S 2341 AYYLIUANI IU FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 2341
BUILDING PROJECT IDIONI'BTCAflON
BUILDING ADDRESS: - SANITARY NR APPLICATION SUBMITTAL DATE
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OW ❑R:S`N'A,,� R�'Q/i POlgr. ' CO 'At�OR'S�Ah{f:� /G � LIC NIC CONTItOLN
ARCIIRECI'/ENCINEER: N LIC NO: A� �S' SS rr�kNN))/�P nr S,J l/�9s/,�3 ❑
CON'T'ACT: PHONE: // BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ � ❑
LICENSED CONTRACTOR'S DECLARA'00N QTY. ELECTRIC PERMIT - FEE
1 hereby acorn than I amt icensel ander,ackinns of chapter 9(contmensing JOB DESCRIPTION
"ZO with Section 7000)of Dlviam 3 ofthe Business and Professions Code,and my license is PERMIT ISSUANCE. RESIDENTIAL:
tYadF in full force and cffcc.��/ / ❑SFDWL ❑KITCHEN REh10DEL
Vi- Licrnw Class 1O Lic N
rF�a Datc �A.�Z�p Convector APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RGPIPE
iARCHI'I'ECT'S DECLARATION ❑MULTI-UNIT' ❑STRUCTURAL.
P.D7 - PANELS
Z O un z 1 understand my plans shall he used as puhlic records MODIFICATION
p Z.-0 UPTO 2MAMPS El INTERIOR El CHIMNEY REPAIR
EisLW Licensed Professinnd 20141000AMPS IMPROVEMENT EJSWIMMING POOLS
9P OWNER-BUILDER DECLARATION OyIiN IOOBAMIM1 ❑BATHRE 0DEL/REPAIR ❑DEMOLITION
y 0 Q I herehy altiner that I me exempt Prom the Contractor's License Law Port Thu e
x 3 L F following reason.(Section 7031.5,Business and Professions Cole:Any city or county SIGNS ELECTRICAL. ElOTHER
..LL.LLO y which copies,a permit to comaua,alar,improve.demolish,or repair any suneme, /i'�_d
prior to its issuance,also requires the applicant for such permit to file a signed nm
aaem /M SPECIAL CIRCUII' ISC
f y that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter9
�� (contmeming with Section701NBef Division Sof the Businexs and Profesxln e,Code)or TEMP METER OR POLE INS)'. COMMERCIAL:
6 a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ifnN Section 7031.5 by any applicant for a permit subject%the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
YF Y am mare than Eve hundred d.11...($50H. IMPROVEMENT
zQ ❑ I,us owner of lM1e proprrty.nr my employees with wuga%m their sole coinpcnsation, SWIMMING POOL ELECTRIC
will do the wok,and the slrueme,is not intended or offered forsale(Sec.1494,Business ❑OFFER
W m and Pmfessions Code:The Contractors License Law docs not apply to an owner of OUTLETS-SWITCHES-FIX'T'URES
tl3— property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such inqui cut are not intended er offered for NEW RESIDEN'1'IAI.ELECT.R SQ FT.
sale ll:however,t he building orimprovement is sold within one yemofeo upleian,the SQ.Pr FLOOR AREA $/SQ.14.
owner-builder will have the hurlen of proving that he did not build or improve far pur-
pose ideal'.),
❑ h m owner of the property,am exclusively romracting with licensed contractors to TOTAL:
creamer the project(See.70,14,Business and Profession,Code.,The Cen.raetor.Li-
same Law due,man,ply to anawnuofpommy who huilAs mimprovu thurcr: ,and QTY. PLUMBING PERMIT FEE
who contracts far such projects with a commisma(s)licensed pursuant to the Condowarrs
License Law. PERMIT ISSUANCE: e r
❑ 1 am exempt under Seo. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of perjury one of the following declarations:
Ihavcandwill maimcmm CvmficateofConmm tosN6insum for Worker,Compem- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
on,as provided liar by Section 37M of the Labor m
r Code,far the performance of the .
