S 2126 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PESITNO 2126
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS'. - SANITARY NO. APPLICATION SUBMITTAL DATE
0 S ts�,C' eT�
OWNER'S N ME: PHONE: CON'IAACI' R'S NAME: I 1 NO:
601
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CONTAC'C T e PHONE BUILDING PERMIT INFO
VYL
Fs� 1 7/V ❑ Consultant Fees Paid by Applicant(initial BLDG ELECT PLUMB MECH
❑ C� ❑ C�
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FBI,
1 hereby amrm that[,am licensed under provisions of Chapter 9 mommeneing JOB DESCRIPTION
wpZ Ih Section]000)of Division 3 ofthe Business and Professions Code,and my license is J RESIDENTIAL
F o full force anJ a /iJ�/� PERMIT ISSUANCE t ❑SFDWI. ❑KITCHEN REMODEL
nu Licen.ve Cass Lic.# � APPLIANCES-RESIDF.NTIAI. C1 ADDITION [I PLUMBING RE-PIPE
y ri Date ARCHITECT'S DE Cof.A ATI:�
PANELS C1 MULTI-UNIT ❑STRUCTURAL
J
Z p y Z - 1 understand my plus,shall he used as public records / MODIFICATION
OIZ^O UP TO 200 AMPS ZO ❑INTERIOR ❑CHIMNEY REPAIR
r is,Fr Licensed Prof®slomal
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
[I SWIMMING POOLS
'y
pp$d,, I hereby afliml hot 1 vat exempt from the Contractor,License Low for the OVER I WO AMP9 ❑BATH RBMODEUREPAIR (]DEMOLITION
EI a Ar F following reason.(Section 7031.5,Business told Profession,Code Any city nr county SIGNS ELECTRICAL [-]OTHER
F Orn which requires v permit to construct,alter,improve,demoli,h ar repair any swemre
yWH pnonoits i.vsuance,also requires the vppllevm[or such permiuo fileavigned staaement SPECIAL CIRCUITMISC.
EC that he is licensed,unmemfothe provisions of the Contractor's license Law(Chapter 9
a (commencing with Section 7000)ofDivision 3 ofthe Business and Professions Code)., TEMP.MBTBR OR POLE INST.
COMERCIA :
d
e. Oo a that he i-,exempt therefrom and the basis her the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ Section 7)31.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
�m ❑TENANT ❑FOOD SERVICE
not more roma five hundred dollars y employees
IMPROVEMENT
❑ Lo(he as va k,mal of the propearti is of aloyeeswilh wages as tes,(Sec.compensation, SWIMMING POOL ELECTRIC
(r wall dnlhewon,aoA the he ConoisnrnsLicense Law redferotapply town Boniness ❑OTHER
3 m and Professions Crude:The Contractors License do Bars not apply to f owner of OU'TLE'fS-SWITCHES-FIXTURES
his o
property wa,builds or improves thereon and who does such tints intended
o f or hough
his own employees,e provided that soca improvementsak,olw are not Intended er offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.Ilhoover.r will hbullthe burenng or of prmenl ithat he id none
wild o,femnplmiogthe OR AREA $/SQ.Ff.
r-builder will have the burden of proving that he did net build or Impmvn for pur-
xoe.).
❑
I,as towner of the properly,am exclusively announcing with licensed contractors to TOTA
El1,as
arose La the does
(Sea.o an owneBrar
oav and rty beswho
bud ds ori The Connector's Li-
cense pacts f nmapply manownerofpropenywhobuildsorimpmves thereof, QTY. PLUMBING PERMIT FEF.
who conwcw fnrsvch projects with v c,nnaomgs)Ilcmised pursuant m the Comocmrs
License law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B.k P C lir this reason
ALTER-DRAIN&VENT-WATER(F.AJ
Owner DaVALUATION
Dole
_ WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
1 horeby affirm under penalty of ran,one of tun following declaotions'. S
❑ I have and will maintain a Cenmeate of Consent to selt-insure for Worker's Croatian- DRAINS-FLOOR,ROOF.AREA,GOND. ST S 'TYPE CONSTRUCTION
satien,as provided for by Section 3200 of the Labor Code,for me performance of the
F]
rk for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compenntinn Insurance,as required by Section
00 ofthe Labor Cade,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS O OUP APN
MyW
Corn cmrke'^CCpc��� mTFlfi7TE —PTpulayoIONIHN:cyOMW RCf� GAS-GA.SYSTEM-OVF.R4(EA) lir OCT IS 1998
/'_ COMPENSATION INSURANCE GREASFIINDUSTR-WASTE1NTERCEP R
UILDING DIVISION PEES
(Tai,vection need not becompleted i(tbe permitis[some hundred deltaic($10(p GREASE TRAP pp
oNenaJ U PLANCHECKF
ioy any lam in the any performance ofthe workms,suhchthio#condo isissued,Comp all SEWER-SANITARY-
not employ � STORM EA.IIID FT.
p y any person in any shone,so as m hecnm suajecuo the Workers Compel- ENERGY FEE ,
� Z nadonLawsofCalif.mas.Do,, WATER HEATERWNENTIELECTR
O Applicant GRADING FEE
r~Ni NOTICE TO APPLICANT:If,after making this Ccaifica d of Exemption,you should WATER SYSTENUTREATING a � SOILS FEE become subject to the Worker's Com�nsdion provisions of the Lmor Cade,you must
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE -
Q
UO
CONSTRUCTION
LENDINGAGENCY NEW RESIDENTIAL ELSE. SQ,FT. PAID
Ihereby whichaffirm thatPermit i isaed(See.30lending agency Tasha perfnmtnnce of Det Recelpl#
W the work for which this permit is issued(Sec.}n9],Civ.C.)
QLenJer'c Name TOTAL:
LenJerAddress TOTAL:
1 _
1 cerlify that I have real this application and state that the above information is BUILDING FF;F:
.. (A social paccur comply with all city toad Wumyodinar,es and nate Is ..china. QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives oflhiscity to cinrupordie SEISMIC FEB
ahivc-mentioned property for inspection purposes,
(We)agree W asm,inden ally and keep humiess the City of Cu idt in,against PERMIT ISSUANCE / p ELECTRIC FEE
liabilities,judgments,costs and expenses which may in anyway accrue against said City ALrERORADDTOMECH. PLUMBING FEE
in mwmanee of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL.FEEQ
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicam/Comracmr Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE _ �•S
Will the applicant or future building ocenpum store or handle hazatd,m material IDEATING UNIT(TO 100,1X0 BTU) L.r�
as defined by the Cuperlino Municipal Code,Chapter 9.12,and the Health and Safety
2—
Code,Section 25532(a)'f HHA'I'ING UNIT(OVER 100,01)BTU)
El Vex [I No VENTILATION FAN(SINGLE RF.SID) PAID
Date Rncoipt#
Will the applicant nr future building axcupam use egaiptnent or devices which
omit hazardous air emnhminants as deaneJ by the Bay Area Air Quality -COMP CHECK 100,000 BTU)
lity Management TOTAL:
oindere
F-I5.es (]Na BOILER-COVE(OVER I0X1,I0XI BTU) �
I have read the hazardous materials tequircmems under Chapter 6.95 of the Cali- AIRCONDUIONER (ISSUANCE DATE
Foods Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Pn o - i r- 9 ,(
huifing does net currently have tenant,that It is any responsibility In notify the occupant
ofthe reso amens which mustbemct prior tu issuance or a Cemnut of Ocwpuncy.
adh so,
. . lair/w
Owns r thorned agent male AL ISSUED BY:
OFFICE