S 2780 (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 Q
RUILBUILDINGI'R(IdEGT IMI'
DRIFICAS 2780
BUILDING
2 1 0
BUILDING ADDRIS9 SANITARY N(]. APPLICATION SUBMITTAL DATE
10521 DAV150N AVE. CUFFMI'i Cor 95or¢ L
OWNER'S'�NAMI;; I � I'fl,O1Nli: 1 OZ,�y CONTHACfOR'S NAME L.IC NO: .J
/STI Ips ITV 'I� 4 N/C CONTHOI.p
ANC({I'IEC'I'/ENGINEF:R: LIC NO, ADDRESS:
CONTACT. PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) FILM ELECT PLUMB MECH
❑ ❑ X ❑
LICENSED CONTRACTOR'S DECLARAI'[ON Q'TY ELECTRIC PERMIT FEE
1 hereby atfrm that I am licensed under provisions of Chupmr 9(commencing JOB DESCRIPTION
WOoO
Owith Seelion 7d0o)of Division 3 oflhe Business and PromosionsCde,and my licensk is PERMIT ISSUANCE RESIDENTIAL
FW in full force and eRcct. ❑SFDWL ❑KITCH REMODEL
QUU License Clan Ltd. APPLIANCES-RESIDIENI'[AL ❑ADDITION BING RE-PIPF,
F Z u1 Date Co or,
y 6 a ❑MULTI-UNIT ❑STRUCTURAL
ARC all be a'S DECLARATION
p.Ola _ PANELS MODIFICATION
Z p h Z 1 understand my plans shall be used az public records
OZ-O UPTONIOAMPS ❑INTERIOR ❑CHIMNEY REPAIR
NQ4,I'C,W Licensed Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER limit AMPS El BATH REMODEIIREPAIR El DEMOLITION
5 Q 1 hereby off.thin I am exempt from the Contmcmrs License Law far the r
k 3 6 V following mason.(Section 7031,5.Rosiness and Professions Code Any city at county SIGNS ELECTRICAL I'R ..
LLl Ir. which requires o permit to construct,ill<r,improve,decnul lsb,or repair any sWmum W/
F+EO� prior to its issuance,also requires theapplicanr for such permiuo file a signed statement SPECIAL CIRCUIT( SC.
sss�,j that he is licensed pursuant to the provisions ofthe Conoxmoes License law(Chapmr9
pJ'Q2 (commencing with Section 7000)of Division 3 ofthe Business and Professions Cde)or 1'IEMPMETE RPOLEINS'L COMMERCIAL'
Q.y e¢a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
uX7 Icy Section 7031.5 by any applicant for a permnsubjectslhuvp,limt ts.civil penahy of 1'OWER :VICES ❑TENANT ❑FOOD S17RVICI:
am re than five hundred dollars(15000. IMP -hldRl'T
SSG ❑I,as owner of the pmIa,my,or my employees with wages as their sole Omos r action, S W MING POOI,EIEC RIG [I 0THFI
ca will do the work,and lhe.strvnure is not intended or offered l is sale(See,](144,Nnxincw
4 3 a. and Professions Code:The Com ono',Uceme Law does tam n apply an owner of NILETS-SWITCHIS-FIXTI
property who builds(ir improves thereon,and who does such work himself Or IMrogh
his own employees,provided Thal such imp nsemenBrt anot intended or offered for NEW RESIDENTIAL ELF.CfR S
gor improvement yearn' p F1}(K)R AItEV� S/.ves .
sale.If,however,the boil din I It,,he did none imam lerfan.the Irll'1rl W 9 �e og
enbuiWcr,will have the hoiden of proving Nw he did no,buildor improve for par.
