S 2793 (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 S 2793
RUILDING PROJECT IDENI'IFICA'PION
11UILDING ADDRESS: SANITARY NO. APPLICA'T'ION sunvinTIAL DATE
1 �., _ 1
v� M ,S j;ICONTRACI'OB'S NAME: LIC NO:
NIC CON'rROLM
ARCHHhUPENGINEEK: [JC NO: ADDRESS: ❑
CONTACT PHONE: -BUILDING PERMIT INFO
E:1 Consultant Fees Paid by Applicant(Initial) BLDG ELECT/PLUMB MECH
E] N ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT FEE
I hereby aflimt Ih:n I am licensed under provisions of Chapter 9(aontmemcing JOB DESCRIPTION
with Se
DMZ ctian JfXO)af Division iuf tha Bminessand Professions Codnami license is RESIDENTIAL
iclaw,
+1 1 O O PERMIT ISSUANCE
in force and eRea. ❑SFOWI. [I KITCHEN REMODEL
aUU Lttmm Clazs Lich APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FZyI [lac Cowman
nn6y ❑MULTIUNIT El STRUCTURAL
❑y ARCHITECTS DECLARATION PANELS
Z O y Z I undersmnJ my plain shall he uscJ us,oldie recordsMODIFICATION
OZ^O UP TO NO AMPS 0INTh:R10R C1 CHIMNEY REPAIR
F��WWWW Linens)Pro(essi...I 201-US0AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVERIIXXIAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
IY C 1 hereby almon that I am exempt from the C..eazmr's License Law far the
yd,O a U fallowing warm.(Section 7031.5.Business and Pm eWro,GMs:Any city nr county SIGNS CLI!CI'RICAL ❑OTHER _
ty 3 W F which requires a permit to comanno.alter,improve,demolish,or repair any stmetute _
O pri�re lts isseauce,also requiresme applicant forsuch permitto l'ileu signed.vtmcmem
> SPECIAL CIRCUI'1IMISCM .
that he is licensed pursuant to the provisions the Cnraceds License Law C M m
(commencing with Seeman 70001of Division 3 ofthe HusinosanJ l'fnlessions CuT I.MV..METER Olt POL.E INST. COMMERCIAL:
L d c C that he is saran daretmm and the basis far the allege)exemption.Any violation of ❑NEW BI.DGIADDITION ❑DEMOLITION
^m Section 7031.5 by any applicum fail is .it.mhjecls the applicam too civil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Z
not more than five hundred dollars(S5[0).} OIHER F:MFN'1
�^QQI,a.owner of the pmpeny,anny<mpinyeeswith wages as their vole compensation. SWIMMING WEILELECfRIC '
will Ju the wank,and e:The cram is nut iateNed or owe do far sole apply
y to an B nee(if ❑OTHER
and Professions Cale:The Convacart's License Law Ates not apply m an owner of OUTLETS-SWITCHES_FIXTURES
prnpany who builds or improves thereon,and who does such work himself or thmugh
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTS SQ FL
sale.If,however,the building o improvenenl issold within mat, car ofmmPidioc.the SQ 17.FLUOR AREA SISQ.FT.
rmolmilder will have the burden of proving dan he did not build or improve frolic.
