S 2399 --APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BjI DINc.-ELKCTRICA1, PERMrr NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 2399
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBM1'1'fAG DXF1
,b 9?
OWNER'S NAME: I fk P ° O�/ CO 'RrCOR'S N.ry ICN : .�Xrk NIC CONTROLp
ARCHITECT/ENGINEER: LIC NO: J 7 (r(55': /I/v�
GµEsTiu QT" 5 - �
CONTACT: PHONE: BUILDING PERMIT'INFO-
r,I �rfb72 ❑ Consuhant Fm Paid by Applicant(initial) BLDG ELY, PLUMB Me
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I herrn,drama that 1 arra femasul ander prowixbsn.of chapter 9 am,l:neneing JOB DESCRIPTION
Po. with Serdiat700D.f Division 3 of the Braame'lil Professions Cade,and toy uprate;, RESIDENTIAL'
F-ly in full force and eReet/� LO �J�k PERMIT ISSUANCL• ( (J
QUV License Cla L� hie, J /�a-,i ❑SFDWI- ❑KITCHEN REMODEL
vFi QL Dam — Conaacn:r APPLIANCES-RESIDUE I[A). ❑ADDITION ❑PLUMBINGRIiPIPE
I„peis ARCHITECI'S DECLARA 0- El MULTI-UNIT 0STRUCTURAL
1 malersmnd my plan.,hall be used a.Puhlic recon], PANELS
Z O MODIFICATION
0z�O UPTO 2(x1 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
n W Licensed Professional 201-1000AMPS IMPROVEMENT
�Yad� OWNIam exe1.UERUECLARAmen ❑DEMOLSWIMMING POOLS
11 C�Q 1 hereby dfimt that 1 um exempt from the Commnor's License Ww for the OVER IINXIAMI'S El BATH REMODIeIJRIiI'AIR �DEMOLITION
06 U following reason.(Section]031.5.Business and Pmfcssians CWc:Any city or countySIGNS ELECTRICAL 2 DOTTER
OF+ which require.n Penult to eonsuuet,alter,improve,dmnellsh,or repaia'any swcmre
priorlo ns ieamors .1w,upaireslheappreanf fm,nch pe.it,,filea.agned smmment SPECIAL CIRCUITIMISC.
�} that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
aQg (conntrcing with Section 7000)of Division Sotthe B,oi rew and Pmfcoions Codc)or TEMP.METER OR 1'01.13 INS9i COMMERCIAL:
6 6 e IY Thal he is exempt Nemfmm enJ the basis for the alleged exemption.Any violation of
X^4' Section 7031.5 by any applicant for a permit subjects the applicant to a civil penal) f POWER DEVICES El NEW BLDG/ADDITION [:1 DEMOLITION
�..to not nave than live hundred dollars $500 y o ❑TENANT
( ). [I FOOD SERVICE
=Q ❑ I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
y E+� will dothc work,and hardenmre isnot intended oroRcred fo...Ip Sec.7U14.Business [:1 OTHER
a3and 1'mfeasiens CWc:The Contractor's License Iaw does not apply ra an owner of OUILEIS-SWUCHES-FIX'I'UItES
property who built[m improves thereon,and who dies such work himself or through
his own employees,provided that such improvements me not intended or offered for NEW RESIDENTIAL ELECT R SQ Fr.
sale.It.however the building orimpnwemem in,old within one year of campleioa,the .FLOOR AREA $/SQ.IT.
ownectatilder will have the burden of passing that W did not Wild or improve for pur-
pose of role). !'
❑ 1,as owner of the property.ant exclusively contracting with licensed contmctocs ro f AL: f
ndrvet the project(Sec.]044.Business and Prefessiuns Coder The Cement Li-
lawdtsl not apply teas with
aofpmpeny who
sedporimpmsen thereon, QTY. PLUMBING PERMIT PEE
win) nnuams for such project with a amaacuu(s)Beamed pursuant to the thereon,and
ILiecna U. PERMIT ISSUANCE,
❑ I nm exempt under Sec. ,B tk P C for this reason
Owner ALTER-DRAIN&VENT'-WATIiR(EA) LUy'ION
Dam !/
.
