S 2491 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY —'
CITY OF CUPERTINO BUILDING-ELECPNICAL PERMITNo
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL S 2491
BUILDING PROJECT IIIENTIFICA'I'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
W;1/ow rove t age �. ,
0 [IRS NAME PHONF: CONTRACTOR'S NAME: I,IC NO'.
"Ibld ) i le 253 � N/ oy1 a SIC CON'FROLIt
etrA CHITECT/ENGINEER: LIC No ADDRESS: �� 4aG2 El3 0
CONTACT PHONE 6UILDING PERMIT INFO
-7o ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MGCB
❑ ❑ F/ ❑
LICENSED CONTRACTOR'S OECIARATION QTY ELECTRIC PERMIT F17E
1 hereby affirm Thal 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO, with Station 700(on!'Division 3ofdm Businessand Protessions Cnae,undmy license is PERMIT ISSUANCE. RESIDENTIAL;
C W full force and rtma. ❑SFDWL ❑KITCHEN REMODEL
<U License Class Lic.X APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING BE PIPIT
y Dae Cnmmator
ARCHI'IT=DECLARATION ❑MULTI-UNIT ❑STRUCPURAI.
F p N PANELS MOI3IFlCA'170N
Lanlm
z Ineremmany plinsabau bossed a'pabherecnrd'
OX-� UPTO10OAMPS ❑INTERIOR C1 CHIMNEY REPAIR
Fs�FW licensed Profnsicnul 201-Ilan AMPS IA1PROVEMGNT 0SWIMMINGP0OIS
OWNER BUILDER DECLARATION OVER Nall AMPS
0 BATH REMODEUREPAIR ❑DEMOLITION
C 6 L hereby Sienna
that 1 am exempt from the Gmtrns Co Licence law Rrt the
u+3PWi z- foIziuh me .reason. am, 7031.5.Business he regi es,di,ani Coda:Any city nrcvmmY SIGNS IA,F.CfRICAI. (]OTIII:R
C,y which mryires a permit no mnamn,ally,improve,aemnli>h,or repair any snmcwre
0� prior mits issuance,also requires thaaPPliwm lar such perosil to rile usigned atucmen, sPlielnLClReurnhRse.
�} That he is licensed pursuant to the previsions ofthc Commences License Law(Chaper9
act]�/�� (commencing with Scdion]IMa)nf Uivision7of the Business enJ Pmtcsions Cndeptr TIiMP.MCI'ER OR POLB INET. Lo
d(y that In,is exempt Iherefrum ad the basis for the alleged em rNion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
kX!
Section 7031.5 by any applicant In a pantie subjects the applicant In u civil penally of POWEI(DEVICGS ❑TENANT ❑FOOI1 SPRVICE
n ntnrc(Iran Hve umdrel dollars($500).
~ZQ ❑I,as owner ofthe property,or my employees with wages us their sole compensation, SWIMMING POOL 1?LEC'1'RI IMPROVEMENT
' �� will dnthework,aadc he orcwou', icensnn otfaafors1aply 1.an,Iluse,of ❑OTHIiR
}r m and arty who
Gila She saes tacmh License Law Aces not apply toll owner e( OU'rl.l3l:S-SWI'I'CIIES-IlX'1'URIiS
propvdy who builds or improves thereon,end who docssuch work hlmsell or through
his s wn employees,provided that such improvements um not intended nr offered for NEW RESIDENTIAL CLECTR SO IT.
,,de.If.however.the building or improvement is sold withyear of completion.the SQ.Ff.FLUOR AREA LSQ.F1'.
owner-builder well hate the harden of proving Ihal h,did not build nr improve for pur-
pose.1".1,J.
1,as owner of the prupeny,ate exclusively contracting with licensed contractors to TOTAL
mstrucl the project(Sec.IIL(g,Business and professions Code:)The Commmers Li-
nncLawdoesnotapply,.an nwnerof pmpedy who builds or nemeses thereon,.,,it QTY. PLUMBING PERMIT FEE
who co erects lot such pmjerts with a contrucmrLs)licensed pursaaa to the Commctoes
License law. PERMIT ISSUANCE g
lam cxoija und Sc 11,91`�C to?,hA//j� ...n
/JY/Y1 ALTER-TRAIN Oe VENr-WATER(Bat VALUATION
I WORKER'S CO !NSAnON DECLARATION a BACK PL
• I hereby affirm ender pet T}ly of perjury one of the following declaration.
