S 2299 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
IDENTIFIC
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECI{ANICAI. S 2 2 9 9
BUILDING PROJET.T ATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
OWNS AMC: PHONE CO ® AMI: LI yp�
Ir/ NIC CONTROL It
. ARC iI'IECT/F;NGINECR: LICNO: A0, ❑
CONTACT: PHONE YT �(l - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
2-S
❑ ❑ ❑
LICENSED CON I RACI OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby amrat ter 1 rpt licensed order provisions of chapter 9(cmnmencing JOB DESCRIPTION
�pZ colo Semina 90 fmvlsl�i• h lltbawss romss�yyppss��� yliccnseN RESIDENTIAL:
F�� in full forces If
(/� �SU PNItMI'1'ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
aVU license Cl" Lie is
APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
N Z a Onto or
G¢{n ARCHITECTSTS DE DECLAA ❑MULTI-UNIT El STRUCTURAL
z Oor,;L Iunderstood mY plans.hall he heed.,P.hlic rewnL (� ODIFICATION
p z_4 C-, UP TO 200 AMPS ❑INTERIOR >=EY REPAIR
P4taI Licensed Professional 201-IWOAMPS IMPROVEMENT []SWIMMING Po019
C � OWNER-BUILDER DECLARATION OVER 1000 AMPS [I BATH REMODEVRF.PAIR [I DEMOLITION
4' 6 I hereby affirm that 1 am exempt fimn the Contractor.,License Law for the
V following mama.(Section 90315,B.,iness and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
y which requires a permit In construct,alter,imm
prnve,demolish,or repair any stractree
0d prior In its i...ance,alsvmquim,the.pplieure larsuch pentane file,signednatcmant SPECIAL CIRCUI'VNUSC. ear
that he r,licensed pursuant m Lha pmviaons rf the Conrtaenh L......Law(Clut,erg
W Gp (crmmenciag with Section AlOt)M Division 3 of lis Built and Prof slim Codynr 'I'N.M P.METER OR POLE I NIST COMMERCIAL:
d c y that he is exempt femfean and(lie basis fur the alleged exempti0a.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
0.
Section 7031.5 by any applicant for a pemdl subjects the applicant to a civil penallyor POWER DEVICES
^.� El TENANT E]TOO[)SIiRVICE
tuaranew Iran Gee hundred mllarxSapp. IMPROVEMENTCoq I,vs nnensffepperty,err myy emes ployees with wagas lhelr axle compensation, h ELECTRIC SWIMMING POOLECTRIC C1 OTHER
1,a, wro
Wwill do the work,and the structure is not intended or offered for sale(See,70D4,Business
¢1 m sad Professions Core:The Contmemr'c License Law doe,Bol apply m,it owner err OUTLETS-SWITCHES-FIXTURE.,
F property who builds or improves thereon,and who does such work himselr or thmright
his.,it employees,pfovided he,such impnwnmenlx are net trended or offered for NEW RESIDENTIAL F.LECTR S FT
sale.If,hew eve,the building or i,nprovemer i,sold wi thin one yearnI can,plelirn,the SQ.FT.FLOOR AREA %/SQ.PI'.
poerr-builder will have the burden of proving that he did not hnild ar improv,for pnr-
c oriole.).
❑ 1,as owner of the property,not exclusively contracting with licensed contractors In TOTAL:
,nswnl the project(Sec.7044.nosiness and Professions C,so The Connaemr's Ll.
,se Law does not apply to an owner ofpropedy,who builds or improves thereon,and QTY. PLUMBING PERMIT PEE
who mmrcts for such proar with a convector(,)licensed pursuant to the Convaro rx
License Law. PERMIT ISSUANCE
Lem exertion,under Sea .B&PChnthismason
Owner Dale
ALTER-DRAIN&VEIN'I'-WATER(EA) VALUATION
[ON -7 —�
WORKER'S COMPENSAd
pc,,,'I on Dfthe Behaving
RACK PLOW PROTECT.DEVICE V7�
1 handwaffirmunderpenahy teperjuryonet) the followingdedaer's Co.
