S 2061 IJPPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE 1"1'NO.
BUILDING DIV ISION APPLICATIONIPERMIT PLUMBING-MECHANICAL AJ 2061
AVEI BUILDING PROJECT IDENTIFICATION
BIJILDIN(i ADDRIS3 SANITARY NO. AI'PLICAI"ION$UdMIT1AI.UATIi
0 I / .24,,q
OW LR'S NAME: rHON': C)I'll'RACTOR'S NAME: LIC NO'.
kNIC CONI'It01,#
ITE iNG :'R. LIC ll: ATRES - I ♦ ❑
CON7'ACP. PHONE: Uv BUILDING PERMIT INFO
�n A—11 �{ � ❑ consultant Fees Paid by Applicant(initial) BLnG - IiL� PLUMB
MEyCr
LICENSED CONTRACIDR'S DECLARATION r QTY 13LECTRIC PERMIT !'EE �/ LJ LJ
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
FQWZ with Section 9(xX))of DivisinnJ of Oteduninexs send l'mfexsinns C:de,undnry license in RESIDENTIAL:
OO full force and effect PERMIT ISSUANCE
qU~ License Class Li<.# ❑SFDWI. [I KITCHEN REMODEL
G V
APPLIANCES-RESIDENTIAL ❑pDD17"ION ❑PLUMBING RE-I'IPIi
vFiai nate eanbamm
bn p y A HITECI"S DECI,ARA11
_ J ❑MULT-UNI"f ❑STRUCTURA.
1 understand my PANELS
zpoZ p
MODIFICATION
O"Q 6�. UP10200AMPS ftlPlI'ERIOR [I CHIMNEY REPAIR
i ._M'W Licenced Professional 2111-IlXX)AMPS IMPROVEMENT SWIMMING POLIS
OWNI3R-ItULLDER DECLARATION OVER I(XOAMPS 111i REMODEVREPAIR (]DIMOLl'1'[ON
Q 1 hereby affirm that 1 am exempt from the Contractor's License Law fur the
X,4° follnwing reason.(Seei.n 7031.5,Business and Professions Code:Any ❑Any city or county SIGNS ELECT OTHER
y which mtmims a permit In construct,aper,improve,dmmolish,or repair any strucmb,
i'LL: pdnnn its i....nee,homquims Cheapplicant lin such passion file a signsrlstatsmmut SVECI AL CIRCUITIMISC.
E�y"' is
that Ie,,lii,,umd pm,urm oche provisions of the Contractors License Los,(Chapter 9
(commencing with Section/010)of Dirision 3 of the Business and Professions Code)or TEMP.METER OR POLE INSL COMMERCIAL;
6qi5 n y' that he is exempt therefrom and the basis lin the alleged exemption.Any violanu n of NEW BLDG/ADDITION []DEMOLITION
Wim Section70311 by any applicant fmaponnit subjmu the applicunuoa civil pmodryof POWER DEVICES ❑TT?NANT ❑FOODSERVICE
n more than f se hundred dollars($5004.
OTHFR IMPROVEMENT
Q pldshe work.the property,ormyotonmaees withwogesus talc(Se 7094, u,imc , SWIMMING POOhIiLF.CfkLC
W�� will doth scions Cd e:The ctureCont iom of s Libicid eria,
ufmocal Low dos not apply 0014,R be,of ❑O'DIHR
W3w :mJ Professions Code:The Contractor's Liceroe Ww does not apply In an owner.f DDTLEI.S—SWITCIIIS—PIXTURIS O
property who builds or improves thereon,and who does such work himself or through
o own employees,pmvidal that such i uprovenicns ore not intended or offered for NEW RESIDENTIAL ELEC!'R SQ FT
saleif how,ver,the boildingnr iponnoWem is sold withinane yearn!completion.the SQ.FT.FLOOR AREA VSQ.IT
owner Wilder will have the burden of proving that he did not build or improve for pur-
pow of,el'.)
❑ I,as r of the prupeny,am exclusively contracting with licensed contractors to JOT
She
curse La the project apply
7041,Business and rty who loci Code:)The cs thecto's IJ
-
nxeLawdtKsnotapplymun ilh aofpropcny whatsedprs imphothcCeremem's QTY. PLUMBING PERMIT FF:F,
who contracts farwch pr Jmis wish o cammctodx)licensed pursuant to the Cnntmemrs
License law, PERMIT ISSUANCE O
❑I um exempt under Sec. ,B&P C lot this reason C
Owner Date ALTER-DRAIN&VENT-WATER SEA) VALUATION
WORKERS COMPENSATION UECefollo following
HACK FLOW PIi(YTIiCT.DIiVICF.