Fu-of xulc.). TOTAL
❑1,as owner of he property,o xciii,ocly contracting with licensed contractors m
constant the project(Sec.7044,Business and Pmfessinto Codc:)Tw Conoacmr's Li-
camse Law does not apply to an cwrcr of propearry who hadds or improves themon,and QTY. PLUMBING PERMIT FEE By
who contracts for such projects with it cammemgs)licensed pursuant to the Conuacmra
License law. 1 I PERMIT ISSUANCE
I am exempt under See .B&P C for this reason
ALTER-DRAIN&VEND'-WATER(EA) VALUATION
Owner Use
WORKER'S COMPENSATION DEC"RATION BACK 17LOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following Jceloodom:
❑ Hadvemalwidnuimuin nCernifcam of Consent ro sit(-insur<fnr Worker's Compen- DRAINS-FLOOR.R00r,,AREA,COND. STORIES IYPIE CTION
nation,as provided for by Section 37M of the Labor Code,for the performance of thep5k ,�^
[3work for which this permit is issued. FIXTURES-PER TRAP fir
I ame and will maintain Workeran
's Compensation Insurance,as required by Section
3700 oldie labor Code.l'orlhe performance ofthe work forwhich this Permit is issued GAS-EA.SYSTEM-I INC.40UTLE1:5 8. OCC.GROUT' /qLN —
My Workers Compensation Insurance carrier and Policy number am:
lJL
Carrier: Policy No.: GAS-EA.SYSTEMAVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEYINDUSTRL WASTE INTERCEPTORCOMPFNSA'1'ION INSURANCE BUILDING DIVISION FIEFS
('Ihisuction need not becomplead iUhe permit is for one hundrWdollms($1(10) GREASETRAP
or lens) PLANCH[CK PEE as
I certify that in the perfoma
reacifthe work for which this permit is issued,Ishall SEWER-SAN]1'ARY-STORM EA.200 FT.
not employ any person in any ntaaner.wt as m hecmne suhjecr to the Workers'Compaq- ENERGY PEE
z swan Luws of CalI tar..Dam WATER 11GTER WNENT/ELECTR
z GRADING FEE
pplkinl
'01 ICE TO APPLICANT.If,after making this Cdoomam of Exemption,you should CATER SYSTEMnREATIN G SOILS I£li
f became subject m the Workers Compensation provisions of the Labor Codd,you all 2
forthwith comply wish such pnovininns nr @is permit shall he Deemed mwked. WATERSERVICE JQ
Q
] z CONSTRUCTION LENDING AGENCY NEW RESIDENT[AL PLMIL SQ ET. PAID Receiptp
V Ihereby affirm that is a construction lending agency fin the parharromed of
U2 the work[nr which this permit is issued Side.3097,Civ.C.) TOTAL:
17�U Lender's Name
Ltd Lenders Address TOTAL: BUILDING FEE
I certify(hut 1 have rail this vpplicritinn and stain that he abuse information is
iF+
tat cancer.I agree m comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V G building construction,and hereby amhnnim represematives of this city to enter upon SEISMIC FEE.
' above-mentioned pmpertY for inspection purposes. PFRMIT ISSUANCE ELECTRIC
(We)agree to save,indemnify and keep M1urndess the City of Cupertino against 1 I URIC FEE
liabilities judgments,costs and expenses which may m any way scene agaimlsaid City ALTER OR ADD TOMECIL PLUMBING FEE
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 1k000 CFM) MECHANICAL FEE
sou Er�R. NS. wn rf
����'n'"I�l M�Jf WS L9f99 AIR HANDLING UNIT(OVER 10,1N)0C' ) CONS'fRUC1'ION TAX
la atm 4plic�rgracmr Dam EXHAUST I IOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or dome builmogoteupomsterc nr handle hmanfnvx material 14EATING UNIT(TO 100.( TU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATINGUNI'T(OVF mMRI�11))
❑Yes ❑No VENTILA'I']ON F (SINGPAID Dun ReceiptM
Will lheapplicaut or future building occupant use equipment or devices which ROLLER-/MP(3HP ORemit hazardous air contam mint,as defined by the Ray Arca Air Quality Management TOTAL:
Digrim^ BOIL' -C P(P(OVER 1❑Yes ❑NoIhavereadheh;vallou.s materials mquirements under Chapter695 of the Cali- CONDITIONERISSUANCE DATE
fnmia Health&Safely Cole,Sections 25505,25533 ural 25534.I undesmnd that it rhe NEW RESIDENTIAL MECbuildin( e,maiffimzedagent Date - ISSUED BY:
OFFICE