role Ter of the pmperty.am exclusively contmctingwith licensed narturchorsI, T dl• dO
ennswer the pmjea fSee.7tH4,Business and Professions CNet)The Conlrucmh Li-
cameLawdocsnntapply m an owner of property who builds or improves thewon.and QTY. PLUMBING PERMIT FEE
whocontracts h, ch prnjaO,with acommands)IicensxJ pursuantmthe Commmor's
License Law. PERMIT ISSUANCE
❑Ism exempt ant r .B&1'C for this reason
AUIGR-DRAIN&VENT-W ( VALUATION
D.m
n
WORKERS COMPENSATIO ECLARATION BACK FLOW PROSECT.DEVICE
I hereby adient under,penahy of perjury
"If'
af the follnwingJMnrmions:
❑Ihaveand will mainelnaCenificae of Comm�ttnselGinsure for Worker's CnmPem DRAINS-FLOOR.ROOF,AREA,GOND. STORIES TYPECONS'fRULT10N
smion,as provided far by Section 3401 of the LaMn Cede,Tor the isufonn m,of the
work(a,which this Permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Wrak A Compensation Insurance,as required ny Section
37Mofthe Labor Cede,for the performance oftho work for which this Permit iskwed. GAS-EA,SYSTEM-I INC.4 OUT LEIS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number am:
Cancer: Policy No.: GAS-FA.SYS'MM-OVER 4(EAI
CF.RTI FICATIi OF EXEMIT ION MOM WORKERS' GRF.A:FIINUUSTRL ASTE INTB iPf01t
COMPENSAT10N INSURANCE 11011DING DIVISION
(Thismedon need not beemin,deeddthelunnit is forone hundred dollars($[(a)) GRP. AP
or less.) PLANCHECK IEE
verify that in the peditmance ofthe work forwhich this permit is issued,l shall I-A
NITARY-S'IY)RMEA1•rya ENERGY 1'EE
,Z ,.tion laws of California.DateIfz APPlicvntEA'TERWN�I. LECI'R GRADING FEE
y NOTICE'10 APPLICANT:If,after making this Certificate of l asur,sion,you should YSTEMffREiUINGFbecome object a the Workers Compemsmarm Pmvicinns ofthe Labor Code,youmustSOI[,S FEIiforthwith comply samsuch Provisions or this permit shall le deemed revoked �VICE
0
0.�. Z CONSTRUCTION LENDING AGIiNCY NEW RESIDENT[AI.FLY B. SU F1. PAID Dal Receipt,
WU O Iherehy chrm matrhewis acmm,Imehano.Cis,agency Sof the pcAanm:ince of
the woe.Na which this permit is issue)(Sec.JIMl7.Civ.C 7 TOTAL:
F-' lenders Name
L) Lenders AdJess TOTAL'
I cenify that 1 have mad This application and sone thin the atone information is BUILDING
rfq
V0.) correct.I agree a comply with all city and county ordinances and state laws renting to QTY. MECHANICAL PERMIT FEE
C.) Z, building construction,and hereby amhoriw reprewmatives ofthis city roamer upon the SEISMIC
.leve-mentioned property far inspection purposes PERMIT ISSUANCE O
(We)agree tosser,indemmfy and keep harmless the City or Cupertino against ELECTRIC FF
liabillties,judgmems,costs undexpeses which may in any wayaceme against said City ALTER OR AUD'HI MIiCH. PLUMBING 4L I.
in consequence m(the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Io,010 CPM)
MECHANICAL 'E
SOURCii LAT10 S.
(� I 99I
HANDLING UNIT(OVER IO.IXq CPM) CONSTRUCTION T'
pplicanUContrumar I) c T HOOD OIRDUC) HOUSING MITIGADON FEE
HAZARDOUS hail
DISCLOSURE
Will the applicant or future hail it g accupanl store or handle hvzauhms material UNIT(TO 1001X0 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Cede,See ian 25532(t)P G UNIT(OVER 100,000 BTU)
❑Ycs ON. PAID ATIONPAN(SINGLERESIDT Date Receipt
Will the applicant o bubo building occipital use equipment or devices which -COMPDHPOR 1[X1,(00BIT)emit hucarch us air contaminants as defined by the Bay Area Air Quality Management UmndJ -COMP(OVER Infant BTU)
❑Yes ❑NoI have read the brvmlws mutciials requirements under Chapter 6.95 of the Cali- OITION[RISSUANCE DATE
Sid.Health&Safety Cede Sections 25505.25533 and 25534.1 malcommdthat if theSIDENTIAL MISCH. SQ.Ff ' /
hudd cummly have alt nh that it in my rcxfemilain,to notify mcaocupumt s-1{ 1 /
ofine, lnis mawldcn t t tpr,ary i.�anntear,c•nir a Ij u
AzeJ.gem I Dae TOTAL: ISSUED BY.-
OFFICE
Y:OFFICE