S 2357 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBIN'G-MECHANICAL. S 2357
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS'. SANI'r RYNO. - AP PLICATIONSUBMITTAL DATE
f' 1// 43 c 2ND AvS U^/� "'p
OW BR'S NAME: - PHONE: r ( 'ITtAC'OR'SNAME: LIC NO�
/CtB7 �• Glty V_Wer i/ Qq A I ^ NIC CON TRIIL#
AIlCyITF.);T�FIN �IGLR.� Si C LIC NO A Til Cue( girt IL l7l� Sr • ❑ O�
CONTACT. PHONE: _/II _ BUILDING PERMIT INTO
�J ❑ Cons.1tent Fees Paid by Applicant(Initial) •BLDG ELECT PLUMB MECH
[/ .. ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. f" FLEC,TRIq PERMIT FEE
I hereby affirm that i licensed ti p rChapler q(Cum» ng JOB DESCRIPTION
WOZ msecdon000)ofD J,lon3 onho Bn' and Pmmalons code and my he..re is RESIDENTIAL,
Fw� con fill l orre and effect. PE1tMIT ISSCANCP. ❑SFDWL ❑KITCHEN REMODEL
�UU License Class Co."Los APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
h u] Dam TSDEmr
C ARCHITECT'S DEC], RATION - El MULTI-UNIT ❑STROC9'URAI.
F 5 y PANELS
Z p h 1 understand my plans shall he used as public cornets MODIFICA'T'ION
OZ-+� UP T02IXIAMPS ❑INTERIOR, El CHIMNEY REPAIR
W Licensed Pm filial aal 2111-IfN10AMPS IMPROVEMENT
a 44�„c 0 SWIMMING POOLS
0.' .<.1 Oin I act RUILDIiR.ar the onneRXI ON OVER I000AMPS ❑HATH RF.M0DEUREPAIR El DEMOLITION
C 1 hemhy affirm That I ken exempt rmm the Connector's License Law for the
3 O W U following rens....(Section 70315,Businessland Profeseiens Coda:Any city nr seamy SIGNS ELECTRICAL OTHER
moi which requires a permal to cmtswCh enter,impowe.dem..elan,o,re......c,mtrum f YTLd-I DyL T1e_ci
Or4 prisms its issmecgalsorequires like applicant lorsuvn permit if)file aligned statement SPECIAL CIRCUIT/MISC. -
�� that he is licensed pursuant it)the pmvlsionsortheGmvncmrs license Law(Chapten9
fcommnncing with Smtiun 7010pdDivisinn 3..f Ne Husinecxland Professions Code)or TEMP.MEgHR OR POLE INST COMMERCIAL•
Ihnt he Is exempt therefrom and the Foas for the alleged exemption.Any violation of ❑NEW HLDWADIDD ION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects theapplicant loaclvil pemltyof POWER DEVICES
^m
FNT
not mora Than five hundred dollars($51iti). IMPR❑TENAOVEMENT El FOOD SERVICE
ZQ ] 1.asowner ofthe pro,seny,or my employees with wages as their vole compensation, SWIMMING POOL ELECTRIC
F� will do the work,and structure scture is sol intendetloA foa
rofferesllle(Scc.7Mq Business [JOU
TER
^m and Preassiuns Code:The Coulmnor's License Law docs not apply to un owner of OUTLETS-SWITCHES-FIXTURES
ti
0.t 3 property who builds or improves thereon,and as)to does such work himself or Ihmhgh
his own employms,provided that such impmvemem,me not intended or olTered for NEW RESIDENTIAL ELP.CTR SQ Fr.
sulr.ILhoweve,Ihebuildingnrlmpmvementissoldwimin oreyed
alid ..refroom Ne SQ.FT.FLOOR AREA $/SQ.UP
ser-builder will have the burden of proving that he did not build or improve for par-
Panic of vale y
] i,a,court,of the prnpcny,ant exclusively remaining with licenced ammectur,to TOTAL:
construct the project(See 7044,Business and Pmfes,inns Gu1eJ'1'1he Connne o'.L.-
crack,Law does not apply him()%net
i-xeLawdoesnotapplymancwnet nfproperty who builds or improves breach,and QTY. PLUMBINGPERMIT y' FEE .
who concocts for such projects with a eontmnor(y)licensed pursuant to the Corme chars -
License Law. PERMIT ISSUANCE
] l am exempt ender See ,B A,P C for Nisreason
Owner DataALTER-DRAIN&VENT-WATER TAO VALUA'T'ION
WORKER'S COMPENSATION DF.CLARA'1'[ON RACK PLOW PROTECT,DEVICE
I hereby affirm under penalty of perjury one or the following declarations: �d .
