S 2370 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL. FERMI'I NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL O
BUILDING PROJECIADENTIF'ICA'TION S L n�j J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMMAL.6A—TE
OW - SNAMEE::� PHONE RA R' AMP.: LIC NO: N/C CONTROLq
i.RC ITECT/IiN,C NEER: LIC NO: A S; �J ❑
/P
CONTACT: - I'IIONfr. BUILDING PERMIT INFO
Gf(��/�O� ❑ Qmeu@ant Fees Paid by Applicant(Initial) BLO Fr PLUMB MBCH
a ❑ ❑
LICENSED CON'nRACnOrpooiseasof ION QTY ELECTRIC PI3RMIT FEE
I hereby firm that I am licensed under prmvisinna of Chapter Y(conunencin
JOB DESCRIPTION
�a'Z wbn section n# r Irl nm amines. Rnfesaioms eode,a my licenses RESIDENTIAL
�- in full force at l PliRNUYISSUANCE
�UV U, tgqqlSSy5kk..• uss ..io# ❑SFDWL Cl KITCHEN REMODEL.
F.aa p , ' APPLIANCES-RESIDENTIAL Ll ADDITION ❑PLUMBING REPIPF,
5th.Dm ARCHITE nyf' PANELS E)MULTI-UNIT El STRUCTURAL
OZ�G IunJersmW my plans.hill he nscd as public rcco UPTO200AMPS Ess)OODIFICATION
F-�,l"J uu]] Lscnsed Pvsfwsmnnl ❑INTERIOR ✓kTCiIIMNEY RI; IR
OWNER-BUILDIFRDECLARA'IION 201-101#IAMPS IMPROVEMENT E]SWIMMING POOLS
1 hereby uflian that I vn esempl('rum the Coal clur'x License Law helmet GVHR 1003 AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
p(311 F+ following reason ISeclinn 7031es
.5,Busins and Professionsde:CoAny tlty or coumy SIGNS ELECTRICAL []OTHER
4411 O which tequitex a Permit to.."n tbalmc improve,demolish,or repair any slrvewre
prior to its issuance,also requires me applicant for such pemtit m file a signed staunen,
rn SPECIAL CIRCUIT/M ISC:
<� that he is licensed puouantmtheprovisionsofthe Commno/s Licenselaw(Chapter9
IyC�C) (commencing with Sectian]OW)af Division 3 ofthe euslneas and Professions Cone)or TEMP.METER OR POLE INST. CQMMERCIAL,
d p m y that he is eacmpt therefrom and the hasis for the alleged excmplien.Any violation of [I NEW BLUGIADDITION El DEMOLITION
LLXl on
y ySection 7031.5 hy nny applicum forxlcrmit sunjens the npplicam toacrvil pemJly of POWER DEVICES ❑TENANT' [_1 FOOD
not more than live hundred dollar,(SNXF.
^�=Q 01,as owner of the property,or my employees with wages as their sole conopensution, SWIMM ING POOL ELECT RIC IMPROVEMENT
a.= will do the work,mal themmcwre ie not i meWN muffercd fn,a e(Sec.714a,(business ❑OTHER
W 3 said Pmfessions Code:The Comramoes License Law does not apply In an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves(hereon,and who does.such work himself or through
his own employees,provided that such improvements are nm intended or oflerad for NEW RESIDENTIAL EI.Fi R SQ Fr..
sale.If,however,the building oa impmvmbeal ir.old wiWinono year mf mnnplctinn,the I'll(AOR AREA $/SQ,Fr.
