S 2700 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECPRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERNIFF PLUMBING,-MECHANICAL O 700
BUILDING PROJECIADENTO'IFICATION /
BUILDING ADDRESS: jhAN,11 ±NOAPPLICATION SUBMITTAL DATE
zlY7 ovitz— ori � �C�6 —OWNI:kS NAMIi: i'IIONii: CON1'RAC'IORS NAML: LIC NO: ONTROLhal LxJ CHI FECf/ENNGINLLIEt LIC NO: ADDRESS: //
O)NI'AC'n PHONE BUILDING PERMIT INFO
❑ Clymmi ant Fees Paid by Applicant(Initial) IiLUG ELECT PLUM MECH
D/ ❑
LICENSED CONTRACfOR'S DECLARA'GON QTY ELECTRIC PERMIT PEE
I hereby alarm Ibn I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
"Z with Scction]r(1(11 ofDivisinnJafthe Rosiness and l'rnfcsxions Cole,and mylilerwi.s RF,SIDENTIAL:
WOO PERMIT ISSUANCE rn
CIF in lull force and ell'err� v" '�,1 ( ❑SFf1WE, ❑KI'fCH1iN REA40UEI.
¢0,U License Cluys� Lic.N _� APPLIANCES-RESIDEN[A1. ❑ADDITION ❑PLUMBING RE-PIPE
ti<1 Date Z7X7$ ! Contractor G
F❑y ARCI IITRCT'S DECLARATIONPANELS ❑MULTIUNIT ❑STRUCFURAL
Zpms� IundcrsmnA my plans shall he used as public records UVT02MODIFICATION
1N1AMPS INTERIOR CHIMNEY REPAIR
O aril— LiscnsA professional 201.1(00AMPS IMPROVEMENT SWIMMING POOLS
fig •l OWNER-BUILDER DECLARATION
9OViHt IIII1rAMPS BATH RIiMODIiIlR1iPAIR [I DEMOLITION
a I herchy affirm that1 am exnnpl from the Contractor's License Law for the
�Sx O d U following reason.(Section 7031.5,Business and Professions Code,Any city nr county SIGNS 1iLEC'I'RICAL ❑OTI LER
W LL 40 y which requires a permit In construct,alter,improve,demolish,or repair any structure
pro h,its issuance,also retinues then"'linmt Burtch'relit fileasigncal"torneat SI'IiCIAI.CIHWITdod
} nut he is licensed pursuant m the provisions of the Contractors License law(Chapter 9
(commencing with Sooner7(X)(1)af Diemen 3ofthe 13 usiness and l'mfessiona Gude)or '1'13M P.M FTER OR POLE I NST. COMMERCIAL:
E.Y c e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑,�,NEW BLDG/ADDITION El DEMOLITION
^H Section 7031.5 by any applicant(a,a permit mbsjce the appluma ,,a civil Penalty of POWER DEVICES yrtcNANT ❑FOOD SERVICE
Qnot mine than five h.ndecd dollars($51X)). IMPROVEMENT
I,as owner ofthe norm mess with woes as their sale compensation, SWIMMING POOL ELECTRIC
❑ th,,u c temp r s fensx
will do the wink.Bud thenmemro is nnYimmnJul en,ffercJ for sole(Sec.7194,Business ❑OTIILR
W and Ionfcome,Gsle:The Commmnts License law does not apply to as owner of OUTLET'S-SWI'fCHfS-I9XtVRESg. -
prnpeny who buJds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements oro not intended or mfcred for NEW RESIDENTIAL HLEM SQ IT.
sale.It,however,the building or imprvemetn is sold within one yearofcomplelion,the SQ.14.FLUOR AREA $/SQ.fT.
en-budder will have the burden of proving Ihm he did not build or inq,mve for par.
Prove of sale.).
