S 2274 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF:RTINO BUILDING-ELECIRIC.AL P17811 NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL V 2274
BUILDING PROJECT IDEM IF'ICATI3N
BUILDING ADDRESS: ��/ • SANITARY NO. APPLICATIONSUBMITTALDATI
O/ r U/ / h0 C� �J�� /v—G YY
0 R'S AMB: 110NE: CONT ACTOR'S NAME: LIC NO:
�rA'M NIC CONTROL
�ARCHITET/BBC ITER:CLNLi / IWJO":` ADDRESS: ❑ GO�/
CONfnCi': R
1 N� ❑ Consultant Fees Paid By Applicant(initial) BLOC I3U1ELECI PLUMB
fBMECH
'K 1W,ZV �� CC7' 2 __
LICENSED CONTRACTOR'S DECLARATION- QTY ELECTRIC PERMIT FEE
I hernhy allirm mat I min licensed under Ptnvoomet mf Ch,ac,9(commencing JOB DESCRIPTION
WCz, widtsartiom 3alolonnmiatr,n3ornte nnsinesa atw Prnress6,ns etule,aw myuatt,e i, / RESIDENTIAL:
F1_ 'n Poll forccand effctt. I'ERMITISSUANCF. J.
W� : ❑SFDWI. ❑KITCHEN REMODEL
If
!U id", scC Clunr APPLIANCES-RESIDEN'f1AL ❑ADDEMON ❑PLUMBING REPIPE
y ANCIII'TECI"SDs offierv...N PANELS ❑MULTI-UNIT ❑MODIFI RAL
MODIFICATION F h10U1PICATION
ZOr�Z IundmtnnA my plansshall he usN as public raoNs UPTO200AMPS
O Z-.A ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-IM)AMP-t IMPROVEMENT 0SWIMMING POOLS
Wsl a OWNER-BUILDER DECLARATION OV12R I000AMIn El BATH RHMODEVREPAIR El DEMOLITION
y 66'' Q 1 to ehy action that I am exempt from the Counselors License Law for the
x a U folrwing rctiam.(Section 7031.5,Business and Prnfeuions Ca dw Any city or county SIGNS ELECT ❑OTHER
W 3 LL Ne which requires u permit In ronslrucl,aper,improve,diem lids ar repair any ame um — -P�A. Q7
CFLLO.] prlortoisixsuntore,ikourfnlrestheapplicantforsuchpemtiuofleaaguedstatement SPECIALCIRCIII'IY SF=awe..
2;!{� that he is licensed pursuant o the previsions of the Contractors License law(Chapmr9 -
W�a00leoarmoving with Seetien 7000)of Division Sof the Rusimessand Pmfrodurss Code)or 'rEMI'.METES OIlii COMMERCIAL:
M y 2� that he k exempt thcreGont and the basis Ino me alleged exemption.Any viumlinn of R ❑NIiW BLDG/ADDITION El DEMOLITION
LLX1
Section 7031.5 by anymplicam fur a suctisuhjecis the applicant m a null penalty of IYIWBR DEVICES ❑TENANT ❑FOOD SERVICE
m
of mo¢man five hundred dollars(5500). IMPROVEMENT
�=Q I.asownerasfineprpny.nrmYcntple eswithwa6esmtheirwlecnm "mion. Ei FICTRIC
THER
willdothc work,and the crucnrcis not mendulmolhrad lar sale(Set.7014,Business /^
W tat and Profusion.Codn Tm Committers License law docs not apply to an owner of I1T1-•- SWITCIIES 14X'1'UN `7
a 3_ property who build,e,improves mercoa,and who dues such wok himself or drought
his Own employees,provided that such inprovelrtents art nod Intended or offered for NIiW RESIDENTIAL ELECfR SQ 14.
sale.PL hnwcver.Ne building orimpnrvcmcm is snhl within Inc yrstr nfcontpletinn,the .Q. T.Irl.00R AREA YSQ.IT.
Owner builder will have the burden Of proving this be did mud build nm improve for pur-
f-1 1,if owner rel 0e property,xis exclusively mmmcdin6 with licensed contractors to gOPAL:77
nstntt the project(Sec.71144,Bminns and Profcoinns Codca I In Irsomm a's Li- �.
