S 2155 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PFRy1`VIT NO. 2155
BUILDING DIVISION APPLICATION/PERMIT PLUMRING-MECHANICAL.
BUILDING PROJECT LINESFIEICAI'TON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
77 42, _
OWNS '.S AME PHONE: — � ONTR ]R'S NAME: LIC NO.
til NEC CONTROhN
CHITECTMNGINEER: LIC NO. AD S N ❑
CONTACT: PHONE: BUILDING PERMIT INFO
/ 3 �J`-5 ❑ Consultant Fees Paid by Applicant(Initial) x1:1 ELECT PL;? MECH 1:1
LICENSED CONTRACTOR'S DECLARATION 7 QTY ELECTRIC PERMIT FEE
1 nereny arrrm Inas I am heensw ower provielons at,enapmr 9 mommendng JOB DESCRIPTION
OaZ with Section 70W)uf Divisinn3ophe Business and Pmre.csion.ceme,and mylicense is — RESIDENTIAL:
w O O_ PERMIT ISSUANCE
a,= iicenlso Cmsand efect Lic.» ❑SFDWL ❑KITCHEN REMODEL
yG6 Dme�Controv APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F y Z 1 understand my plans shall be used as public records PANELS MODIFICATION
OZ-" UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
, Licensed Professional 201-1000AMPS - IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION
C"� a OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
6 I hereby affirm that I am exempt firm he(d ntmeror's License Law for the
iry5, d U following mown.(Section 7031.5.Business and Prnfesvions Cade:Any city or county SIGNS ELECTRICAL TH
1q++ p y which requires a permit to coreamcq ahem,improve demolish,ec repair any atmcmrc )
pri t c'. mane 1. q ...theapplia n mip ,1 fire.'g d,elemenl SPECIAL CIRCUIT/MISC.
that he is licensed P u fl p f he Cmunicus,License Lue,(Chapter 9
WC�� (am g lh9 1 70W1 fD n9 !th B . dP fCodepn TEMP.METER OR POLE INST. i 'COMMERCIAL'
d pr M a Ihvt Ines exempt therefrom and the basts for the alleged exempuon Any v;Nabon of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^w Seclbn'1031.5 by any applicant for a permit subjects the applicant In a civil penally or POWER DEVICES .1_1` El TENANT ❑FOOD SERVICE
Fx0ant mom than five hundred dollafs($500.
❑I,us nwnerrftnc propeny,or mycmployoexwirh wages anlheir solecnmpmemier, SWIMMING POO .CTRIC IMPROVEMENT
Er ❑OTHER
will do the work,and lhcstrucmre isnel inendedornBered for sale(Sec Jl144,Business
W and Pcofesslnns Code'.The Contractor's License law does not apply to an owner of OUTLETSOSWITCHES-FIXT
property who fields or imo thereon,and who doessuch work himself or through
his awn employees,provided that such improvements are not intended or offered for .W RP.$IDENTIAL
sale,If,however,the building or improvement is sold within one year efammplenrn In .t SQ.FT.FLUOR AREA $/SQ.FT,
owner-builder will have he bardenaf placing that he did not build or impro _
pose of sale).
i,as owner of the property am exclusively contracting with lieens rnnmema too
TOTAL. -
mstruct the projem(See.7044,Busines and Profession,Code:)The Imcln' Li-
cense Laos doesact apply la son monafpmpary who builds or lmpmv d PLUMBING PERMIT FEE
who contracts for such projects with a counteracts)licensed Pursuantiothe tmemv's
License Law. PERMIT ISSUANCE
slam exempt under Sec. ,B&PC[oro
Owner Dam ALTER-GRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herchy affo-m under penalty of perjury one afire fol lowing dedaratima:
J (have and will muintainaCedifcate of Con.cem mself-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STOILG,S pnXIII TYPE CONSTRUCTION
smion,as provided for by Section 3700 of the Labor Code,for the performance of the or 0
wolfI which Ibis permit is issued. FIXTURES-PER TRAP
have and will maintain WnRefs Componsmide insurance,as required by Sedlian
3700 er,he Lab or Coda,fur Ne performan sd be workk and f�tryywhich
�this
vpe4.it is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS 'V C. AIN
My Cm Wor pr's Co ermrion loser r�nen'ierPnl'cy Ncl/�Inw,59J GAS-EA.SYSTEM-OVER 4(EA) p,N 'V
MFI IC
TIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE,INTERCEPTOR
BU_ILDINOU 3 )N FEES
on less)(This section need not be compined ifthe permit is panic hundred dollws(SIINp GRFASETRAP P
IcenilyNmin theperformance of the work frrwniclr eM1is permit is issued,lshall SEWER-SANITARY-STORM EA.200 FT.
oat employ any person in any manner.vm e m become subject m the WorkersCompen- ENERGY FEE
ZZ satins Laws of California.Date WATER HEATER WATNDELECTR
Q Applicant GRADING FEE
h NOTICE TO APPLICANT:If,after making this Cdnificme of Exempljnn,you should WATER SYSTENYTREATING
1"I > became subject m the Weir Compensation provisions of Ne Labor Cede,you must SOILS FEE
Lakl Q forthwith comply with such Emissions or this permit shall be deemed revoked WATER SERVICE
� Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MR. SQ.IT. PAID —'
I hereby affirm that(hereis a construction lending agency four the performance of DDaa xl ReceiplM
U0 the wfor which the,permit is Issued(Se07
e N ,Civ.CJ
u" F'' ork Lender's Name TOTAL:{U Leader's Address IY)TAL b BUILDING FEE
eF"y' I certify that I have read this applicnlion and state that the ahuve information is
Va] cored.1 agree m comply with all coy and county ordinances and send law.,elude,Ir QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize representatives o'this city to enter upon the SEISMIC FEE
above-mentioned propeny Por inepeclion purpn.es PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City or Cupertino against, ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way accme against said City ALTER OR ADD 10 MECIL PLUMBING FEE
in asequence of the granting of this permit.
APPLICANT UNDF .T AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 PE
O CFM) MECHANICAL. E
SOURCE RE`Gy ON��J� )
I / /,24- gr AIR BANDUNG UNIT(OVER 10,001 CFM) CONSTRUCTION TAX
f
Signature oApplicanUan
CenOor ((OD Dote EXHAUST HOOD(W/DUCT) - HOUSING MI9'IGATION Mr..
HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant or future building occupant store or handle hazardous material HINTING UNIT(TO 100,0110 BTU)
its defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Coal Section 25532(x)'/ IIEATING UNIT(OVER 100.000 BTU)
E]Yes b1i VENTILATION FAN(SINGLE RF,SID) PAID pale ReeeiprN
Will the applicant of future building occupant use equipment or dOties which ROIf.ER-COMP(3HP OR 100,000 BTU)
emit hanu
zafds air contaminants as defined by the Bay Area Air Quality Management
OJO
Dislridl
E]yes AI_�/NO BOILER-COME(OVER 100,000 BTU)
(have read the havudous materials requirernents under Chapter 6.95 of the Call- AIR CONDITIONER ISSUANCE DATE
lnia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that lfrhe NEW RESIDENTIAL MECH. SQ.IT.
'addingJcesnotcumently avealenanl, at it is my resCuldfulity en notify the occupant
Uthe requir i t be met prior o Issuance of a Centro
f Occ n�.
� i
Owner or authorized agent are TOTAL ISSUED BY:
OFFICE