S 2861 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PIB MIT NO.
BUII,DINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, A PLICATIO ,'Tl M DATE
0151Ur
W R'S NAME: PIIONE: COM' OR'S NA LIC NO:
IA.Ik'S LK6A a 1 O NIC CONTROL If
ARCHITECI'k3NGINEER: LIC NO ADDRESS:f ❑
CONTACT: PHONE: BUILDING PERMIT INFO
�✓/`N /Q ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELHC'P PLUMB MECH
❑ ❑ El— ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECfRIC PERMIT PEE
I hereby 41.that I.,it licensed made,prusixior,of chapter 9(emmnOne,ag JOB DESCRIPTION
0CZ with Swann 1n001mfDisisloa3ol'the Business tied Profession,axle,wdnty 11canxe ix RESIDENTIAL:
W OO PERMIT ISSIIANCIi
�. in full fined s effect. O SPDWL ❑KITCHEN REMODEL
QV(D Lieemc Class Lic.d APPLIANCES-RISIDFNTIAL ❑ADDITION BPL4h1131NG R&PIPE
eµ61 Due CaaOaeor
ARCHITECTS DECLARATION PANELS (3 MULTI-UNIT El STRUCTURAL
Z O'�s Z I understand my plans shall h used as public records MODIFICATION
OZ4— UPT0200AMPS OPELFRIOR C1 CHIMNEY REPAIR
F+ot Llcenwd It l'essional 201-100AMPSjo
IMPROVEMENT' []SWIMMINGPOOLS
OWNER-BUB-DER DECLARATION OVER IfyH1AMPS ❑13ATH REMODEURITATR ❑DEMOLITION
6 I hereby affirm that 1 am exempt from the Contractor's License Law for the
6 O L U fallowing reason.(Section 0031.5,Business tend Profasi...Cate Any city lir county SIGNS ELECTRICALOOTHER ~
3 0 res which mquires a permit to construct,Other,improve,demolish,or repair any structure
Epp-'LLOe prior m its issuance,also requires the applicant for such permiun file a signed statement SPECIAL CIRCUIT/M ISC.
qyC`µ�Y that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
W�CD (commencing with Secured 1000)mI Din, 3 tete Husina,,rodprnfeaslen,Coda)m TIIM P.ME PER Ok POLE INST. COMMERCIAL,•
Q. m C thin he is exempt thcrefmm and he hands for the ul tried exemption.Any violodun of O NI?W BLDG/ADDITION ❑DEMOLITION
Ian
Station 7031.5 by anyapplicunt for.permit subjects the...icanua a civil penalty of POWER DI:VICIiSOTENANT ❑FOODSERVICE
of mord than five hundred delta.( Eft
F Z IMPROVEMENT
=6 O Lo Thevwork,the propeny,ur myetinten edwitfinedf r talei(Sec.cnmpenation, SWIMMING W30L ELECTRIC
�p.0 will do The work,and the The cture Comalcmintendedo Law
of apply it)
Business DOTTER
�3mand Professions ander The Cnntrnaor's License Law don not apply himself ten owner of OUTLETS-SWITCHES-FIXTUR
propeny who hurls,or vales th tsucha and who dscs such tinte sed(itof through
his own oweverea,building that such mentis old w are not intended d lir offered for NEW RESIDENTIAL.HLF,CTRsale.'builderwill hoses in burdenmvementi had hdid noneyeor imprveforthe SQ.FT.FLOORAREA SISQ.FT.owner-M1uiWer will have the buNcn of proving thn he JiJ not build or improve for pvr- ZL
O has owns,of the propeny am calusivelY mmrxting with IiaxnuN cnmractors m
19
constant the project(Sec.7044.Business and Professions Cade:)The Contractor's Li-
seLaw docsnot apply Loan owner of propeny who builds or improves darned,and QTY. PLUMBING PERMIT FEE
who contras mr such ponects with a cnmmctof(s)licensed pursuant um heContractor's
License Law. PERMIT ISSUANCE 5s a J 0
❑I am exempt under Sec. ,B&P C for this recon
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PNOI'F:CT.DEVICE;
1 herebydl... under pennay of perjury one of the fit lowingW Work
C..