❑I hwcand will mnimuin aCemfica,enf Cnnsenno self-insom for Worker's Compen- DRAINS R,N ' ' COND STORIES 'rYl'Ii CONS]RUCTION
sation,as providW for by Section 3700 of the Tabor Cade,for the Perfomtmce of the
work fnr which an,Peron,is issued I"'TURE. TRAP
El have and will maintain Wiskees Com
peneuion Insurance,as required by Section
3700 ofthe LahorGMe.for the performmnce of the work for which this Ferour is issued GAS-EA. ' 'EM�N$1( 'I'LET. OCCGROUP APN
My Workers Compensation Insurance carrier and Policy number are:
$TEM-0VIiRA(EA)
Cartier. Policy No: GAS-FLA. '
CE RTI FICA'1'E(117 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASM 1) S'fIll.WAS'I'H IbUiRCEPPOR
BUILDING DIVISION EKES
G'husseeaonneednettbecotnplctel iDhepcmtit lx linen.hundred dollars($I00t GREASE'[' iR��
or less) PLANCHGCK 14iE
I certify thm in the perlormann nfthe work for which this permit is insueJ,ldwll SIiWIiR-SANITARY-S'1'ORM EA.21X1 FI'.
not employ any person in any manner no as m become subject m the Workcs'Compete ENERGY THE
ZZ 'anion laws of California.Use WATER HEATER WIVENT/ELEC OR
0 Applicant GRADING FEE
,o) NOTICE TO APPIACAN-n If,after making this Certificate of Eaemption,you should WATER SYSTCMO'BEATING
a , become siddea ,,the Worker',Comp, aflon provisions tittle Luhnr Cude,you must SOILS PER
forthwith comply with such provisions or this pemtit shall be dimmed minced. WATER SERVICE
Z CONSTRUCTION LENDING AGENCY NOW RESIDENTIAL PLMB. SQ.FT. PAID
V 0 1 hemba
yRrm lhacti
there iso communion lendingnmine,for the perfrimeracal Dae a Ip
In 1"'
the wok fin which this Penni,Is issued ISco.3097,Ci,C.)
Lari Name TOTAL:
O CLI Lender's Address 1 L:
1 certify firm I have mad,his anglicism.and cote that are aMwe marc restom is IF BUILDING FEE
.�. VJ correcn.l agree no comply with all ciry and county ordinances und woe h,wre rcludngm Q'PY. MECHANICAL PERMIT FEE
U builiingrommuction,trod hereby amhmim representatives of this city toc teruPon the SEISMIC FEE
abase-mentinned property fnr inspce inn purposes.
(We)agree to save,Indemnity and keep trimness the City of Cupertino.gunnel PERMIT ISSUANCC ELECTRIC IV
liabilinies,judgments,costs and expenses which may in anyway accrue against said City ALTER OR ADD TO MCCH,
in nseguenceof lbs grandaunt this permit, PLUAfBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI`(TO IB,00 CFAO
OURC IAT UFS. MECFl 'AI.PEE
7 AIR HANDLING UNIT(OVER 14000 CFM) CONSTRU IONTAX
Signature of Applin mtractnr 4 Dam P.XIIAUS'I'HOOD(W/DUC) I OUSINGMITIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilding iccupunt store or handle hanutlous material HFAI'INC.END'o O 100,000 BTU)
us defined by the Cu,s,mne Municipal Code Chapter 9.12,trod,he Health and Safety
Gale,Section 25532GO'! TEM INC,UNIT(OVER IN),1IW JITC)
❑Yca bill VENTILATION FAN SINGLE RI''Sit» PAID
DateBermsReceipt p
Will the applicant nr future building nCcapdpl use equipment nl aeviocn which
emit hneanloux air comantinanns asdcfnN by the Bay Area Air Quality Management BOILER-CDMP(3HP OR IPU.INa B"1'U)
Dntdcl!
EIYcs t]"FIn BOILER-COMP(OVER 100.000BTU)
u I have rend the humNous material x requabalmts under Cotner 6?5 of the Cul,- AIR CONDI'1'IONER ISSUANCE DATE
feria Health A,Safety Cele,Sections M505,25533 and 255311 undentanl that if due NEW RESIDENTIAL MECIL SQ.Er
huildin emence�or h;mm,enum,thmin ismy rcarymsihility mnoif the swcy-
I , hicht h clpnR .tnceniaCrniticate of cu tcy. _
amhoriz .. t Dade r I TOTAL: I ISSUED HY:
OFFICE