S 2125 —APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEgk�ITN°. 2125
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDEM'IP-ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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OWN 'SN E: PHONE: CON T'RACTOR'S NA F.: LIC NO:
6—Y�
NIC
CONTROLM
• Ak HIT.CT/F.NGINEER: LIC NO', K(/ AD RE.S: ❑
4
CONTACT: HONE: BUILDING PERMIT INFO
�� ❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT - PLUMB MECH
oEl2-� E;.-- 1�-�
LICENSED CONT'RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby mourning join ocrnsed under prnviions of Chapter 9(commencing ]OB DESCRIPTION
FICZ with Secti.n70W).t Division3.flhn Basineseand Pr afessions Code,and my licennc is RESIDENTIAL:
X in full Ince and PERMIT ISSUANCE ❑ Ll KITCHEN REMODEL
�UZu License Clio" � 9Gwa 1_1111 c. �G3E/
vFiQL Dam lin" C1111c. APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPH
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
F 7 m PANELS
CZ , lundersmnd my plans shall be used as public records MODIFICATION
OZ UP To 21NIAMPS El INTERIOR (_1 CHIMNEY REPAIR
C__W Licensed Professional 201-10B)AMPS IMPROVEMENT E]SWIMMING POOLS
[6L 9999 OWNER-BUILDER DECLARATION OVER["AMPSElBATH REMODEIJREPAIR ElDEMOLITION
C4 W 6 I hereby affirm that 1 am exempt from the Cmurarmra License Law for the ❑OT'HPR
3 m U following reason.(Section 70315,Business and Professions Calc:Any city or county SIGNS ELECTRICAL
2y which requires o permit to construct,alter,improve,demolish,or repair any stmetnre C
a, His,to its ismunce,nim requires the opplicmt larsach pefmitm file osignedatotcnmnt 1 SPECIAL CIRCUI'VMISC.
y thathe is licensed pursuvmmthr provisions of Ne Cnmmgnrs License Low(Chupter9
0�0 (commencing with Sectinn]OW)of Division cotes Husinexs and Professions Code]or TEMP.METER OR POLE INST. COMMERCIAL:
that he N exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^w
1edion703156yany applicant fore,ermitsultras theapplicant maund penaltyof POWER DEVICES [-]TENANT ❑FOOD SERVICE
> not more than five hundred dollars($500), IMPROVEMENT
�Fd Lasowmrofdutope norm em ISWIMMING POOL ELECTRIC
tended
ill dothe sime,and the[tenure is hots License La does of applyt044,Business ❑OTHER
0.3 and Professions builds
or ire eves then' License Law does not apply to if owner of OUTLET'S-SWITCHES-FlXTURES
his
property who builds m improves thereon,and who does such work himself or through
his on oweverecs,provided that such imprnvemenw thin on intended nr Offered for NEW RESIDENTIAL RLECTR SQ FT.
sale.11;hnwevec the building orimprovemem is sold within one yenrof completion,the SQ.FC FLOOR AREA $ISQ.FT
caner-bcildor will have the burden of proving that he did not build or improve for put,
pose of sale).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
nnsnuct the project(See.7044.Business and Professions Code.)The Contractors Li- JJ VV
cense Law does and apply to an owner of property who builds or Improves thereon.and QTY. PLUMBING PERMIT FEE.
who contracts for such projects with a coneractogs)licensed pursuant to the Contractor
License Law. PERMIT ISSUANCE
❑I am exempt under Sm ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE7" 0 d
ry
I hereby union under penalty of perjuone of the following declarations'
❑ I have and will maintain a Cenfieste of Consent to set f-minim for Worker's Cumpen- DRAINS-FLOOR,ROOF,ARE ,CO y t (7SfDRIES TYPE CONST RUCTION
santion,as provided for by Section 3700 of the Either Cade,for the perfhrmnnea of the
rfor which this permit is issued. t FIX'I URES-PER TRAP
wo J
1 hath and will maintain Workers Compensationrequired by Section
3]W of the Lahnr Cssde,for the pertonnancc of the workrk fine for whila chh this permit is issued GAS-F.A.SYS'1'EM-I INC.4OUTLETS DEC,GROUP APN
Crrier �.Comp mtioo lnsur ecarriera ley N"y qhyr�afV�w .J � � GAS-EA.SYSTEM-OVER 4(EA) /Y��
CEkTIFICATE OF EXEM ION FROM/WORKERS' /`-'
COMPENSATION INSURANCE GREASUINDUSTRL WAS
BUILDING DIVISION FF.PS
[This sectionneeJ Out le,wmpleted if thepermit lsforone hundred Dollars DianGREASE'tkAP
Or)c,4.)(This
PER
I certify that inicepc,focnonmof,hc work far which this permit is issued,I shall SEWER-SAN]'I S'T'ORM P.A.2W ET.
ret employ any Person in any manner so as to become subject the Workers'Compen- ENERGYFEE -
z ,'� [mica haws of California.Dam Wq'TF.k HEATER tN'f R 6
Apphotat xe GRADING FEE
h NOTICE TO APPLICANT:If,after making this Cenitien a of Exemption,you should WATER SYSTEM EATING
? become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
DJ forthwith comply with such provisions or this permashall be deemed revoked. WATER SERVICE.
CONSTRUCTION LENDING AGENCY NEW RESIDENT] . 'f PAIDt Date Receipt#
L.I Q I for whiuimispidmiti issco (Sec.3nlending agency fonhr pmfornance of
w
the work for which this prrmit is issue)(See.3W].Civ.CJ
WLender's Name OV TOTAL:
Lender's Address TO'T'AL o
y I certify that I have read this application and state that the above information is BUILDING FEE
V] correct Iagreo to complywire all city and county enhancers and state lows relating to QTy, MECHANICAL PERMIT FEE
F-t
V z hconstruction,nsconstrauthorize representrepresentativesion,and hereby authorize o[thic coy to enter mind the SEISMIC EEE
above-mentioned property for Inspection purposes. PERMIT ISSUANCE /+t
(We)agree to Bove,indemnify and keep harmless the City of Cupertino against J S ELECTRIC FEE e�
Iiahilities,judgments,c(sts and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in fthe t foil mit. PLUMPING FEE
onsegmenceo coming permit,
•�
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,WOCFM) MECHANICALftEE
SOURCE REGULATIONS. —I I
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signature of AppliwnbContrmmr Date EXHAUST FOOD(W/DUCE) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEAPING UNIT TO RX1,000 BTU)
as defined by the Cnpenino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)'! l / HFATING UNIT(OVER 100,000 BTU) rte` C
El Yea (]Wn VENT]LATION FAN(SINGLE RESID) PAID�w�
Date ReeenptM �..e— ��
Will[lie applicant
umrsfuture building occupant ase equipment nr Micaswhich BOILER-COMP DHP OR IW,WO BTU) Ja
emit haFI_Vms air conmminon J by the Ray Area Air Quality Management TOTAL
Uiatrict'I BOILER=COMP(OVER IIHI,OIIn BTU)
❑Yes
I have read the hazardous notecials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ' )N sISSUANCE DATE
fomin Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.Er, \(`jtCJ�,t,3J/l
huilding does not currently erre a tenant that it ix my responsibility to notify the occupant
of the qm ansate which mustbemd prihrm issunnee hPo Cenificom of Oecupvn y.
Ow6cr orauthnnma agent Date TOTAL: ygx ISSUED BY:✓� 7aM,r✓e.ef
OFFICE