S 2200 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO [%Oil DING-F.LBCI'RICAL PERp11T NO. ^
Ru1LDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL l`7 LG
BUILDING PROIF:C'I'till NTl..LAI ION
BUILDING ADDRIisS: SANITARY NO. APPLICATION SUHMITIAL UATE
5 C'.v�n� 331—ReoC, �
OWN AME: p. PII(INE: CU TRACTOR'S NAMIi: LIC N6
01 &j / r FjeN� l5 — �G 7076 NIC
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D .RGL«
gRCIIITECf/F.NGINF:ER: LIC NO: / DsI L - O 7�/ ❑
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CONTACT: �g PHONE: F,-
(' G ) BUILDING PERMIT INFO
rJ!"g /% ,e15n� '. 6o_s & ❑ Consultant Fees Paid by Applicant(Initial) BLDG EIF.CI' PLUMB MECH
iKk/
LICENSED CONTRACI'OR'.9 DECLARATION QTY ELECTRIC PERMIT FEE
1 bcrahy arum that I am licensed ander pmvisian,of Chapter ,a(cmmmemirg JOB DESCRIPTION
QgeZ .hSxc6mr7")ofDiviom.3 mftM Bii,ro,sand Pmfs,imv,Cmd,mx1 myliceme is RESIDENTIAL
FWD na full free and IT PERMIT ISSUANCE
U 707`u V ❑SFDWI. ❑KITCHEN
�U icenseC Com ''LT' Gar APPLIANCF_s-RfiSIDENT1Al. ❑ADDITION ❑PhUMBING RE-PIPE
�'Z urn Cnnoumor-(�J/ysgyy-
Q ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
F 7 m PANEI,S MODIFICATION
Z O do Z 1 understand my plans shall be used as public records
OZ'41E UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F. Yl Licensed l'mfessinnul 201-10MAMPS IMPROVE MENT E]SWIMMING FOOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS El BATH RIiMODEVREPAIR ❑DEMQLH'ION
CL Q 1 hereby rinsed that I an,[scant Toon the Commnor's License how for the
�xL 6 U 'M following reason(Section 7011.5.Busme,s and Pmfcasiovs Coda:Any city of wamy SIGNS ELECTRICAL 0TH R ^
W LL e.ti M
which requires v Permit to constructstructure �•� ,
construct,alter,improve,demolish,of repair any structure ,W
6� pro onoto,issmncc,vlsoreyuirestheapplicam lormon,armifto fileasignedamtement SFECIAL CIRCUIT'/MISC. W�✓
n, .but he is licensed pursuant to tlmproviaionsol'the Ciann s Liceme Luw(Chapter 9
z (mmmenci..gwith Seatl.n)1NN0 nfDivisirn 3.f the Rusinery and Pmfev�inns Crde)mr TEMP.METER OR POLE.INS'f.
6 d a C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
a- Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
r rn ml more than live hundred,.Ilacs SNXF.
^ Q Lasownerocli. n IMPROVEMENT
tropey,mntycmplended combated
for sale
cumpaosiness SWIMMING POfII.ELECTRIC
$W will Probe wonsCde: atmcmrcistors License Law
rot aWly to an Business ❑OTHER
W 3 m and Probes ions Code:The Contractors License Ivw Jaws moo apply iv if owner of OUTLETS-SWITCHES-FIXTURES
pmpcny who builds tar improves thereon,and who Pres such ante himself or through
his own however,
the provided ,in such improvements me nm intend[,nr offered for NEW RESIDF.NI'IAL ELECTH SQ f4.
salts lL however,the M1uilding nr intprrvemenl la nolJ within ono yearmfannpinian,the SQ.Irl'.FLOOR AREA $ISQ.IT
owner milder will have the human of proving that he did not build or improve for pur-
poso of sale.,
[If Las owner i the property,am exclusively contracting with licensed conorvemts in
amidom t the pr jeo(Sea 9844,lum,mess and Professions Cale:)The Contractors Li-
ccnscLawdxxnmupplymetownerrfpmpcnywhohullJxnrimpnrvcs thcram,ane QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contmemgs)licensed purviond 10 the Contractor's
License lass.. PERMIT ISSUANCE.
