S 2336 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL.POINT PEN ONLY
CITY OF CUPERTINO - BUHAING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2336
BUILDING PROJECT IDENT'IFICAT'ION
BUILDING ADDRESS SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
� GO "--1 1- /,0y5- S to Il jw /0-.9s'�Y
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO.
-E A NIC CONTROL#
AR ITEC'1'IF.NG NEER: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT LUMB -MECH
� 2S?r3'Lvd L� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(cammanning JOB DESCRIPTION
wa0 with Section1000)of Division 3 ofthe Business and Professions Cold.and my license is RESIDENTIAL
�
Fin full I..c and effect. - PERMIT ISSUANCE
�U License Class Lia# ❑SFDWI. [_1 KITCHEN REMODEL
rFDate Cnnaranor APPLIANCES-RESIDENTIAL ❑ADDITION L1 PLUMBING RE-PIPE
F. ARCtI1TECT'S DECLA RATION El MULTI-UNIT ❑STRUCTURAL
z O z 1 understand my ale hall be yy55rd as puhlie records PANELS
Oz," 2.L1 Im A �..wylpL� UP TO 200 AMPS MODIFICATION
F`4'rZ 111 Llcc rfneflmariF El INTERIOR ❑CHIMNEY REPAIR
'J 201-1000AMPS IMPROVEMENT SWIMMING POOLS
�'y,' OWNER-exempt R DECLARATION Contractors
ON
WW C w� I hereby nfiinn that 1 am exempt from the Cammemr'a License Low for the OVER 11%X1 AMPS �BATH REMODEVREPAIR ❑DEMOLITION
%�dU JRawin p -
g rinse..(Section]onsum Business and Profession.Code:Any city n larrmy ❑OTHER
613 c F SIGNS HLIiLTRICAI.
FAQ ey which q ' . p 'It consumer, h p d I:h p- ytwnure _
w prat t ' c alsoreunion,tM1epple f M1pe 'sic .L dttemenf SPECIALCIRCUIT/M15C.
W p0pr tramthat licensedp a th p nth C t 't L L (,Come) r
(cont ene'ng w'Ih Sedan]Ilfppd D'v'sio 3 [tb Business dP le stens Code)or TEMP.METER OR POLE INST. COMMERCIAL
4 y m eG that he Is eco mat therefrom and the basis for the alleged exemption.Any violation of
W Section 7131.5 by any applicant for a permit subjects the applicant to a civil penalty of POWERDEVICES ❑TEWBLIIG/ADDITION ❑DP.MOLITION
not more than Five hundred dollars($500), ❑TENANT ❑FOOD SERVICE
FZQ ❑ 1,as ownerofthe aroaeny,mmycmployees with wages as pentacle tompensmion, SWIMMINGPOOLELECfRIC .kms IMPROVEMENT
F wdl do thewark,a.d lLcsemmmis nntimended or aHB..dfarsale Xce.7W4.Business J ❑OTHER
a,3 and Professions Cade:The Contractor's License Low Joos not apply to an owner of Z OUTLETS-SWITCHES-FIXTURES (.1
property who builds or Lnprovea demon,and who does such work himself orIhrmgh _
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PT
sale.If,however.the building or improvement is sold within one yearnfcompleti.n,the SQ.PT.FLOOR AREA $/9Q.FT.
awnenbulWer will have the burden of proving that he did not build or improve for our- '
e of oats,. 5'9.70
❑ 1,as owner of the properly,am exclusively contracting with licensed contractors m TOTAL
ontnmat the p rpoo,(See 7 aD,Business rad Professions Gdd)no Contractor's Li-
seLaw does•not apply.)an Owner of property who builds or improves thereon.and QTY.A
PERMIT FEE Gw$
ahe commons far such Pocinets with n eonmaia Ud licensed arroa rm the Conom"os
Licence Law.