1 hereby nlfinn under penalty of perjury one of the following declarations:
I have anA will mainmina Cenificme of ConsenuosdGinsum for Workers Campen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES
YPE CONST RUCTION
sation,as provided for by Section 3/110 of un
the labor Code,for the perlimnce of the
work for whlchthlsl<rntit is issncJ. FIXTURES-PIiRTRAP jill, 4VO
I have and will maintain Workers Cotnpemsation Insumnre,as required by Section �-r^f
37M ofthe Lahr Gyle,for the performance ofthe work for which this permit is issued. GAS-EX SYS TEM-I INC.4 OU'G.ETS V OCC.GROUP APN
My WorkersC openoinim huumnce carrierand Policy number oro:
Comer: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) I
CER I"IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATI ON I NSURANCE GREASEIINDE STRLWASTEI BUILDING DIVISION_ITFS j
Cfbis section noel not he completed if the permit is fiu ome hundred dol lam IS 110) ' SE TRAP
or Icas.7 PLANCI LECK FEE
y(hatln the pefl ro eto,he wok he whlob this permit is issued,lxhnll B -Sn ARY-STORM P.A.2(X1
not employ any penton in any manner sate,m became.object to the Warmm'Co.,.- ENERGY FEE
Z saton laws of California.Date W .I Ilii
O Applicant GRADING FEE
.~N. NIIIIC17 TO APPLICANT:If,after making this Cehileme of Exemption,you shouldW iH SYSTLMG`REATING
a , become subject to the Workers Competion provisions of the Later Cale,you must SOILS FEE
W foshwith comply with web Pmvi,dons or this pernnt shall be demoted invoked. W TER SERVICE
d G
z CONSTRUCT ION LENDING AGENCY NI LAID a Receipt#
U O 1 hereby affirm that there is a conmruaioa lending agency fat me pmform;msx of
the work for which his permd is issued(Sec.3097,civ.C.)
Q ULender's Name TOTAL:
Lenders Address 0 O
I certify that I have read mix application and state that the aMwe information is BUILDIN
tF-t
CA cartecL l agree to comply with all city..it..my ordinances and some laws mImmU. QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby authorise lcpfexmatives of this city to enter upon the SEISMI 'i
13 2-
above-memiumd property for inspection pnrpoxes. I (J
(We)agree 1.rove,indemnify mad keep Impacts the City of Capuchin.against PERMI'L'ISSUANCE 3 ELECTRI IT 0
liahilitics.judgmems.costs and expenses which may in any way amore again.a said C#Y
AS ERORADD'1'OMECII. /
in consequence of @o grunting of thisµrmit. PLUMEIN PEIi
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,001 CPM) MECHANICA FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0011,CFM) CONST RUCTION TAX
Signore cf Applic.WCWIW,u.r Date EXHAUST HOOD(W/DUCT) HOUSING All'I'[GAS[ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant..hoose buildingaccupamsmrc or handle Witudiot matelot HILI ING UNIT CFO 100,0010 BTU)
as defined by the Cupertino Municipal Core,Chapter 9.12,and the Hea int and Safety
Crul Section 25532(a)? BEATING UNIT(OVER 110,000 BTU)
❑Yes C]No PAID
VENTILATION FAN(SINGLIiRES1O) Dote Rcurm,#
Will the applicant or future building occupant use equipment or dcviccs which
f hazardous air contaminants as defned by the Bay Arca Air Quality Management BOILER-COMP(311POR IIXI,(H0H'fU)
il
kimrid^
qyl
El Yes No
BOILER-COME(OVER 100,000HTID
❑
I have read the hamrdous mammals rrynirements under Chapter 6.95 of the Cali AIB CONDITIONER ISSUANCE DATE
Samna Health&Safety Coce,Sections 11505,25533 atW 8534.1 undemand mat if She NEW RF_SIDENHAL MECH, SQ.FT. AS `
building den not currently have a mount.that it is my responsibility to notify the occupant `p
.f the requirenmnts which must be met prier to issuance of a Cehificate of Oceup.ney.
Owner of author".,cut Dote T L: - ISSUEDBY:
OFFICE