owner-bullder will have the burden nl'Proving that he did nm blind or improve on pro-
pose of,vied. - t
I,asem r of the property.son exclusively contracting with licensed contractors TOTAL:
ill the project(Sec.]OTA,Business and Professions Code:)the Comruct n's Li-
cenx Law does not apply to an owner of property who build,or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contmmor(s)licensed pursuant to the Conlmnnr's
License Law. PERMIT ISSUANCE,
I am exanpt nndar Set. ,B&PCfor this ma,un
ALG:R-DRAIN&VENT-WATER ROG
Owner Dam VALUA'T'ION
WORKER'S COMPPSSATION DECLARATION BACK FLOW PROTECT.DEVICE
1hereby afBroeunder Faulty ofperjury one ofthe fnsum ierWrker's m:
❑(have and ems!f.imdnaCrn 3700 of the sent toLabor ode,for forerfaros eFit h- DRNNS-FLOOR,ROOF,AREA,COND. S ORIES TYPE CONSTRUCTION
wdoo,vs hick ilia
for mi Section 3]00 of the Labor Calc,for the performance nl the
w for which lhls ptnarim issued. FIX'I'UITES-PER TRAP 'Z,
1 hove and will mnimvin Worker's Cmnpenstint htsurance,ns mquirW by Section
J]lydol�l}f�L ,�C,{a�le,fon�II�p1,,e.fuarnowe of,hI work lnrw 'ch this Iis issued. GAS-EA.SYSTEM-1 INC.q OUTLETS OCC.GROUP APN
Curies! /'"� ePolcy No I2 GAS-F,A.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GR17ASUINDUSTRL WASTE INTERCEPTOR
G Ink senion need not be completed If Oa mmnit is f hundred dnll.re($Ilse BUILDING DIVISION FEES
or
It,,.) GREASE TRAP PLANCHECK FEE
Icenifythatinthe Perforit,martmnce e, elthe Feu.lakHsrwhich jeet1.permialeft'Compact-ued.[,hall SEWER-SANITARY-STORM EA.200 FT,
.or employ nny Bonn i aany manner..n a.to Fecome object m the Worker.'Compact- ENERGY FEE:
O Z Apsalplicant
nt of Celilomia.Dae WATER HEATER W/VFJJT/ELEC R
Z 0 Applicant GRADING FEE
y NOTICE.TO APPLICANT.IL alma making this Circum, t the
Exemption,you should WATER SYSTEM?BEATING SOILS FEE
a hocnme subject IF the Worh To Compensation provisions ala de Lvbor Cade,you mux, 10
W forthwith comply with such provisions ur this permit shall MJenned revakeJ. WAI'lili SERVICE
ELI Q
z CONSTRUCT DON LENDING AGENCY NEW N&SIDENTIAL PLMB. $Q,IT. PAID
V O 1herehyaffirm that there ia.cmmhareion lending agency forthe perfonnunmof tc Receipt#
the wort for which this permit is issued(Sec.309/,civ.C.)
Lender's Name TOTAL:
WLcndaAAddresa TOTAL:
fy 1 ten ify that I have read this nppl kation and nam that the above inf abodin I is HUILDIN 9iE
V) correct.I agree it)comply with all city and county ordinances Find state laws relating to QTY. MECHANICAL PERMIT FEE
building corn udm n,and hereby authnHze representatives of this city to enmr.Mm the SEISM( EF,
above-mentioned property for Impcdion purposes. PERMIT ISSUANCE
(we)agnm m save,indemnify and keep hamdess the City of Cupenim.,in,, CfRIC FI s
liabiliiies,judgmems,costs and expenses which may in any way arcane against said City
'n corse yeti of the gmmin f ALTER OR ADD TO MBCH.
go pcmtit. INGPnil
SO + ' UNDER TAN( A D W ILL COMPLY WI'fli ALi.NON DINT AIR HANDLING UNI'I'TI'O l OJgO CFM)
SOU ' .I:OU NS. �� E 1A C I"'
AIR HANDLING UNIT(OVER 10,PMICFM) O R TAX
-S-P-1.rcof Applicmn/Con �� Dam EXHAUST DOUG(Wq)I1C) HOUS ING MITIGATION FF,E
HAZARDOUS MATERIALS DISCLOSURE
Will the npplicam or home building eveopant nom Fir hour le hazardous material I]RATING UNIT PO 100.000 BTU)
as defined by the CupenizIpa Mu ' I CWe,Chapter 9.12,and the Health and Safety
Code,Scedon 25532(x)] HIIAI'ING UNIT(OVER I1111,00o BTU)L]Via o VENT(LATIONFANS I NGLE RFS Io) --- PAID
W IIthev licant uilJin t um e ,or Devices whish Dam Receipt#
pp goecupany quip Quality
Y & BOILER-COMP DIIP OR 100,000 BTU)
emit hazardous air cnnmran." a definN h the Ba Arca Air ualil Mena ement AL.
District Yes Nn BOILER-COME? 10n,001)BTU)
I have read the ancolousmaterialsrcmmon is under Chamr6.95nfdm Gt0- AIRCONDITIONP,k
9 p ISSUANCE DATE
bumia Healt to I Code.Actions 25505.25533 and 25534. m motif d that if the NEW R[SIUENTIAL MECH. SQ.FT yt`
of
building oat I val.m itis roreepmsihil' mnotif / r
of the c mu- son priors'ssuanc Y.
14-1
O authorie age Dam TOTAL ISSUED BY:
is, OFFICE