❑ I am exempt under Sec. ,B&P C for this reason
T- T
Owner Date VALUATION
Wm under
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE O
I handw will
mai under penally,Of e perjury one of the following declarations: /O V
,.Iran,
as and will foi by maintain,' 3700 of Conthe[..bent ar
Code,
self-inforthe ermorls Comptheear- DRAINS-FLOOR,HOOP,AREA,CONE.
nation,as Provided for by Section 3]811 of the Lnhor Code,for the aerformance of the Xp6huts TYPE CONSTRUCi'ION
work fn,which this annual is issued. FIXTURES-PER TRAP '
❑ 1 have and will maintain Wakens Compensation Insurance,a,required by Section
`' 3700 oflin Labor Code,tot performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCU CROUP ANN
/�' My Wor s Cam tion Insumnc c rri r and Policy Immbermw
/ GniacPolicy No.: GAS-EA.SYSTEM-OVER 4(EA) V
BRTIFICA"fE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(Thio section need not be completed tribe permpis forone hundred dollars(51 W) GREASE TRAP BUILDING DIVISION FEES
or less) PLANCHECK FEB
I employ
tiny the in the any mention
oc olas i work for which this permit is Workers'
fr Until -
notmnplaynnypersoninanymammrsnasmbecomesnbjenoohs Workers'Cnmpem SEWER-SANITARY-STORM EA.20(1 FT. ENERGY FF.E
cation Law,�sl�f California Date
O I' \i �1,� WATER HEATER W/VENTIF.LECTR
ap leant \ L$�l y�•LN uw GRADING FEE
OTICE TO AP.IS,Work If,after making this Cisions of of Exemption,you should Wq'I'IiR SYSTEM/I'REATING
a became scompl o the Worker's Compensation provisions of the Lobar Code,you moat SOILS PHE
LTa tonhwilh comply with such provisions or this pemtit shall be deemed revnkeU. Wq'INR SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.ET. PAID
U p Thereby off thnnhom icnainstmcdon lending agency fonhc perhrzmnnca of Dam Receipt#
W H the work for which this permit is uttered(Sec.3097,Civ.C.)
WLondon,Name TOTAL:
Lenders Address TOTAL:
F, I certify that I have read this application and mother the above information is
BUILDING FEB /
Pi
Come(.I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
V G building coaiaractiom and hendyvmborize representatives ofthis city to enterupa me SEISMIC FEE
above-memlnned property for Inspection puryosas `
PEkMI'I'ISSUANCF: • 7
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEF.
liaemses,ludgmf ts,the costs miagoxpenccawhich may In any wtry.centc against said City ALTER OR ADD TO MECH.
in asequence of the granting of this pemtit. PLUMBING FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) ' 1 SD
SOURCE REGULATIONS. MECHANICAL.FEE
fxI \� - nM�6� O�rr ftl� �� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
a YV1ULCrmtmetor � HXHAUS'l'IiOGD(W/DUCT') HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will theapNicant or town building occupant store or handle hazardous material HEATING UNIT TO 100,050 BTU)
as defined by the Coleman M oldirpel Code.Chapter 9.12,and the health and Safety
Cade,Staniar 25532(a)'! HEATING UNIT(OVER 100.000 BTU) p�,y
El Yes VENTILATION FAN(SINGLE RESID) PAID
--
Will the applicant or future a building occupant use equipment or devices which Date Receipt#
emit M1azerdnus air mnmtnimm,as defined by rho Noy Arm Air Quvlity Management BOILP.R-COME OFF OR 100,000 BTU)
��
District^ �/' TOTAL: 1
❑Yes L7Na - 'BOILER`-COST(OVER IfX],f1000'1'U) ' 316
30
1 have read me havardou.s materials requirements under Chapter 6.95 Of the Cali- - AIR CQNDITIONER ISSUANCE DATE
fomia Health&Safety Cale.Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL.MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibility to notify the occupant
quirements which must he etpnortoissuanceofa CenifimmnfOctipaney. -
�
Ocaner ora l gent C pate �— TOTAL/07.5a ISSUED BY. e' •'w�Q wCC'I
OFFICE