S 2055 (2) A,,PLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD R:NG-ELEC'1'RICA],
BUILDING DIVISION APPLICATION/PERMIT PLUM NG-MECIIANICAL Pf�f'�"" 2055
PUILDINI PROJECTIDENTIFICATION
BUILDING ADDRESS. SANS MEN NO, APPI,ICA'fION SURMIITiAL DA'Z'E
/ z Ff v PPA
OWN R'f�NAME PHONE: RACfOR'S NAME: LIC NO:
i teO/' �tlti TAue}av O Wits DO B/�O — we cGNTRUL x
ARCHITECUENGINEER: LIC NO. AU}RESS: ❑
O 750 A.4 S4N/ /✓ ON/D /-1d cos
CONTACT PUoNH: BUILDING PERMIT INFO
Q a I\5� ❑ Consultant Fees Paid 6y Applicant(initial) BLDG ELECT PLUMB Mb❑Cx
LICENSED CONT'RACTOR'S DECLARATION Q'T'Y. ELECTRIC PERMIT FEE
I hereby afrrm that I am fren,ed under provisions m Cmnpmr 9("an nemaing JOB DESCRIPTION
Qq'Z wird Sxtion]IKK))nf Divisinn3 ofthc Business and Pmfeasinns Cwle.end my littrlse i. RESIDENTIAL,
F00 'n full force and ccyy.F PERMIT ISSUANCE
C,F �`9 / S `Z G ❑SFDWI. ❑KITCHEN RI'MOD[L
F Zw Licca Lic.x API'LIANCIS-RISIDEN'TIAL ❑ADDITION ❑PLUMBING RE-PIPIT
NQ L Dam Contractor
ARCHITECTS DECI. PANELS MODIFICATIONw ATION ❑MULTI-UNIT ❑STRUCTURAL
ZOr-Z 1 understood my plans shall M used us pub
records
OZ—� UP'1'0200AMPS ❑INTERIOR El CHIMNEY REPAIR
W Licensee Professional 201-I((1AM1'S IMPROVEMENTSWIMMING POOLS
OWNERBUILDERDECLARATION OVER I000AMPS C BATH RF.MODEURE' IR D DEMOLITION
C W Q I hereby affirm that I am exempt Tram the Contractors License Ww for the ❑OTHER J
iqqiS5 O q V minwing mason.(Section 70315,Nosiness and Profession,CnJd Any city in,county SIGNS ELECTRICAL /
I++�C y which requires a mrmit m e ranrm,almc improve,demolish,m repair any swm
< re
yWN� prior to itsissuance, is requires the applicant fsuch permit file asignedstatimmat SPECIAL CIRCUIT/MISC.
C�
that he 1,, dp lo the provisions ulth C tx,no,Lo,co,c L (Chapter4
W.^p0 (o g ithS I 70(11 fDos J fth Bane. and ProfessionsCode)or TEMP.METIe O LE INST. COMMERCIAL
q p,o eG thinhe Is exempt therefrom and the basis far the alleged nscmphnn.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
WSection 703 1
moue Rao fiby any ve oundmdndollenla Lee it
xaljr,s he appl icanl In u civil penaltyol' POWER IIEV TENANT ❑FOOD SERVICE
^ZO (] I,as owner of the property,or my employees with wages as their sole eommnsedion, SWIMMING POOh EL IC IMPROVEMENT
Sa will Aothewmk,md them-ame intnot.rwridedoodkord bade(Sec.]6/4,Boon,, C3 OTHER
W and Professions Core:The Comracmr's License law don nut apply t.an owner of OUTLETS-SWITCHES-Iy NES
momy who builds of improves thereon,and who dues Inch work himself or Ihmugh
m
his own employers,provided that such impmven¢nts arc not intended or offered lir NEW RESIDENTIAL ELECTS SQ FT.
sale.IL however,the building or improvement is mold within one yearofcumpletion,thr SQ.FT.Iq.00R AREA S/SQFT.