env:Lawdnes noutpplymanownerofprnpery who baldsoo improves thereon.and QTY. PLusinING PERMIT FEE 9
who contracts for such promm m
projects with a contractors)licensed punthe Contmcmrs /
Liven a I.aw. PIiRA1IT ISSIIANCL'
17 l um exempt ander Sm. ,B&P C for this reason pp
Ow.,
Date AI:TI[It-IIItNN&VENT-WATF.RIBM IJQ VALUA'I'ION
Om
O �
\ WORKEk:SCOMPENSATION DECLARATION BACK Fl.OW PROTECT.DEVICE QV
Thereby ofEnn under penalty of horjury ane nCthe following dedtumion ''VV
I have and will maintain a Certificare ofConcennO self-insure far Workers Compere- DRAINS-FLOOR,ROOF,AREA,CONE). S'I' RIES TYPE CONSTRUCION
,inion,as provided Ito by Section 37W of he fusion,Cods,for the performance Of the
work fur which this pent h is issued FIXTURES-1'EN TRAP 2 Sri_
1 hmc and will retortion Worker's Canute ainn Imuronee,;is nor.tied by Section
3700of the labor Cale,fonhe perfarome,of the week far which this permit is i,seed, GAS-EA.SYSTEM-I INC.4 Of TLETS PICC.GROUP APN
My Workers Compensation rsuome,tinc,,cid Policy numberam:
Currier: Policy No _ GAS-L'A.SVS'1 (I
'HM- VBR4(CA) {
.:
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASFJINDUS"181.WASTE INTERCIiYI'
COhtl'F:NSATION INSURANCE BUILDING DIVISION FELS
(1'1iissec,0 dadnm he completed ifthe pend,is fore.hundred doRar,(SIgh IGRF.ASETRAP
or IcssJ PLANCHI!CK FECBro
I certify that in the performnnce of the wark for which this permit is issued,I%hallEWER-SANITA -STORMno,employ any person inany manner so as m become subject to the Worker,'Compen- ENERGY ITIi /Og,1-
OOicantf onto.Date ATBk IIF:ATER W iLF.CIt:tion Lows of Calpp Z AfERSYSTIiM/IRP 1,5 Flilibecome subject m the Worker's Compensation previsions of the Labor Code,you mustforthwith comply with such previsions or this permit shill hcdmed revoked. ATER SERVICE, p//� G 07$ ZCONSTRUCTION LENDING AGENCY CW RESIDENTIAI.I'LM S i'AID/�
V ftmodmj
I hereby allimnhat there is a constmction lending agency for the performance of Dade Receipt 11
(L F the work for which this pend[is issued(Sec.3097,Cw.CJ �-S^
V Lendds Name TOTAL: qQ,7.2_G4.1L1a l.cnder',Addmas gYITAI.: 8--.v
ht 1 certify that 1 have read this application and crate menhe illove infornminn is BUILDING FEE 3elFf,oC
ty rA corm'.Initricwcomplywithallcityandcountyordinancesandsdate,laws rising m QT'Y. M17CIIANICALPFRMIT TEF, 3.
V building umdmninn,anA horcby vndbnrire rcpr„emmivex of this chytorcau.ponthe SUISMICEPE
above mentioned property for inspection purposes. ITEROTt ISSUANCE
(We)agree m snes,indureiry and keep harmless ma Cn,of Cupertinoo agaima JJ s V ELECTRIC P t r S O
liahililics.judgtnen¢,cost.v and expense,which may imany way accrue against said City ALTER OR ADD'IO MECII.
inconsequence of the granting of this permit. - Z7 I'LUMI GPI 1 x270
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ONE F CIO 11,100(1 CIM)
SO. I E REGULATIONS MECH .FEF. SCS d�
' OLA AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRU. INTAX
I IturcofApplicanta2mllnion, /Dan EXHAUST HOOD(W/DUCT) D s rO HOUSING MI1 IGATION FEE
HAZAi0ous MATERIALS DISCLOSURE
Will the npplienttt um from,building axmpant sem nr handl,hnooducs tnountil I IEADNG ONE T OD ISMO(M)BTU)
as defined by the Consent,Municipal Cafe,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)^ / HEATING ONE"1'(OVER 100,010 BTU)
E]yl,' B'IG PAID
VENTILATION PAN(SINGLE BESIDE
sVdI the applicant nr Immo building ovemer,use equipment or devices which One Reecipt Is 7G
Ida ltmzldous air comaminvntsasde ed by the Bay Area Air Quality Management BOILER-COMP(3HPOR 1('A)JEWRTU) TOTAL:
�Didnictl
❑Yes BOILER-COM p(OVER 100,000 BTIH
I have lead the hanudeus materials requirement under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
fentiv Pleahh&Safety Cade,Section,255115,25533 and 25534.1 understood that lithe NEW RESIDENTIAL MECII. SQ.EL
building does nomnrrently have a tenant,that it is my responsibilitym notify the Occupant YC je
ofdh mmmentwhich mud n tpnonoissuance nfa Cerificae fflecupn '
� Tal I�n.7�n ccc f
Ow ramhoriztd agentDae TOTAL: . ISSl1ED BY
OFFICE