❑ I am exempt under Sec. ,B&P C for this reason
ALI'17R-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby allin t under penalty of perjury one of the following acclamtions:
❑ I have and will maintain a Ccnifiree of Consenurself-insure for Worker's Canter- DRAINS-FLOOR,RODE AREA,COND. STORIES TYPE CONSTRUCTION
union,os provldel for by Section 3900 of the Labor Cade,for the perkmource of the
work for which this Permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Co eptate .r.Insurance as required by Section
3900.1'the Labor Cook,.soli[perfonnaneeofthe work far which this permit is issued. GAS-EA.SYSTEM-I INC.i OUTLETS OCC.GROUP APN
My Warks' nr nd Policy nm er are:
Curier:�.—.CH13�Policy No.: GAS-HA.SYSTEM-OVER Y(EA)
CERTIFICA9 E 017 EXEMPTION FROM 1 RS' GRFASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
.('this section reactant berompleted ifthepermtivf....sa undteddidons($100) GREASETRAP
or loss) PLANCHECK FEE
I,amr,thou in the perhnnurceol the work for which Ilia perm➢I,lavaa,I shall SEWER-SANITARY-S'FORM EA.200 FI'.
not nnploy any some in any manner mus,,became mbject ro the Workers'Cm,wn- ENERGY THE
OZ satin.Laws mf Califnmiw Date WATER HEATER W/VENPELF.CTR GRADING FEE
Q Applicant
NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should WATER SYSI HNIO'RF,ATING SOILS EEL'
.4 ^N' .warmed subject to the Worker's Cmm cricainn provisions of the Lamor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
aQ
DZ CONSTRUCTION LENDING AGIiNCY NEW RESIDENTIAL PLMH. .U. R ci .«
1 herehy atlino that there is u construction lending agency for the performance n1 p
U Q the work for which this permit is issued(See 1099,Co.C)
L4 Lander.,Name TOTAL:
0 U Lenders Address A
1 realty than I have rand this ap,liamio.and s,.a that the.......forma.....is EP
IN 1'
b+. A entree,l vgve,to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL.PERM. FET.
UZ building consbanion,and hereby outhorivn representatives of this city to enter upon the n C f
n1pose mi.nul property for inspection purposes. PERM IT ISSUANCE [J ELECfR O
(We)agree t.save,indemnify and keep lunates,the City of Cation..against
liabilitie,jodgmenq costs node ,which may in any wxy accede against said City ALTER OR ADD TO MECH. ING E
incox
mega' mf DFRS toy a tylJpernit.
APPLICA " rDF.RS D WILL COMPLY WITH ALL N 1N-POINT AIH HANDLING UNIT LTO I(I,INNI CPM) MECHANICAL FE
SOURC EGI ,A'T
X �7 AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
.tore of Appl'amin Comntenr
Date EXHAUST HOOD IW/DUCI'1 HOUSING MITIGATION FILE
HAZARDOUS MATHRIAIS DISCLOSURE
Will.he ePpliamom,future building mccupantalorcor handle Wooden,material HEATING UNIT LTO 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 2fi532m)9 HEATING UNIT(OVER 10TO XI BTU)
❑Yea [:j No VI?NTILATION FAN(SINGLE RP-SID) PAID
Uate Receipt N
Will the applicant or future building..,.t use equipment or devices which
emit hasardous air contaminants as defined by the Bay Area Air Quality Management 9(IILER-COME DHP OR 1(X1.0011 BTU) TOTAL'
Distiictp HOILER-COMP(OVER 10,000 BTU)
El Yes ON.
I have mad the haemlass materialsis under Chapter 695 of the Cali AIR CONDITIONER ISSUANCE DATE
[quire
fomio Heohh a,Safety Code Sections 255(15,25533 and 255.31.1 to notify
that if the NIiW RESIDENTIAL MECH. SQ.P.
bniWno chemens which
have be.1,that,,is issuance
c eof.Cality m entity tbc.ccupnnt
of the requirement.which mustM:mea prions issuance oft Certificate nflkcupancy.
Owner or authorised agent Date TOTAL ISSUED BY:
OFFICE