.
own
or-builder will have the harden of proving that he did not Mild or improve for pur-
pose of sale.). -
❑I,as owner of the pmm peny,nexclusively removing with liaised emarect.rs m TOTAL:
morst the project(Sec.](H4,limine,,,and Pmfuxalonx Cole:)'Ihc Contract.,',Li-
cense Law does nor apply toanowner ofproperty who builds or improves thereon and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a comm mens)licensed pursuant to the Contmemrs
Liense Law. PERMIT ISSUANCE
❑I am exempt under Sec. .B.P PC for this mason
ALTER-DRAIN&VENT-WATER(LA) -AN0 &
Owner Dam v` V
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirmai under penally of perjury one of the following dalaer's Ca
❑ ultras and will for
inection 37M of the Latin ode,forte Worker's Compctr. DRAINS-FLOOR,ROOp,AREA,COND. BIBS 'fYPIi CONSTRUCTION
abort,as hick this
forma Section 3]00 of the Lehr Code,for the performance of the
work for which this,mal is issued. FIXTURES-PER TRAP
I have and wllhmainf Worker's Compensctfen Insurance, h his peril,i Section
3]W of the laborCMe.fin the perfonnana of the work for whish this permit is issued. GAS-EA.SYSTIiM-I INC.4OUTLETS OCC.GROUP AYN
My WmkeJ9¢ppg� yOM py rner and PnIieY not be :
Goatee bbQQ AAI( C .f'
policy No. Aw5oo_.2 GAS-G.SYSTEMAVER 4 U:A)
CERTIFICATE OP EXEMPTION FROM WORKERS' GRF.ASFIINUUSTRI.WASTE INTERCEPTOR
COMPENSAIION INSURANCE BUILDING DIVISION FEES
('This section need not becompletad lithe permit is home hundred dollars($100) GRFASETRAP
or less.) PIANCIIECK FEE
l anifythm lathe pmfrmnaarcofma work ferwhim RNIonno is issued.[shall SEWER-SANITARY-STORM HA.200 IT.
oat employ any mnxan in any manner so us to banme wbjcm to the Worker'Comma- ENERGY FLE
zz salon Lawsof Califnmia.Dam WATER fIF.ATER WNENT/ELHTR
Applicant GRADING FEE
N NMICL'TO APPLICANT:If,after making this Cenifcme of Exemption,yna should WATER SYSTEMO BEATING SOILS FEE
a hemme subject m the Workers Compensation Provisions of the Lahor Cole,you must
bothwi N comply with such prb,Wum or this permit shall M dremed revoked. WATER SERVICE
Q
CONSTRIICfION LENDING AGENCY EW BESIDE IAL PLMB. SQ.IT. PAID
U 0 (hereby ithom hat iso construction lcndingagrncy for elm perfnrmananr Dum RaceipT
E^ the work far which this permit is issued(Sec.3097,Civ.CJ
OLnder's Nemc TOTAL:
V I<nders Address AL:
-77
1 cenify that I have read this application and sum notifications,information is I TNG FF.F.
Lr y correct.I agree to comply with all city and county ordinances and state lows relating to QT HANICAL FERMI FFB
Ubuilding combination.snit berebymohnrim represemative,or this city to enter upon the S SMIC PEE
shore-mentioned property for inspection puryoscs. PERMIT ISSUA
(We)ugmc in sive,indeCatoctin.nify and keep harmless the City of Cunbt.oguinm iLEC`UUC FEE
liabilities,judgments.costs and expenses which may in any wuymerue agafn.audCity RORADDTOMECH. 'LUMBING HE
in consequence of the gaming of this pen 'I.
APPLICANT UNDERSTANDS AND s LL TE
WITH ALL NON-POINT UNIT(TO 10,0(1CFM) 'CHAMCALFEE
SU Ti REG LN'IONS. x
(PIS/I NR HANDLING UNIT( C M) CONSTRUCTION TAX
S a am mfAWlicanVCnnmour Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future buildingacerpumstoreor handle humol material HEATING UNIT(110 101,000 BT of
efined by the Cupertino Municipal Core.Chapter 9.12.and the Health and Safety
ole,Section 23532(x)'! ITFATING UNIT(OVER 100,000 B
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID -
Date Receipts
Will the applicant erfuture building occupant use equipment ordevices which BOILER-COMP(3HPOR IW,(%1 BTU)
mit havarduus afr contaminants as defined by Ihc Bay Area Air Quality Manage0mnt I'A O
nslnm❑Yes QNn BOILER-COMPROVER 100,00(i
AIR CONDITIONER ISSUANCc DATE
I have real are hater,ntsSc materials 255 5,2553 a under .1und understand
of the i f the /� ^ Q a
fomiagdoesn Safety Cole,Sections .that,isanyand25534. undrnLnJ norm!the NEW kIiSIDEMI'IAL MIiCH. SQ.FT. n
of the requirements
mmwhich must
tNtemet prioroismyrcofabntricanotlfyNupincy. 17/5
of the rcquiremems which sun M mel prior to issuance of a Certificate of acupancy.
Ownerorauthnrixedagent Date TOTAL I
ISSUED BY: • _
OFFICE