❑on,a,I have and will for by Section
17M ofow Consent Labor
Csell ode.sures Workers Gtmpen- DRAINS-FLOOR,ROOF,AREA,GOND' ST IES TYPE CONSTRUCTION
Work f r provided for by Section 3]00 blow Lahot Code,for the performance of 0,0
Work for said
maintain
PIX TURNS-NERTRAP SP.o:.._
❑I have nIJ will maintain Workers CooperstownghIroumnce,as require)by Section
3](Nl nfihcl dear Code,""he
pe train c [the woo �th �Irkpissued. GAS-F.A.SYS9'F.M-I INC.40UTLErS (KCGROUP APN
My Workrand Poli a caws /
Cartier. Policy N, GAS-EA.SYSTEM-OVER 4(CA)
cNRTIPIcxpF'Op EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE IN"rERCEFi'OR
DING DIVISION FEES_____d
(Thiescmion need err hecompleLel lfthepetmil is for one handed dollars(5100) CREASE TRAP
or less) PLA ECK
Icrlfy lhutin the perf0rmnnu.nrlhewnrk forwhich lhopem,h is....ed.ishull SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so ns In bea,me,ubject la the Workers Cnmpen- ENERGY FEE
z cation Laws rf California[)ate WATER HHATP.R WATIN'UUI ECTR
Zt] Applicant rGRr��' CEI
y NOTICE TO APPLICANT If,after ranking this Certificate of Extinction.you should WATER SYSTEM/TREATING 11
a , hocome wpoct to the Worker's Compensntian provisions of the labor Code,you must SOILS NHH
ftl forthwith comply with such provisions lir this permit shall hedeemedrevoked. WATER SERVICE
C1 Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ. .7
V 0 Z' Thereby uffim,lhuuhere iso mnswdiun lending agency fonhe perfnmmnce err Vale RecetplK
the work for winch,ho permit is lssued(sec.3097,Civ.C.)
pH Lenders Name TOTAL.
V Lender's Address TOTAL:
1 codify that I have read this application and state that the ahrve itifmmaion is BUILDING FEB
�-,0 rurrecl.lagrne to emnply whh ell shy ttnd county omltrnces and state Iowa remtmgm QTY. MECHANICAL PERMIT FEE
U ,•7. huilding conmmmion,and hereby authorize representatives of this city m inner upon the SEISMIC PEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Caperton.agafs, ELECTRIC FEE
liabilities,judgments,coax and expenses which may in any w'ay acme agaias,bid City ALTER OR ADD'IO MECH.
in stn. PLUMBING PP.E
eqa•Tee dee gramrttg onniap a,
APPLIC TI' NDSA' WILL CO WLY WITH ALL ON-PINT -HgNDLING UNIT(TO IIL(IIIaCPM) MECHANICALFEE
SOUR RF I( S, ��l
` AIR HANDLING UNIT(OVER IQOfq CFM) CONSTRUCTIONTAX
Sig Wm til APPlican onlmclrr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant9 'lure buldugoccupatsmm or handle Incorrect as material HEATING ON['[(TO OQ000 BTU)
as defined by the Caparvno d Code,Cbapmr is 2,end Ibe Health and Safary
Code,Section 25532 ay} aa� HEATING UNIT(OVER 100.000 11 TO)
�
Yes PAID
[:] VCNTILATION PAN(SINGLE RHSIO) �ie •Re7ceiptk
Will the applicant or -tore building occupant use equipped lir devices which J✓VV
enat haanNess all tBolton' ' tsa,defined by the Bay Aroo Air Quality Management BOILER-COMPCHPOR 100,000B'I'U)
Distrito? 'TOTAL:
❑@x BOILER-COME(OVER 10d,00 1ITU)
AIR CONDITIONER
It Ilhe hazl ous none ars require,nan,s un Chapter 695 rah Cull- ISSUANCE DATE
famia If&S 'sly C. Sectio 25505.25533 and 2553 1 unlerstnnd that if the NEW RP.SIDP.NTIAI.MECH. SQ.ff..
huildi dnesn Iren a mm,thmit is my mspnnsibi tyro noufyd orpup yyy,,s
nf,b r u musts nor to isswnm or tifirm a .'•{
O a,dthor7,ol ug t Date / TOTAL ISSUED BY � ANe7olwc Gl
OFFICE