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S 2247 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO - BUILDING-ELECTRICAL PER�41'I'NO, BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL ``J BUILDING PROJECT IDENTIFICATION 2247 BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE 7.2 t s 16 -.Z© �� OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: 4"441*16 J4$rwg&-gA4eajm%s sgis N/C CONTROL# •�ARCHITECT/IiNGINEER: LIC NO: ADDRESS'. ❑ coNTACr: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ L1crNsen CONTRACTOR I, A'1{ON QTY ELECTRIC PERMIT FEE I hereby:tram met 1 am licensed under proeist "'chapter 9(commencing MWC04with Sactim90W)of Division 3"fthe Business am Professions Code,and my license is JOB DESCRIPTION RESIDENTIAL' a se Lic.# Fp+� is full force and d PERMIT'ISSUANCE ElSFDWI. El KITCHEN REMODEL 4UU Li � hQS Dae Conlmmo APPLIANCES-RESIDEN'T'IAL ❑ADDITION ❑PLUMBING RE-PIPE ARCHITECT'S DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL OZ- z Iundersmnd toy plad,dall beucedaspublic re uml.r MODIFICATION UP TO 20s)AMPS [=4i:1w, uccrrreJ Profccsmnal [I INTERIOR El CHIMNEY REPAIR OWNER-BUILDER 201-100JAMPS IMPROVEMENT DECLAItA'1'ION ❑SWIMMING POOLS fk Q 1 hereby eBlrm tbar 1 am exempt from the Connectors Licenser Law for the OVER I000AMPS ❑BATH REMODEUREPMR DEMOLITION 3 0. follmwiag oarmu(smtion 90JI.5,Bueinaes trait Pmfeeeions CnJe:Any airy or amnty SIGNS ELECTRICAL ❑OTHER W y which requires o pemul to mnstmcp.ober,improve,Jemoliah,or mpnir any swcwre prior to its issuance.also requires the applicre Fmsuehpermif to file asigcaddatemem SPECIAL CIRCUI'1'IMISC. qty that he is licensed turn;anunthe provi.icm,d,he Crnmashm,License Law(China,9 D im (commencing with Section O00n)el Division 3 of the Business and Professions Crile)m THMP.METER OR POLE INST. COMMERCIAL' m y o C the,he is exempt therefrom and the basis for th'e alleged exemption.Any vidminn of 0 NEW BLDG/ADDITION ❑DEMOLITION fL y Section 90JLS by any npplicem for npwnm subjects the applicant penalty of POWER DEVICES ElTENANT ❑FOODSERVICE gidnot more than Five hundred dollars($5110). ❑ Las cwner of the propeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT F� will Jo the work,and the structure is not intendeil or offered forxtde(See.]IW4.Business ❑OTHER [il 3 m ..it Profeevions Code:The Contractors License Law does not apply to un owner of OUTLETS-SWITCHES-FIXTURES C property who builds or improves thereon,and who Anes such work himself or through his own employees,provided that such improvements ure not Intended or elmral for NEW RP.SIDEN-F AI.HLECTR sale.If,however the building or improvement is said within one yearofcompletim,the SQ.Fp.FLOOR AREA s/SQ.FP ov,star will have the barren of proving that he Aid not build or imprnvc for pur- lo a of sale.. ❑ 1,as owner of me propeny,am excltvively contracting with licensed contractors to TOTAL: construct the project(Sec.7044,Business and Proressions Code:)The Contractors Li- seLaw does-at applY to an nwnmof properly who builds m improves thereon,and QTY PLUMBING PERMIT FEE who contracts for such project with a contraaor(e)licensed pursuant tome Contractor's License Law. PERMIT ISSUANCE 1:1 Join exemptunder Sec. ,B&PCfor sale reason Owner ALTER-DRAIN&VENT-WATER(EA) VALUATION Mule WORKER'S COMPENSATION DECLARATION BACK FLAW PROFECT.DEVICE 1 hereby eRrm under Penalty of perjury one of Inc following