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affair under Penult,of perjury nue of the following declaratioe:
❑ l have and will maintain a Cenificam of Consernn self inure for Workers Cou,en- DRAINS-FLOOR,ROOT'.AS G.COND. 49
series,as provided for by Seainn 3900 of the Labor Code fonhe perfm
orance ol'tha STORIPS CONSTRUCTION
9for which this rennin isIssued. FIXTURES-PERT RAI'
we 1 have and will common Wmkds Compensation Insurance,as mquimd by Section
.)anof the Labor Code,for the Performance of the work for which this permit is issued. GAS-EA,SYSTEM-1 INC.40171'LEIS
My Work
Carrier lns�ur�lItee cum ]Policy ten P ANN
Cam¢ /C!1i Policy N�.:�tn- SQA GAS-F.A.SYSTIiM-OVER4IRA)
- C��1ct��((jj'IC�OMPIIfSA?MNINSURO O hiRS IkA/'r I
COMPENSATION INSURANCE GREASVia NODS'fRL WASI'F,IN'I'IiRCEPI'OR
(Thee section need not hecompl<aed ifthe permit is bureau,hundred dollars(Stan) BUILDINODIVISIO F
or less.) GREASE TRAP
Icenilythalinthcperlinnnanccnftheworkforwhichthispermitisi...ed,I shall SEWER-SANITARY-STORM FA.2001T
not employ any Person in any summer so as to become subject as the Workers Camped-
z mtien Laws of California.Doc ENERGY 1936
OO Applicant W'A 1'EN IIEATER W/VF.NI'/ELEC'I'R
AUINO PEE
y NOTICE TO APPLICANT:IL after making this Certificateof the
Exemption,you shouldno-t WATER SYSTEAt/fREA'I'ING
abecome subject to the Workers Compens thi provi,inm'of the Labor CWc,yea must SOILS FEL:
� forthwith comply with such provisions ar this lnrmit shall MdecmW revoked. WATER SERVICE
R Ll
aOz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMII. SQ.FL PAID
U p I herebyaftina thotthere is.consmetion lendingagency for the pc'mor Bream' Dam Receipap
Pthe work for which this permit is issued(Sec.309'/.Civ.C.)
U Lenders Name.
O WLender's Address " 'TOTAL: TOTAL.
�-a p, 1 certify that I have read this application and state that the above information is BUILDING FEE
rA correct.I agree to comply with all city and county ordinances and.mate law,relating to QTY. MECHANICALPHRMIT FEE
building condmption,and hereby authorise representafnesef this city to enter upon the SEISMIC FEE
above-mentioned pmperty for inspeminm purp,ve,.
(We)agree to nave,indemnify unit keep hamde.ss the Cily of Cuprninn against PFiRMIT ISSUANCE ELECTRIC FEE
Iiahilities.judgments.costs and expenses which may in any way accrveogoirm said City ALTER OR ADD TO MECII.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('D)la000CFM)
SOURC iEGUyI LA9'IONS. M17CHANICAL FEE
'fes\4'���e--` e
1 AIR HANDLING UNIT(OVER III,WO CPM)
CONSTRUCTION'I'AX
Signature of Applicant A` hoc lar Dam EXHAUST HOOD GiODUC'q HOUSING MITIGATION FEE
HAZARDOUS MATE ,I S DISCLOSURE
Will the uppfcant or future building eccupam store epic hatWlr hawed,).,material HEATING UNIT(TO 10DAW BTU)
as defined by the Cupeninn Municipal Code,Chapter 9.12,and the Health and Safety 2-0
Code.Section 2553o_(a)'! HEATING UNIT(OVER 100.000 BTU)
El Yes No
VFNTILAI'ION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which / Date Receipt 4
emit hazardous air cnntaminams as scared by Ibc Bay Area Air Quality Mantgnnem f BOILER-COMP(1HPOR IW.(XX)BTU) Q
District BUILER-COMP(OVF:R Rx1.Bf1111tTU) 10 L O
❑Yes
I have mid the hitiorM usual,requhcmere,under Chapter 6.95 of the Cali- AIR CONDITIONS ISSUANCE DATE
Temic Hrilth&Safely Cede.Secdons 25505.25533 anal 25534.1 undentmad that if the NEW RESIDENTIAL MECH. SQ.ET.
WalAmgdnrsa lcurremly hnvextennnl,that it is my rcagmsibilnym nnGfy the occupant
of the reyuirem which must he met p' a of a Canil'atte nl'lkc-pyy
Owner or aulh recd agent Dare 'fOT ISSUED BY: �
OFFICE