S 2583 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDwG-FLECFRICAL PERMIT No. r^
BUILDING DIVISION APPLICATION/PERMIT PLUMB ING-MF.CIIANICAL S 2583
BUILDING PROJECT IDENTIFICATION
RUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
V?XV6 Howge.D co�aT �R ►iN0 . cA LOT #& 2- L2-c(
OWNER'. N ME: E: p CONTRACTOR'S NAME LIC NO'.
TAX E- DON
wow!' gr Xl opw N/C CONTROL#
CHITEC iNGINLER: LICND' ADDRESS
VV:
�kE C- 2!230 ( -79
-CONTACfT�: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB StEC
G E�— En- In-
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby offirtm mal 1 am licensed under Foremen,of Cheerer 9 Uourr ,ening JOB DESCRIPTION
w0c)atz with Section"IUW)r[Divlsinn 3ofthe Business and Professions Gde,and mylicenxc is RESIDENTIAL'
I- Ir full farce and ellen, PERMIT ISSUANCE �b,�
�UU License Class LinC18F
# DWL ❑KITCHEN REMODEL
N4G Dam Contractor APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RF,-PIPE
O
F nARC]IITECTDECLARATION PANELS'S'22� []MULTI-UNIT ❑ FI '
2 y q 1 nndcrsmnd my plans shall he liberc
l as public cordr MODIFICATION
RZ-1 UPT0200AMPS E3 INTERIOR [I CHIMNEY REPAIR
F �W Licensed Pro e"i'mal
PZ
„'y' ,`.�) OWNER-BUILDER DECLARATION 301-1000AMPS IMPROVEMENT 0SWIMMING POOLS
a C' U 1 hereby o irm that I nm exempt from the Contractor's License Law for the OVER 1000AMPS El BATH REMODEVREPAIR Q DEMOLITION
O L Ubillowing reason.(Soviet 7031.5,Bisms s and Profession Cade:Any city or¢runty SIGNS ELECTRICAL, ❑OTHER
oya wh sh requires a pe I to consumer, II prove,dcrookh.(it repairany stricture
H3 prione)its issuance,also quires the applicant fh pereadI file a signedstatement SPECIAL CIRCUIT/MISC,
thin he licensed ptt.IseTro,......totdise C t rrr's License I' (Chapter9
W
(dommencng wiES.m m70BdolObeen3ofthe Business and Prdes,mrs Code)or p O TIiMP.METER OR POLF:INST COMMERCIAL
that M10 is cacmpl IM1erctmm and We basis for me alleged exemption.Any violation nC
tiXl�r�
Section 7011,1 l
by any applicant for a pernaid icesme applicant no vcivil Penalty of POWER DEVICES ❑NEWBLDG/ADDITION ❑
yy ammse than five hundred dollars($100). ❑TENANT ❑FOOD SERVICE
FRdO 0I,as owner ofthe progeny,army employees wish wages as ihnrsrle cumpemmion, SWIMMING POOL ELECTRIC IMPROVEMENT
will de the work,and the structure is not intended or offered for sale(Sec.'/044,Buir e„ ress, ❑OTHER
W� m :rad Polesslons Code The Comment',Licene Law dues nm apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work hi mae]f or through
his can employees.provided that such nonmemberls rte not rumored nr offered for NEW RESIDE L ELECTR SQ
sale.Il,however,the buildingnr improvement inenld within one your ofabmpleion"he SQ Fr.FLUOR AREA $/SQ.F'r
evened-builder will have the burden of proving that he did not build or improve for put, AMA Iromoranle.). IVs1 A#�t,I@^
❑ 1,vs owner of the property,am exclusively contracting w'uh licensed commemas m TOTAL: -{ L s
rostrum the pri(Sec.9044,Business end Poressiom Cndc:)The Contractor's Li- 4.4',
�7
c am Law dons not apply to an owner ofpmpeny who Hailes or improves fiti tied QTY. PLUMBING MT F (/ iII�ZWa�
who c.mhaeb for such projects with a contortions)licensed pursuanno the Contractor'¢
LlceneLaw.