] Ihtwc and will ntninmina CertiOrvte of Gmsem mself-inwre for W.rker'x Compel- DRAINS-FLOOR,ROOF,AREA,GOND' STORIES TYPECONSTRUCTION
cation,as provitled for by Seclinn 37f10 of INc LuMa Gnle,for the perfm'mmme el the
work for which bis permit is issued. - FIXTURES-PER TRAP
] 1 have and will maintain Workers Compensation Insurance,as required by Scroll
3700 of Ne Labor Code,farthe perturreaecofthe work forwhich boa permit is issuer], GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CER'I117ICKI E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRI.WASTE INTERCEPTOR
(I,'hk 9UIL41N0 DIVISION 14,4
is serf...need oat be mvnpl.mdi[Nepennh is fnnmehundred dollars($ItNp - --• -
nr lea) GRF.ASE'I'RAP PLANCHECK FEE
I mortify that in Ne per[ormanccoflbc w rnnvhich trisectionis issued,Ishall SEWER-SANITARY-STORM P.A.200 FT. -
mm�nployany non m rg� Itbc oke trolhc WorkerA Cnntpcn- ENERGY FEE
Z Adulawso [o % a�% L rsytlyee
!� 7` WATER HEATP.R W/VENT/ELI?CI'R
7 Q Applicants,'v G OP9
Gy NOTICE APPLICANT:If,aOcr making Nls Cenifcvmo[Bxemplinn,you,hnuld WATER SYSTFM/TRHA1 ING
F !+ become s.bjaano the Worker's Compensmion Forskikka d the 1ahe,Code, normal SOILS li.
sly b
W hmhwiN comply with such provisions.,,his perm.shall be deemed revoked. WAFER SERVICE
Q
'7z CONSTRUCTION LENDINGngAGENCY
agony NEW RESIDENTIALPLMB. SQ.Pf. All>
hereby which this
iss ermSea 30 len ding agency forthepetlormance..f t#
U
� the work for which Nis pannit is issued(Sec.31197,Civ.CJ
Lenders Name TOTAL:
WLenders Address TOTAL:
d 1 certify that 1 hove read this application and lade That the above information is - I.
m .correct.I agree m romply with all city and county ordinances and ante law.renting In QTY. MECHANICAL PERMIT EEE
U � huilbng eonalrvcrinn,mdherebyvuthnriurepresemativenol Wiscity lnenlnupnn Nc SEISMICP . O
above-mcntinnni Draperty for inspection pnryoses. PERMIT ISSUANCE
f Wel agree m save,indemnify and keep harmless the City of Cupntinn eguinsl ELEC I RN FEE
Iiabilitile,judgment.. ...oand expetnes which may in any way accrue against said City ALTER OR ADD TO MECI{. PLUMRIN PEE
in comelmnce of the granting ofllds permit.
APPLICA r UNDERSTA/f/N%/r]WAND WILL COMPLY WITH ALL NON-POINT AIR IIANDLING UNIT LED Ith01N1 CPM)
SOUR�;GU AT///C'✓' CONS I RUC FEE
AIR HANDLING UNIT(OVER 10,000 CPM) CONS'fRUCT10N TAX
Onatnre of AppllcmUContmetor Dale EXHAUST HOOD(W/DUCT) IIOUSING MITIGATION LEE
I IAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future huilding occupant store or handle hazardousmaleri:d HEATING UNIT(TC,100.000 B GO -
m defined by the Cupenine Municipal Code,Chortler 9.12,and the Health and Safety
Cade,Section 25532(x)7 - HEATING UNIT(OVER 100,000 B'FLU
]Yes No VENTILATION FANS INGLF RES III) PAID
Dam Receipts
Will the applicvm or encore building he B use equipment or device,which BOILER-COMP CHIP OR 100,000 RTLD
\
ni0-- f hazardous air commitments as defined byy the Bay Area Air Quality Management
�an ric (, TOTAL
L
ON. - r BOILER-COM P(OVER If10,fN10 RTU)
.J the hazardous m rials AIR CONDITIONER -
q ,oil
dee Chapter understand
of at Calle / ISS�N�ATE�
&Safdy C d Se I :25505 25533 a 125534 I d t nd thmf br teurentlyh 't t,than: y pt sibiltyt dry thea cpanNEW RESIDENTIAL MP.CH. SQ.PI'.nts which must be met prior to issuance ora Certificate of Occupancy.
a,ad agent Dane TOTAL ISSUED BY:
OFFICE