declarations: ❑I have and will mainmfn a Certificate of ConsenttosdLlnnure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. soden,ns pmvided for by Section 3700 ofthe[.;then Core,f"r the pvrforamned of the STORIES TYPE CONSTRUCTION work for which this permit is issued FIXTURES-PER TRAP 1 have and will maintain Worker's Compensation Insurance,as required by Scetion �IlO of the Labor Cade,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OU FLETS OCC CROUP qPN My W... cam. 1l�t�(nec npr and Policy ; w Carrier: policy No.: ���d�E GAS-HA.SYSTEM�OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE. GREASUINDUSTRLWASTF„INTERCEPTOR (This seai"n omit ani ba eonpplaallf the pmrntit is'"rant hundred dollar,(5100) BUILDING DIVISION FEES _ or lees. GREASE TRAP PLANCHECK FEE Ioyary that in the perfonnner of the work&nwhijM1this o tare Wokissued,Ishall SEWER-SANITARY-S'1 ORM EA.2011 FE not employ any persnn in any Da manner s”as to hecoma subject in the Workers'Compen- ENERGY FEE O z eminn laws of California.Date WATER HEATER WNCN"T/ELECTR z 2 Applicant GRADING FEE t-i y NOTICE TO APPLICANT.If,after making'his Certificate of Exemption,yen should WATER SYSTENIGREATING a , become subject to the Worker,Compeassum provisions"Rhe Labor Code,you must SOILS FHB Lkl forthwith comply with such provision,or this perainahnll hedeemedrevoked. WATER SERVICE On G CONSTRUCTION LENDING AGENCY Uz Ihacb fiifmthmthereisacomtorcumbleadin 'oohs f NEW RESIDEN'T'IAL PLM B, SQ.FC PAID Data c pt# C.J O the work f"r whish mi, r;,ismwl(See.309].Civ Clancy per nmm�ca ry f'• tenni U Lewers Nanta O {hl Lender's Address TOTAL: F0t 1 certify that I have .it Bis upplicatinn and spite that the above information is BUILDING FEE to a"rmv L agree to comply with all city and county orrinnncea and mac laws relating to QTY. MECHANICAL PERMIT U z Mid,'-gcm.irvdiro and M1erebyamhmim representatives of this miry roomer upon the FEE SEISMIC Fee nbavr ampt(We)agree property fir emnify an ralkeep ea. ( gee yon p y„ p g PERMIT ISSUANCE (We)u m save,indemnify d which harmless w Cit fea snits i sins' ELECTRIC FEE incorsiojpupg of thets,Basing ft his eswhich miry many way accmcagnim'said City AUGER OR ADD TO MECH. A PLANT UNDERSTANDS of this PLUMBING PCG SOURCE REGULATIONS. ANDS AND WILL COMPLY WITH ALL NONPOINTAIR HANDLING UNIT(TO 10,000 CFM) SOURCE REGUTATIUNS MECI{ANICAL FEE AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX Signature of ApplieeHDate EXHAUST HOOD(W/DUCE) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE. Will'fit...Ii..[or future huildmg ommarl,me par hansuch...ol mv'trial HEATING UNIT(10100,000 BI'U) as defined by the Cupeninn Municipal Code,Chapter 9.12,and the Heath and Safety CnJe,Section 25532(a)7 HEATING UNIT(OVER 100,003 B U) El Yes C)No VENTILATION FAN(SINGLE RESID) PAID Date Rmeipt# Will the appliend or future building occupant nso......don"r devices which ends ltacunlous it communism,ns defined byline Bay Area Air Quality Managemenl BOILER-COMP QHP OR ion,"ILI District, (Yf C]Yen E]No BOILER-COMP(OVER 100,000 BTU) I have reed the hazardous materials num mems ander Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCEATE 'amid Health&S ty C Seamans 25505,2SS33 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. / /7 IF ]it urre loonsibil'aymnodlytherccupaid ,,fine re a ms fi spa csod a Cenificape of Occupant. u i b ow as t,: agent nate TOTAL IssueD Br OFFICE