S 2468 (2) -'APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONXERMIT PLUMBING•MECHANICAL S 2468
BUILDING PROJECT IDENTIFICATION
t
BUILDING ADDRESS: SANITARY NO. APPLICATION SIIBMITTAI.DATE
4 OWNER'S NAME: PHONE: CONT GFOR'S NAME: / LIC NO:
II IS� J1�C M R•E /C t.r(�� r NIC CONTROL M
HCHITECUENGINEER: LIC NO: AD ;ESS: ❑
So 0sJYto r. 'izo-r4
CONTACT: /"� ...0 it or11ovgkr,1rw F4C-1,1 r cittptfi BUILDING PERMIT INFO
\ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT'/ PLUMB MI' 11
L J"�/c.cNC 252—$ LrJJ El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT 17EE
1 hereby orm den Iran Iicert,ad took,provisions of Chapter 9(commencing JOB DESCRIPTION
WQ ith SectIXID)oOO wion] flif DoOsm.Sof the Itusinessind Professions Code.ond my live san R SIDS ENTIAL:
W PERMIT ISSUANCE O
in full force and eR r0 r S ❑SFDWL ❑KITCIIRN REMODEI.
aUV Licens Clus — - 03
Con APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RELPIPE
h-Z W Dme Contmdo
rn<a ❑MULTI-UNIT ❑STRUCURAL
ARCHITECTS DELI
�p n z I undnstmtd my drio,hull be used us public nand, PANELS MODIFICATION
DZ,•,Q ' UP'1'o 2IXIAMPS Z O ❑INTERIOR C1 CHIMNEY REPAIR
y F-Iy Licensed Preassi...I 201400OAMPS IMPROVEMENT E]SWIMMING POOLS
WdOWNER-BUILDER DECLARATION OVER I(NM)AMPS El BATH BATH kEMODELMEPAIR DEMOLHTON
x m in
G 1 hereby to t that I an earand Jr..The Contran nf's License Law for the
.., V following reason.(Section]031.5,Business ami Ernestine,Cod,:Any city or county SIGNS ELECTRICAL ❑fT11ER
LL w which requires a permit 10 conmm'.alter.improve,demolish,or repair.ny swaure
Q prior to its issuance,also requires the applicant forwch parmilm 1 o,igncdnlu¢•nant SPIECIAL CINCUI'I'/MIS0.
t "yi1 that he is licensed pursuant o the provisions of the Contmctory License how(Chapter 9
4 m
(comencing with Section]00BI of Divmon 3 of the Business and Profession,Coact or TEMP.M METER OR PULE INST. COMMERCIAL,
Y y M q that he is excmpl therefrom ad the basis for the vlleged nrntplian.Any vinlminn of ❑NEW BLDWADDI'1'ION ❑DEMOLITION
iuG1 u•
Section 7031.5byany app heart Iota permi...bjecu lheapplicint to.civil penalty of POWER DEVICES ❑TENANT [117001)SERVICE,
not more than five hundred dollars($500).
FZO ❑I,as owner of the property,or my empinyces with wages as theirsnlc compcnserinn, SWIMMING POOL ELECTRIC
IMPROVEMENT
$a willdo the work,and lheslrucmm is not hocnl.doruffred battle(Sec.](H4,Business ♦ ❑QT'HER
LL1 .ad Profes,in.,Code:The Can onical's License Law does ant apply to an ay,er of ( 0 D'TLETS SWITCHES-FlXTURES ' 00
a' prapeny who huilds nr improves Thereon,end win does such work himself or through
his own employees,provided Thal such inipmearace s am not intended pro;cred far NEW RESIDENTIAL ELECTR SQ FI'.
sale,If,however.the building or improvement is sold within one year of completion.the
SQ.14.FLOOR AREA $ISQ.IT.
ownef builder will have The burden of proving that he did not build or improve for par,
,awr of sole.).
