S 2965 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION S 2965
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DDAATE
`137 2«,xG - 'JE LTJ _ 22-Q7
OWNER'S NAME: PNIC CONTHONE: CON NAME: LIC NO:
sIt� c. sr k I r 996 2 b nrEZQ
CHITECT/ENGINEER: LIC NO. ADDRESS: ❑
CONTACT. PHONE, BUILDING PERMIT INFO
Ce D ❑ Consultant Fees Paid by Applicant(Initial) BLU ELECT PLUM MECH
sG e ❑ ❑
LICF,NSE>CONTRACnCLARATION
1 hereby al'flnn That I am licensed underderprovisions ofChapmr 9(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
woo ME Section 7000) 3ofthe Bnelnevand professions Code,andany license is pHRMI'r ISSUANCE
RESIDENTIAL:
F W F in full untreated eller. ❑SFDWL ❑KITCHEN REMODEL
�VV License Class Lic.N
ti<WW Dale Contractor APPLIANCES—RESIDENTIAL L1 ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION
El MULTI-UNIT ❑STRUCTURAL
OZun
a,z I detsatndmy pIars,hall be used as publicrecords PANELS MODIFICATION
UP ID 200 AMPS -1 INTERIOR [:1 CHIMNEY REPAIR
f—`3 W Licensed Pndessional 2BI-IBIXIAMPS IMPROVEMENT
g�j OWNER-BUILDER DECLARA'T'ION .f�swr� ❑SWIMMINGPOOI.S
Vr Q I hereby affirm that 1 nm exnnpl from the Cantracmr's License haw for the OVER 1003 AMPS apgt p REMODEUREPAIR ❑DEMOLITION
dV following maam.(Sermon 7031.5,Bosinens and Professions Code:Any city or eounty SIGNS ELECTRICAL ❑OTHER
W y which requires at permit to construct,alter,improve,drnoll,h,or repair any suicmre _
�i—r�Q priore.aso,rames,also arduous the applicant for such pdrail o file reigned state
mum SPECIAL CIRCUIT/MISC.
W That he is licensed pursuant w the Provisions of the Cotnmcia' License Law(Chapetr9
W ❑0 (commencing with Section Mad)of Division 3 of the Business and Professions Code)or TEMP.METER OR DOLE INST. COMMERCIAL
4 y m rGL Ilett he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^tn Section 9031.5 by any applicant faro permit subjects the applicant to a civil penalty of POWER DEVICES
F p. am more than five hundred dollars($500). ❑TEXAS T ❑FOOD SERVICE
� QO Ib,11,15"owner of the Property,or my employees with wages as Hat...y ymrnpensmmr, SWIMMING POOL ELECTRI IMPROVEMENT
will Bothe Work,and thexwesure is norimeuded orottered for sale(See.]W4,11mar av DOTH�:R
til ' and Professions Code:The Cnntractor4c Lieeme Law days not apply to an owner of OI1TLEf5-SWITCHES TO ' n•
C property who build%or improves Iheretm,and who does such work himself
or
IhmughLj
his own employee,,provided that .an improvements are nal intended or offered for NEW RESIDENTIAL.Pwe
role.If,however,the building orimpmvcmem is sold within nn eyeanrfcompletiogthe .FLOORARFA �� 3/,
cr-builde39
r will have the burden or proving that he did not build or improve for put- APR 2 2 U
❑ Las owner of the property,am exclusively contracting with licensed contractors to
mulanal the Firmer(Sec.7144,Business and Professions Ced,)The Contmcmr's Li-
eerueLawdacsnolnPPlylannownerafPrnpenywhohuildsorimprovecthrecm,and QTY. PLUMBING PERMIT PEE By
whocommus formch project,withaeonnwhah')lleare dpunoam to the Couuamarn
License Law. PERMIT ISSUANCE
E] lamm exempt Sec. ,B&PCfor thhancon
Ox Date
y qy 4
ALTER—DRAIN&VENT—WATER GIA)net VALUATION
affirm
COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �j OO O -
I hereby arm under penalty or perjury one of the following declaration,: ,Z
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPECUNSTRUCTION
fusion,as provided for by Section 39(10 of the Labor Code,for the performnnse of the
work for which this permit is issued. FTX'I'URGS—PER TRAP
❑1 have and will nmiumin Wotkefa Compensation Insurance,as required by Section
37M of the Labor Code,for the performance afthe work for which this permit is issued. GAS—EA.SYS HIM-I INC.4 OUTLETS OCC.GROUP
WF 7�
My arkers Compensation Insurance carrier and Policy number are. pPNJ
Curries Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUST'RL WASTE INTERCEPTOR
COMPENSATION INSURANCE:
(Thisseconn need nm be cmnpleted ifthe poet,,is far one hundred dollars(SIIX) BUILDING DIVISION FEES
or less) GREASETRAP -----
PLANCHECK FEE
Loy any that
Per int he pa,diduur,e.o do e work
for which lb is permit i kmsc ad,[,hall SEWP,R—SANITARY—S'FORM P.A.21X1lN.
not employ Any person in any manner,so as In hecnme subject to We Workers'ComVen- ENERGY FEE
O z ,ation laws of California.Dade WATER HEATER W/VENT/ELECPR
Applicant GRADING FE
tiNOTICE 10 APPLICANT:If,after making this Ceniliate of Exemption,you should WATER SYSTEMTREATING
became subjer to the Worker's Compan,mion parrumme,of the Lima,Code,you man SOILS EE
W forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
ao
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FUND. SU.FT. PAID
Ihereby whichaffirm thatthereisaedtSecti30oCry.agency for the Performance of De ReceiptN
[U � the work for which thin Permit is issued(Sec.]099,Civ.CJ
Q Lender's Name TOTAL:
PLenders Address TAL'.
i I certify that I have read this application and.state that the above informwion is BUILDIN P, O
i..r VI correct.I agree for comply with all city and county ordinances and state laws relating In QTY. MECHANICAL.PERMIT FEE SEISMIC !
building concoction,and hereby authorize representatives or his city to enter upon he
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
Iiabilities,judgmentx.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the gmnurg of this panni. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT ATR HANDLING UNIT(TO 10,000 CFM)
SOURCE R/E/G{�'I-A' )NS. MECHANICAL PLUM
/[/ %L r�i:/99 AIR HANDLING UNIT(OVER IB,WB CFM) CONSTRUCTION TAX
Sign�u ' f ni m/Ca of , Date EXHAUS9HOOD(WMUQI) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Willthcapplicant orfnure buildingnoctocan,ore m handle hazardous muletim HEATING UNIT(TO 100,000 BTI)
as defined by the Cupertino Mnntdpal Code,Chapter 9.12,and the Health and Safety
Code,Section2553$,)'1 HEATING UNIT(OVER I ga"BTU) I�
❑Yes 011T.
VENTILATION FAN(SINGLE RESID) PAID �
Will the it coma or furore building occupant use ea Air Qu or Marta which
Date
ist hazardous air contaminants as defined by the Bay Area Air Quality Management HOLLER—COMP(3HP OR 1(1(1,000 BTU)
District? O
e
❑Ycf {f.Nn BOILP.R—COMP(OVER 1(10,000 BTU)
I have read the hazardous maledms requirements under Chapter 6.95 of the Cali- AIRCONjHriONGR ISSUANCE DATE ^y
famin Drum,&Safety Cade,Sermons 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SO,FT.
building does not currently have a serum It Iii ism re sit my to unify theoccupant
of the reyuirc 'eh el be me eauunce ofn Cenlfiwten Occupancy.
XUwner or mW ed agertl zl'are�r9 OTALISSUED BY
OFFICE