS ❑INTERIOR CHIMNEY REPAIR
Licensed Pmfessionnl 2UI-IU(NIAMPS IMPROVEMENT E)SWIMMING POOLS
y OWNER-BUILDER DECLARATION OVER HIM AMPS ❑BATH REA1ODEVkEPAIR DEMOLITION
Q 1 hereby urfimt that I am exempt from the Character's License Law battle
W F following reason.(Section 9N 1.5,&tsinoss end Professions Cade:Any city or county SIGNS ELECTRICAL ER
q
ya which requires a permit to amshuct,alter,improve,demolish,or repair any saucmre
.] priori.its issuance,ine,requiresthe applicant forsmh pmritm File asignedstmement SPECIAL CIRCUIT/MISC.
'j Last he is licensed pursuantalhe......inns of the Contrnmur'a hicenae Lnw(ChapR19
COMMERCIAL:
(y 00 (commencing wLM1 Suction 91N10)af Division]ohhc Busc,and Processions r 'rBM
CodgeRMETERORPOLHINST
m
that be is assamu theocrat,and the basis print,alleged exemption.Any violation of LlNEW BLDG/ADDITION ElDEMOLITION
W to Section 9031.5 by any applicant far a permit subjeme the applicant to a civil penalty of POWER DEVICES CEENANT ❑FOOD SERVICE
�Xybarman,than rive hundred done,,($100). IMPROVEMENT
O
Q O Las owner mf the Penpeny.or my employees With wages m their sole comen
psation, SWIMMING POOI.CLECI'RIC
will do the work,and the structure is not intended or offered fnrxale(Ser,9044,Business [-]OTHER
0. m and Professions Code:The Contractim i License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds lir improves thereon,and who dues such work himself...thmagh
his own employees,provided the,such inspervesenm are not intended or offered far NEW RESIDENTIAL ELECTR SQ IT
sale.If.however.the building or improvement issold withir one yearofcompletion,the SQ.IT.FLOORAREA $/SQ.FT
err-builder will have the harden ror proving that he did amn
t build .improve for poo-
p rte or sale.).
C I,a.owner of the property,our exclusively contracting with licensed contractors to "TOTAL:
construct the project(Sec.71144,Business and Professions Code:)Tim Contractors Li-
cense Law does not apply it)an owner of property who banes or impales thereon,and QTY. PLUMBING PERMIT FEE
who convects forsacb projects with n cnnwe.ns)licensed parva....m the Contractors
License law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C fnr.his reason
Owner Date ALTER-DRAIN&VENT-WATER EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECTIDGV,IGK •--� -1 /��` B'd
• I hereby affirm under penulty of pejury one of the plainsong reductions: /
❑ Ihvve and will nmtinminvCcniGcam of Consennnself-Insure for Worker4 Compen DRAINS-FLOOR,ROOF,AREA,CDN, -. STORIES TYPECONSTRULTION
ami work f ac provided for by Section 3900 of the Lubar Code.far 0c performance oC the
work for which this permit a tionissued, PIXTURBS-P'3R'IRAP
C I have and will maintain Worker's Compensmcnn Insurance,as required by Section
Carrierl:the Labor Codej.nheperfonnanec of.hework forwbieh.his permit is issncd GAS-BA.SY�1% M-11 PAR T:Z',T. OCC. ��mtt7
My Werke' G m en ti nw ariePodi Policy t : GAS-EA,SV91 .M-OVER 4 Pat
alicy Nn.
CERTIFIC .OF MPTION FROM WORKERS'
COMPENSATION INSURANCE GRIiASFJINDUS'IR�ft..ASTE INTE BUILDING DIVISION PEES
ITh::edioa need nor becomplewl dth a perrou is Ensure Ironclad dollars(SAID)
tor I.,) GREASETkAP PtANCHF.CK FEE
I certify that in the performance ofthe work for which this permit is issued.]Call SEWER-SANITARY-STORM EA.200 Hf.
amt employ any pea",may r s
manneo as m became subject to Workers'Cordaro- ENERGY NEE
rsn
z ,'C. .urian Laws of California.Dare WATER HEATER WNENT/ELECTR
(3 Applicant GRADING FEE
H 0 NOTICE TO APPLICANT:IC arter making this Coolant,of Exemption,you should WATER SYSTEM/TREATING
Fx �
become object In the Workers Compensation f the Labor Code,you most SOILS FEE
j o prmit hal n
� forthwith comply with such provisions nnhis permit shall he deemed revoked. WATER SERVICE
Q
CONSTis.aeronautics
amstromLENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Receipt
I busby nnirmat ththou ismion lending agency far the perfnrmana of at
U O the work for which this permit is issued(Sec.3099,Civ.C.)
{Ir f•" Lender's Name TOTAL:
WLeader's Address TOTAL:
,rye I certify that 1 have rend this applivmion and ,.at,that the above information is BUILDI G EE
-77
Fat Cn correct.l agree to comply with all city and county otJinances and state laws relating m QTY. MECHANICAL PERMIT FEE
UZ hndiingcamstmdion,and herehy amismAcramesentmlvesnfthleci.y memm,upon the SEES BE
above mentioned propciry Int inspection pulp....... PERMIT ISSUANCE
(We)agmen save,in blocify and keep harmless the City of Critical no again. ELECT C PEB
IlabilineeJudgmmns,costa end expenses which may in any way accrue against said City'OALTER OR A DDT'O MSCI I. PLU GFEE
in +nrequerce of the gaming of this permit.
APPLICA N U N DEES'I AN DS AND WI L M PLY WITH ALL NON-POINT AI R I I ANGLING UNIT(TO 10.000 CFM) MECHANIC LHE
SOUR :GULAI'IUNS
0 / AIR HANDLING UNIT(OVER 10,000 CFM) CONS]SUCTION TAX
SignatumofAp un .Immo. Date EXHAUST HOOD ADDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant scorelir handle hceardons material DEA'L'ING UNIT H O Hod"BTU)
as defined by the Cupertino Municipal Coda,Chapter 9.12,and.he Health and Safety
Axle,Section 25532(a)P HEATING UNIT(OVER 1011,000 BTU)
C Ver CNo VENTILATION I-AN(SINGLE RESID) PAID
• Data Receipt#
Will the applicant or Comte building by
Btaacan Air Docordevicewhich BOILER-COMP(3HP OR 00,000 ETD)
mit ict, us air contaminants as Jefincd by the Bay Amt Air Quality Mmmgement TOTAL:
Uislria?
F1 Yes ❑N.. BOILER-COMP(OVER 100,000]it'll) It
f
I have read the Inizarchors,materialsrequirementsAIR CONDITIONER under Chapter 6.95 of the Cali ISSUANCE.DATE
faro:.Health&Safety Code,Sacdn.
o255(I5,5,22553533 v 5514.1 ttndersasnd that if the NEW RESIDENTIAL MUCH. SQ.FT.
bdldingdoi currently havrwcpant.that it ism msihility mnmify the rampart
ofthe requir which anus rolp"Iiortol a cni cafe of Otcupanc
1111 C.�
Owner tor antifirmixeda m Date TOTAL ISSUED BY:
OFFICE