❑ I,as owner of Ile,properly,am exclusively contracting with licensed contractors to YYI
construct the pr.jet,(Sce.70,14,Business and Prefir,ions Code:)The Cnntracads Li-
verve Law does nan apply to an owneradproperty
i-venseLawdsesnmapplytnunewnernfproperty who builds or improves thereon,and TY, PLUMBING PERMIT FEE
who canna,forsuch pm]ccas with a convacmrts)Floured paranoia m do Conga cmre
Liccnu law. PERMIT ISSUANCE
❑ I am exempt under Sea. ,B So P C lint this reason
la HR- )RAIN&VENT-WA'I'FR(. VALUATION
Date,
WORKER'S COMPENSATION DIiCLARAf1ON RIMF .) ROIEC'I'.UIEVICIi
1 herchy affirm under penalty of perjury one of an,following declamfions:
❑ I hnve load willmainlain a Certificate of Corwrt on sel4lnsure for Worker's Coupon. D INS- .00R,ROOF,AREA.CONU. ST 1fS 'fYl•1i CONSTRUCTION
nlioe,as provided for by Section 37(X1 of Ehe lahnr Curb.for the performance of the
work for which this permit is issued PIXTUR:. 1 TRAP
❑I have and will maintain Workers Compen.wtimt Insurance,as required by Sectio
37(Xlofmn labor Code,for theprfonnance ofthe work farwhich lhu,smarit is issued. GAS-EA.SYSTEM-I INC.4 OUTLET'S OCC,GROUT' APN
My Wmkcr Cn�t,pun�s+nion Lis.ntnce earlier am)Policy t n �rm, ,71:7 GAS-EA.SYSTEM-OVER 4(EA)
Carries t- Z� Policy No.:
CIiKFIFICA[F 017 EXENIFOON PROM WORKERS' •��
COMPENSATION INSURANCE BUILDING WASTE INTI3RCIEI'ION BUILDING DIVISION FEES
(This section need not be completed ifthe pennil is bureau hundred dollars Vo Ilk) GREASE'I'RAI'ar IessJ PLANCHLCK Fi'C
Icemifythat inthe performancenfrhe xnrk forwhichthix pcnnilis issuW,lshell SEWHR-SANITARY-STORM HA.210 F1'.
net employ any penin in any tnanner sn as m hemme suM1jem to the Warkers'Cnmpen- ENERGY FEB
O Z smion Laws of California.Date WATER IEATIER VINE N'1'/IiITC'I'R GRADING FiHi
Z Applicant
NOTICII I'0 APPLICANT If,after making this Conifieme of Uxentption,you should WAI Ilk SYS'I'EmnRE,ATING SOILS ITE
(•` become subject to the Workers Compensation provisions of the fahor Code,you must
fomhwiah comply ,in such provisions nr this na niuJudi he dcemcJ rcvnked WATER SERVICE
0
CONSI LEADING AGENCY NEW RES1DENf1Al.PLMB. SQ.let. PAID
U O Dam Receipt#
I hereby uffinn than there is a ennnmetion Icndittg agency for performance of
the work for which this pennil is issued(Sec.3197,Civ.C.)
C) F' Lender's Name TOTAL:
[U Ixndcrs Addtnss 'TOTAL:
t1 I certify That I have read this application and nine that the above irdimmullon is HUIL01 '.F
iF"ih comm.Iagrecm comply wido.11 chymtd coumyordin...u,, ed,cf,lawarahaingm QTY MECHANICAL PERMIT FEE
U Z building construction.and hereby authorise rcpresenlalives ii memeril the SEISM .IR
lohovo-mcntionW pnrpeny for impeeden purposes PERMIT ISSUANCE(WO agree utsave.indemnify and keep harmless the City of Cupertino against IELBC IC qiE O
Iiahi lilies,judgments,costs and expenses which may in any way sector against said City AI•TER OR ADD TO MECH. (,(p 0
consequencein onla,granting oflhi.s permit 1'LUM9 CFEE
APPUCAN'1UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IIANDLING UNIT(In 10.00XI CFM)
MLC11 CAL NEE
SDUI1CIi kIiG11LA1'IONS. r to �
. J/z AIR I IANDLING UNIT(OVER IQ000 CFM) CONS 'ION
mrc nfApplievnUCnnlrem ' --
Signuor —/ , Dump EXHAl1S'1'11000(Wd)UC'1'I MOUSE 'FIGAT10N FT31i
HAZARDOUS MATERIALS DISCLOSURE
NIl aha upplinmt nr Gnus build occupant stare or bundle lmmrJous timet Irl III?A'GNG 11N1'I'(TO 100,000 BTU) FYI
as defined by the Cupertino Muni'pal Calc,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)^ IIHA77NC UNIT(OVER Iclit.mlo if IT)
❑Yes Nn PAID
VENTILATION FAN(SINGLE RESID)
Will the applicant to,future huilding occupant use n rip num or device.,which me Rsrei N
emithmarJnas air ttmmminants as defined by the Ray Area Air Quality Mana6ement BOILER-COMP(3HP OR 1011,000 BTU) TOT\L
Dlsnim't
❑Yes 0''�1 BOILER-COMP'(OVER 1Wp1ID I3'TIL
V t
I have rcml the hnardn��iViI mmerinksentcnteans under Chapter 6.95of the Cali- AIR CONDI'I'IONER ISSUANCE DATE
fnmiu Health&Safety Code.Sections 8585,25533 and 255341 nnJetsmnd that if the NEW RESIDENT[AL MECH. SQ.Fit / �'1
huildingahesma cuncntly have.Errand,Ill.]it is my.,,.,in y inn ify the occupant (i 7
,,fibs inn stet min,issvarreuru mire or Oecnpaney.
owner rout mixed agentnn I)me If. ISSUED BY: r
OFFICE