S 2684 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECIRICAL PE-RMI I'ND.
BUILDING DIVISION APPLICA'1'IONIPERMIT PLUMBING-MECHANICAL S 2684
III111,DIN01'RI1J PROJECT I,)",IPICAT'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'Z'E
/9P/I ,P/LL= vG So ,3-& -7 9
OWNS 'S AME PIIONE: CO ACIYJ bt h I.IC NO.
C/ zz 6� NIC. CONTROL Or
•A CH li /ENGINEER: LIC NO: ADIMPJC a: �� �� ❑
CON PALL PHONE w HUILDINC PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B D HLeCT PLUMB MECB
72-- / z8� ❑ ❑ ❑
LICENS17D C(JNTRACI'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby effirm that I an licensed under provisions of Chapter 9(emarromias JOB DESCRIPTION
O Ti'Z with Sect ion 9x01 IU' si Jof the Business�pd Ry( Cade.vnA rp�Iicenu is RESIDENTIAL
FOS in full force an a /y /!_5 J PRRMI'1'ISSIJANCE
CW1„ % /c^r / ❑SPUWI. ❑KITCf11iN kCMODEI.
a,VV Dre 11Clvs. LicJ APPLIANCES—RESIDENTIAL ❑ADD)T]ON El PLUMBING RF.-PIPIT
y6a Iya¢ Cnnmmmr
E,brn
'Y777--ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑S'IRUCPURAL
ZO`�„Z- Imal,roandmyplan.a shall be used vx P.M1lie reconfs ODII'ICA'I'ION
OZ C UPT02cx AMPS []INTERIOR 'HIM .YREPAIR s
ha^�1p'{v1 Licensed l'mfcusionul 201-I01(IAMPS IMPROVEMENT SWIMMING POOLS
Cu , OWNER-BUILDER DECLARATION OVER IBM AMPS El BATH REMODEIAREPAIR ❑DEMOLITION
NQ I hereby mfr.rot Thal I an,exnnpl from the Cnlnrvcmrs Licen.c Law far the
?WW?S5
Il police,followde
ing reason.(Section 7031.5.Business and Professions Ca :Any city nr county SIGNS HLECIRICAL [I OTHER
xa 3 LL y which retptires it pennll In construct,alter,'onprove,denolldr or repair any suuemre
,I".,�f0ryn� prinnnirc issuance,also myuims the applicam for such perrnilmBle aligned smteme^t SPECIAL CIRcuri miss.
EWvJ Y Ih.t he is licensed punuvnn,the provWonsaf the Cmducter's License Low[Coup¢r9
W Cq� (commencing with Section 7")of Division J ofthe Business and Professions Code)or TEMP.MEOiR OR POLB INS'C COMMERCIAL,611 pa
an he isexempt fheref or and the Iasis lir the alleged exemption.Any violation of [INEW BLDG/AUDITION ElDEMOLITION
X[n,N Section 7031.5 by any applicant for a Permit subjects the applicant m a civil pmulty of POWER DEVICES
not marc shun five hundred Aolvrs($Stln). ❑'1'1?NAN'f ❑FOODSERVICE
F ZS 7+ IMPROVEMENT
HFq ❑Lmowner of the propenY•onnyentployces wish wages..theirade mmpecosion, SWIMMING 11001.ELECTRIC
will do the work,and the smtcmre is not intended orotlemd f e sale(See.9044.Business OTHER
ELE m and Professions Code:The Contmcmis License Law does not apply to an owner of 0UTLFI S-SWITCHES-FIXTURES
property who builds or improves tbere.m,and who does such war,himself m through
his own employees,provided that such improvememe arc ma intended or ofcmd for NEW RESIDENTIAL ELECT ,SQ PT.
sale.[I,however the building or imprwernent is sold within one year ofcomplenon,the SQ.FIL FLOOR AREA $/SQ.FT.
owner-builder will have the hunlcn of proving that he did not build or improve far pur-
pose of mle.l.