I,as owner of the property,ten aceta>ivdy contrvcting wish IicenseJ convactnrs to 1i
consumer The project(Sec.]OW,Business and Pro@snions Code:)The Contraetor's U-
nscw
ladresnotapplytoanownerofpropertywhobuildsorimprove&thereon,and QTY PLU IN ERMIT FEE
who corm's ter such projects with a umon'm(s)fansed pmsuaal In the Contractors
License Law. PERMIT ISSUAN
❑ I um esempl under Sec. .B&P C for this reason
A ITER-DRAIN&VHN'17 RHEA) VALUATION
Owner ])are
1 WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVIC
Ihercby affirm maintain
ai ender penally to of
Consent
of the -la b fallowing dedamuo o
❑ ]have anti maimai Se Certificate of he Lids sel,for'he Woerrommnmpen- DRAINS-PLUUR.NO(IE AREA,COND. STORIES TYPE CONSTRUCTION
'bons as provided fpr mi Section 7100 of the Lahir Code,for 0e&performance of the
work for which dile permit is issued. IIKI'ORES-PER TRAP
❑ I have and will muinmin Worker's Cmnpensotion Insurance,o,«ynireJ by Section
3]IXlpf roc labor Calc,fpr the Perfnrtnance ofihe work farwhich this Nonanininwed. GAS-G.S YSTF,Md INC.40UTL-TS OCC.GROUP APN
My Workers Compensation lnwmnce canitemid Policy number are: GAS-EA.SYSTEM OVER 4 EA) '111 r•Q'(ssO(1
Carrier: Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRPASF/INDl15TR1.WAST• CF. R
COMPENSATION INSURANCE BUILDING DIVISION FT:ES
(This auction need not he completed if the permit is for one hundred dollars(Sl W) GRI!ASE'1'R
or Icy,.) PLA NCHHCK FEE
I certify that in The Performance of the work for which this Permit is issued,IstndEE.jAP Y-S RMEA.. I
not employ any person in any manner so as m become wbn
jeco the Workers:Cmapen- ENERGY FEE
Oz eatlna Lows of Calilinn'ni,Data 'PIER tXJFRW/VF /t. TIE
z Q Applicant GRADING F
y NOTICE TO APPLICANT..If,ifier making this Ccrtifcamof Escmption,you should ;RS iA NC
became suhjcct m the Worker's CnmP,vam loo pnrvidnns of the Lobor Code,yon maul SQTIs FRE,
funhwllh comply wish such Provisions nr this permiuhdll be deemed revoked. ER S RVICE
0
= z CONSTRUCTION LENDING AGENCY N RESIDENTIAL PLMR SQ.FT. PAID
L) 0 . Ihercby a0imnhw there inaamtlmclian lcnJinK agency for the penbnmmnac of Dao ,Receiptq
the work for which this permit is issued Soc.3097,Civ,CJ
O U Lender 'TOTAL:
Leader's Name TOTAL:
Uhe der',WAddress
1 certify that 1 have read this application and nate that The above information is BUILDING F I
rn correct.l agree to comply with all city and sconly ordinances and stale laws relating to Qry. MECHANICAL PERMIT FEE
V building cnmtmetion,and hereby authorim representatives of this city m enter open the SEISMIC f1.
.hove-mentionmi property for insWction Purposes PERMIT ISSUANCE
(We)agree to save,indemnify and keep hvrmless the City of CuPenin s against ELECTRIC FF.1:
Iiabildies,judgmenis,cpas and expenses which may in any way rcme agninsisaid City AIXER OR A DD TO M HCH. I
at msequcnccof the got i fthis pent. PLUMNINC IIAi
APPIACAt ' DF 'T P IS AND\'ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ID(X10CFM7
MECHANICAL ITE
SOWJCERI ',L
AIR HANDLING UNI'I'IOVER 10,M)CIPM) CONSTRUCTION TAX
i nature of Apphcnn omrmbr Data EXHAUST HOOD(W/DUCE) HOUSING MITIGATION IEE
HAZARDOUS MATEIRIALS DISCLOSURE
Will The applicant or future building occupant store or handle hmarJous material HHA'I'ING ON I'F(TO 100,000111 U)
as define)by the Cupertino Municipal Colo.Chapter 9.12,and the Health and Safety
Code,Scan..25532(al^ �r-a�/�/I^ HEATING ONE r(OVIER 100,00d TITO)
❑Ycx ICJ"" VENTILATION FAN(SINGLE RIES ID) PAID Data ReceiptM
Will the applicant or future building occupant use equipment or devices which
emit hnimdous air cpnluminunts}'s defined by the Buy Amo Air Quality Manugeo'nt ROILER-COME'611POR 100,00011TH)
DisuicTOT
C /
❑Yen QNo BOILER-C(]MPIOVIER I(1(I,IXq BTUI
I have mad the haardoymanterialsreyairemems under Chapter 6.95 ofine Cali- AIRCONDI'NONER ISSUANCE DATE
forma Health&Safety Cade,. Flions 25505,M533 and 25534.1 understand that if The NEW RESIDENTIAL NIECE. SQ.FF.
boiWingdmsnm nJy It n1.lhmitismy csponsibility mn0lifythe occupant
of the Ir�u rowe>�bprie— fmRrtllicam ofUccupuncY.
sQu Igor audinn d gs�l'K� Date TOTAL ISSUED BY:
OFFICE