❑ Ihava and wle main by eCion 37tenf Consent tat sell-insurefof Wmdera re if h- DRAINS-FLOOR,RWP.ARP.A,CON 1). � / STORMS TYPE CONSTRUCTION
sation,as provided for r Section 3100 of me Labor aNe,Period if re of the TSO I/q
work for which this permit is issued, PI%TURFS-PER TRAP
❑I have vat(will maintain Waders Compensation rkfor hi h require)by Section n
3100 of the Labor Critic,brute perfnmtanee of the work for which this permit is issued. CAS-En.SYSTEM-]INCA OCC GROUP
� 2^
MyT or 'e C. prytyati In. ranccaEi¢ and Palsy Noy? 9Oe U' . -EA., ':M-OVF. 4 EAIIf
ClikYT'IFFICATIi01'li%Ti T1ONpROMWORKF.RS ;AS S' ,WASTE TNI I3H i H V
COMI'13NSATION INSURANCE BUILDING DIVISION IBES _
('munition need not Mcamplaed if the permit is forovehunmed dallars(SI00) :ASF TR -
m less.) PLANCHF.CK FE[
I certify that in the performance of But work forwhich this permit is issued,l shall :WF .A TA Y-STORM F.A.2
not employ any person in any manner so as to Mcome suhject m me Workers'Compea- ENIiRGY PEE
,Z action Laws of California.Date AT ER HEAl'ER WIVENT/ELECTR
7�7 Applicant GRADINGFEE
G7 NOTICE 10 APPLICANT If,liner making This Cambicate of Exemption,you should SYST' SOIIS FTE
a become s lfjest to the Workers Compensation provision,of the IrMn Code.you must �^
forthwithrnmply with such provisions or this permitshall be deemed mvokcd. AT ER SERVICE
In
� z CONSTRULTPLATE.N LENDING AGENCY NEW RESIDENTIAL PLATE. SQ.FE PAID Da Receipt It
L) 0I hereby affirm that there is a construction lending agency for the performance of
u' Pthe work for which this permits Issued(Sec,3091,Civ.C)
Lenders Name TOTAL:
1 Lenders Address TOTAL IOa20 BUILIOIN E
1 certify that I have radius application and more That the above information is
Fr fA concert.T agree to comply with all city and county oNinances and state laws relating in QTY. MECHANICAL PERMIT FEE SEISMIC EEE
U s� building construction,and hereby avthoned representatives of this city m enter upon Line
tr above-meminned property for inspection purposes.
(We)agree to ve,indentnby and keep hammlas the City of Cupertino against PERMIT 15911ANC11 ELECTRIC F
ro
Iimbilnics,judgments,costs and c3penseswhich may in any way accrucugmatt said City ATTER OR ADDTD MECH.
in nseyuence of the great o ,mit
n , f thi . PLUMBING FEE
APPLICANI'UND STS , WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO TO."CFM)
MECHANICAL ITS
S (RCE RE C O
AIR HANDLING UNIT(OVER I0,IX0CFM) CONSI'RUCf10NTAX
Sigvnwr pli U ¢ `f o'
Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION HE
I IAZ RD(OUS MATERIALS DISCLOSURE
Will theapplicatd or forum building eccupam moreor handle huz.Nariontmal HEATING UNIT 00 100,000 BTU)
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Station 25532(x)? HEATING UNIT(OVER 100.000 BTU)
OYes VENTILATION PAN(SINGLE RESIDI PAID
Date Receipt#
Will the applicant or future building occupant use equipment lir devices which BOILER-COM('(3HP OR 100,000 131
dealt has othan,air couvmincou ns defined!by the tiny Are.Air Qumlily Management AL:
District? BOILER-COMP ROVER 100,000 BTU)
❑Ycx $7 mT'�'
I base read me Isomerism;materials,cgairentcnts under Chapter 695 of the CNi- AIR CONDITIONER ISSUANCE DATE
Train Health&Safety Cale,Sections 25 25533 and 25534.1 understand that if the NEW RESIDENT[AT,MECH. SQ.FT. 9
huildingdoes nttcura tLvmyrcegmsihilby to naify the occupnm V , Y "?l /
l
n>�cyuirvtncnts �nn�air not,yypaenfa Cenifc �C ol0,upypeY.
Owner ors age fir-�--Z/ Dater TOTAL: ISSUEDBY:
OFFICE