❑1,us owner of the property am exclusively contracting with licemed ronmmms m TOTAL:
instruct the project(Sec.90W4,Business and Professions Cod,the Comrecmn's hi-
nseLaw does not apply mvnowner ofpropeny%no builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who counties no och projects wall acnntmnar(s)licensed pursuant to the Contractor's
License Lie. PEIi MTI'ISSUANCE
Iain exempt under See. ,B A,P C forlhix reams
Owner Date ALI 17R-DRAIN et VF.N'Y-WATER(EA) VALUATION
WORKERS COMPIiNSA'1'ION DECLARATION BACK FLOW PROTECT.DEVICE
I heathy vlfirm under Nein y of perjury,one of the following dalvmtions
❑I have and will mvinminn Cenificvlenf Cnnscnnosclf-Insure for Worker'sGmlpen- DRAINS-FLOOR,ROORARFA,COND .S"1'ORIFS TYPE.CONSTRUCTION
out ns provided for by Section 3]0)of the Labor Code,for the performance of the /
'for which mil permit is issncA. FIX'I'ORES-I'IiR'I'RAE'
w 1 hove and will maimain Werkee,Compensation Womble.az".'led by Sai
.Iyµhhe Labof Cod c,fort he pefarmanceot;^hdeoulk h9his suet. GAS-EA.SYSTEM-I INC.4OU1'AHS OCC.GROUT' APN
Cnrrimr .;C
V✓f Uw epolicy No. CAS-EA.SYSTEM-OVIiR4U..AI 69 _0,5
Polic
CERTIPICATF.01'EXEMPTION PROM WORKERS' / O�
COMPENSAOON INSURANCE GREASEIINDUSTRI.WAS'Oi INT IRCE1H'OR
BUILDING DIVISION IFF.S
(This suction need not hecompinNilthepennit is hrtnne hundred dnllvts($1 W) GREASE'I'RAI'
or less.) PIANCHF.CK FF.E
I rectify that in the performance of the work tinwhich this permit is issued,l shill SIMER-SANI'1'AItY-Sr FORM EA.200 IT.
not employ any person in any manner so m m u
become subject the Workers Comil ENERGY FEE
p Z .tylion laws of Califomin,Dam WATER II RAI 17R W/VEN'WEI,IiCI'R
Z Applicant GRADINGFEE
reds NOTICE TO APPLICANT:If,after making this Cenificvte of ILentption,you should WWI 17R SYSI IiM(I'RUA'I'I NO
a > became subject a the Worker's Compensation pmvisionn of the Labor Code,you must SOILS FEE
fnnhwith comply with such prnviamtsnr 11re,co it shall be deemed revoked. WR'I'ER SIiRVI '
Q
CONSI'RUCI'IDN LENDING AGIiNCV NEW ItESIUIiNr 01 SQ.Irl'. PAID
LJ 0l hereby affirm that merek a construction lending agency for the performance of Date Reaiptp
the work for which this pennll is scored(Sec.3041,Civ.C.) n 8
W f•' lenders Name TOTAL:
V Lenders Address 'FOI'AL:
1 certify that 1 have read this application and nate that the altar,information is BUILDIN
Va] corvaa.Ias.to comply wish on it,and county onlicana.,and nee Inws retuning In QTY. ME J ICAL PERMIT
V Z building construction,and hereby vut rinse representatives of this city to enter upon the SIiISMIC P.
eMwe-ntcntiened property for inspection pupx'ses.
(We).gran 1..e.indemnify and kap harmless the City of Cupertino against PERMIT ISSUA ELECPRI iE �
Iinbilitics' meats.cot dcx caseswhich in yiaany way.ccrocvguirast said City ALT17R OR ADD'DO MECH.
cyuem of the gmming suis permit PhUMBIN ,
AP CAN U S AND WILL COMPLY WITH A.I.NON.I'OIN'I' AIRIIANDLING UNIT(TO IO,00OCFM) MIiCHANICAL .E
S - IONS ��/9
AIR HANDLING UNIT(OVER O,OWCFM) CONSTRUCTION TAX
Signamrc of Appd,auo/C,m air Ilse EXIIAUS'1'HOOD(W/DUCI) HOUSING MITIGATION FEE
HA'J. DOUS MATERIALS DISCLOSURE
Will the applicam m houre building occupamsmmor handle actinium,macrul HEAPING UNIT(TO 1010,00 BTU)
as defined by the Cupeninn MEn ,co,to
' Chapter 9.12,anA the Ileallh and Sxfdy
Cale,Section 25532(0)'! 1IHAI'INC,ON1'I'(OVER 100.000 BTU)
Yto
� VfUd'1'ILA'PION RAN ISINGLP,RPSIU) PAID
• Date Rccdpt a'Will the supplicant ti fteBuse equipment ar dMana which
emit h.tmdous air contaminants as Acfined by the Nay Area Air Quality Management ROILF.R-COMP(JHP OR 100,0(g)BTU)01 TOT
Dinncf! � / BOILER-COMP(OVER 100,0B1'Iq
AIR CONDITIONER
I have read the Code Se materiels 5,2553 can undo Chapter h95 of the Cali- E$SUANCF.IJATIi
!Dense ntlt s.'sfdy CnJe,Sectio ns 24(15,is yand25534, umderxtnnd Latif me NEW RESIDENTIAL MF.CII, SQ.PE
build gd ono a
out.(but it is my rtslnnsihilinrusnm000�oojjJJJ///111thc acupant
off I, s11 tuna amt prinnnissnanceo �i�I �yp, t
Owner or aumnriuJ age nt Dan TOTAL: ISSUED BY:
OFFICE