work for which thl%permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insumncc,as required by Section
J9WafthgeyLittle,
Ctdde,bathe perfommrecof the week far which,hix pemtit is is issued. GAS-EA.SYSTEM-I INC.4 OUTLUS OCC.GROUP APN
CarrWrrk4Jd/M/ObIInOHncel'nl cY Nn.�n t .p—.L.L GA. - .SYSTE .R 41EA)
CIiRI'IPIr-_--CA E OVEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRI NO 1. 1 WA E INTERCEPTO
BUILDING DIVISION ITIS
(This rection need not ed eompleted ifthe permit is fonmc hundred Dollars(SIM)
or less.) OR R PIANCHECK PFG
I certify that in the pednrnanee or work for which this permit is i.%sund.Ishall SE -SANITARY-STORM IiA.210 FI'.
rte employ any person in any muter.-as m become-hijcat a:the Workerr'Campea- ANERGY FEE
Z ,Z anion Laws of Califar ia.Date WAT HEATER WNENT/ELECTR
Q Applicant -1 Z GRADING FEII Ali
hs y NOTICE TO APPLICANT.If,attar making Ibis Cenificma of Exemption,you should WAT R SOILS FEE F� become subject m the Worker,Cnmpensutian provisions nTtM Lobar Code,you ntmt
UJ 0 timhwith comply with such pmvi.sions or this permit sEall he deennd revoked. WATI7R SERVICE
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,U. PAID
U 0 l hereby affirm that lhereis a construction lending agency for the performance of Dole ReceiptM
— the work her which this permit is issued(Sec.9097.Cie C.)Ii' -
U Lenders Name - ^ TOTAL:
U Lermi'v Address Tf V
1 certify that 1 have read thi,application and seam thea the above inferemarm is BUILDING I
N corer.)agree to comply with all city and county on in...vi and state lows malting to QTY. MECHANICAL.PERMIT FEE
SEISMIC FEE
U Z
building caluawdiamand hereby nuttioriurpsorarepresentatives of this dtYmcnter neon the
r. ahwe-(We) oproperty far imnify apmprmes. PERMITISSUANCIi _
(We)agree to cove,indemnify and keep harmless the City ime apenst s against ELECTRIC
liabilities,judgments.costs ormind expcnus which may in anyway nccrve against said City ALTER OR ADD TO MECH.
in consequence of the gaming of this permit PLUMBING ':E Z 2 d
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNI'T('1010.INN)CF1,) MECHANI AL 'EE
SOURCE RE/pULATIONS. �
�� ONS. It AIR HANDLING UNIT(OVER Ia.01p CFM) CONSTRUCTIO AX
Signature of Applime ConteI�DweV 7 EXHAUST HOOD(W/DUC) HOUSING MITIGATION pE13
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hamrdaus material HEATING UNIT(To I On"BTU)
as fin
deed by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Gds,Section 25512(x)1 HEATING UNIT HWER I OtMO)BTU)
EI Yes PAID
NEW EL LATION PAN(SINGLE RISI D) Date Receipt#
Will the applicant or future building occupant use equipment or devices which
krait hasnrdous air contaminants as defined BOILER-COMPIMP OR 100.000 BTU)
by the Bay Area Air Qualify Management 2 O
District?
El Y,,, Foci BOILER-COMP(OVER I BOOM BTU)
I have read the hazarchaw materials requimmena under CTaper 6,95 of Cali AIR CONDITIONER ISSUANCE DATE
s fnmia Heahh&Safcty Cafc,Scctinm 25585.25511 end 255,1,1.1 undemanJ that if Ne NEW RESIDENTIAL MECH. SQ.FI'.
building does not cameady have a tenant.that it is my responsibility to notify lheaccupxm /O / L
.fthc/rc�y_Ircrt`yntr which�ma�j j�j�,tUionu isxuanco ol'a Cemicaa ofOccupancy.
Owner nr authodrsJ agent T Date TOTAL: ISSUED BY: 1
OFFICE