YC
❑ exempt
PERMIT ISSUANCE �l L.lfz
Ind and rSm. BPCfonhis reason 4:
ALTER-GRAIN.@VH, r-WATE A) VALUATION
woes_ Dole
WORKER'. COMPFNS O DF.CLARA'I'ION HACK PLOW PROTECT DEVICE � 'J y� O
I hereby affirm under Perot ly of pe In -ane of the billowing declamfinns J CJ
❑ Ihave nnd will maimeinaCertifiemerfCnnBeth mself-insure❑n Worker,Cormi DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
satien,as provided for by Section 3900 of the Labor Code,for the perronnance of the
work for which this pernfit Is issued_ FIXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Inxuunm,as required by Section
3900ofthe LVMbr Cods,for tile Performance of the work for which this permitinsued. GAS-EA.SYSTEM-I INC,4 OUTLETS OCC.GROUP APN
My Wad v ,Compensation Insurance varier and Pudiry reciter am:
Carrion: Policy so, GAS-EA.SYSTEM OVER 4(EA)
CERTIVICATE OF EXEMPTION FROM WORKERS'
COMPF,NSAT'ION INSURANCE GREASFAINDUSTRL WASTE INTERCEPT OR µU11A1NG DIVISION PEES
(This section need not be con.poled i f the permit is for one hundred dollars($100) ____.-_
or less.) GREASETRAP
PLANCHECK FEE
1 employ
any that in the my nam ber.of the work fur which Ihis theta a no'Ci,i shall <
nal cmpldy an SEWER-SANITARY-STORM H.A.200 FT
y person it any nbunner xn ax m hand¢snbjev tome Wmkerc'Cnnbpen- ENERGY FEE
Oz Applicant
Laws of Culifomiv.Dote WATER DEALER W/VEN'UHLCCTR
NOTICE
OTI E GRADING PEE
pj become subject
APPhhe AN I:Work II eller making this Cdisions of of Exemption,yet abmuld WATER SYS)T?M/TkBA'I'INC
a t^
become subject m the Worker provisions,
ro Compensation provisions of the Labor Code,you must SOILS FEB
B.I G ibrtlbwi[h wntply with such provisiore rr this permit shall he deemed revoke!. WATER SERVICE
�O CONS'I'RUCTION LENDING AGENCY NEW REST DENTIAL PLM r'3. SQ.FT. PAID
I hereby uffcar that here is a cannon...,lending agency traffic poor conceaf Date Receipt#
L>w the work for which Ibis permit is fisted(Sec.3097,Civ.C.)
O U
Lenders Name OT,
(
Leaders Address L:TOTA
LU
11 I certify Ihat 1 have road this application and state that the above Information is BUILDI E. r
., 0 cotrecL l reared m comply with all cityona ormayordimoreiandwam]aws relating to QTY. MECHANICAL PERMIT FEE
U,Z building constmmien,and hetehynoantle repreaematives ofthi,city to enterupon@o SEISMIC
show-memtoned property for inspection purposes. G'�T
(We)agree toms¢,indemnify p y r . y PERMIT ISSUANCE 7 V
6 yard Ince hay in an wait bCn tinoavi City
ELECT 7
inconieq judgments.costs and expenses thispermit.
they in any way ocemd ngainst,uiJ City ALTER ORADDT'O MHCH. `2n
consequence(ifthegranting Sthisp WILL
PLUMB ,E 7�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIM' AIR HANDLING UNIT(TO 10,00f)CHAD SOURCE REGU ATIONS. MEC [CAL It tbn
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION AX
SignaluiT of Applicaiiye.n ems Dole EXHAUST'HOOD(WMUCT)
HAZARDOUS MATERIA DISCL RE HOUSING MITIGATI
Will the applicant or future huilding occ rear handle hmardrua materiel HEATING UNIT(TO 100,0011 RTU) {� J
as defined by the Cupertino Mimieipal Code,Chapter 9.12,and dm Hudlh and Safety
Code,Sectio 25532(x)7 HEATING UNIT'(OVER I00,00D BTU)
❑Yen ❑Nr
VE SIT LATION FAN(S INGLE RESI D) PAID -
Wi11 thea tam or Room boilein Dam Receipt#
pp g oaupnnlnA.Air emrndeviceswhkh BOILER-COMP(THE OR 100,000 BUJ
net buenNnus air eonmminanls ns defined by the Bay Area Air Quulily Munagcmmn )
Di,lricl^ TOTAL
❑Vas E]Nr BOILER-COMP(OVER 100,010 BTU)
I have rad the hammi r ilea rc oimnmrl,tinder Chapter 6.95 of the Cali- AIR CONDITIONER
0 P ISSUANCE DATE
RomWgdoes&SuCmy Gu la Sectionst,thati 25533and25534.1 to notitytth Thinif the NEW RESII3ENTIAI.MFAH. SQ.IrF. —� t^N�
building does not currently heves tenant,that it h my responsibility m notify the occupant s l�
of ma require mswhieh nm,t he me ionuistnnce oft Cenoficate of Occupane.
iic
Owner authorized ab Dute TOTAL:
ISSUED BY:
OFFICE