S 2653 --APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT,PEN-ONLY ONLY ,.,
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. S 2653
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL,DATE
D a/ ea �� e erhaa C,111 1ro1 � y- Z -g 9
RSNAME PHONE: C 'I�LTp SN h(al / _ / �IC NO: / N/C CONTROLK
-0 IP4
ARCHITEC-FIFOINEER. LIC NO: ADDRESS N O.1pWu LUSO /W/.LWi,�I ❑
CONTACT PHONE: BUILDING PERMIT INFO
1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
lN\ LIICCENN/8-EDD CONTRACTOR'S DECLARATION ❑ ❑ ❑
I herehy affirm the,I am licensed ander p..e,,ners of Chapter 9(eomnienein QTY ELECTRIC PERMIT FEE,
p s JOB DESCRIPTION
�Cz mSamion]WO)dDtvTsionq3oftheBusinesxand Pmf,sinrt GNe,andmy licenseis
��O wh PERMIT ISSUANCE RESIDENTIAL:
CWF in Poll form and 40 ❑SFDWL ❑KITCHEN REMODEL
.t U Lironse Li APPLIANCES-RESIDENTIAL ❑AUDITION El PLUMBING RE-PIPE
yC L Dam Convacarz
ARCHITECT'S DECLA ATION ❑MULTI-UNIT (]STRUCTURAL
PANELS
Z O to� coders and my plans shall be used us public records MODIFICATION
O IZ�Q Oil TO 200 AMPS ❑INTERIOR L1 CHIMNEY REPAIR
F.�l..F".W Licensed professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
X .'.'•44�
OWNER-BUILDERraptfrom
DECLARATION OVER IOW AMPS ❑BATH REMODEL EPAIR DEMOLITION
W W 6 I hereby efOrnh that I exempt from the RAI I to['6 License Law for rho
'3 E following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL QTHER TEQ
F^o which requires a permit to construct,alter,improve,demolish or repair any mrecmre
primmitslssuvnce,dlsnrequirem!
sthe...heasuch permit ,to fileaanedaunemom SPECIAL Cl RCUIT/MISC.
�} that he is licensed pursuant to the provisions of the Grmraemrs License Law(Chapter 9
(commmtcing with Section"IOW)of Division 3 of the Business and Pmccuuns Code)or TEST..MET I'R OR MIT..INST. COMMERCIAL;
d q o q that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
Y� u' Section 9031.5 by anyvpplicunt For a permit subjects the applicantm a civil penuhyof POWER UP,vIC05
y TF ANT ❑FOOD SERVICE
not more than five hmtdred dollars($50p, MOVEMENT
�qol,asowneroftheprogeny,ormyemployeeswithwagesastheirsolecompensation, SWIMMING POOL ELECTRIC
pyo will do the work end mcebucwre is notimended oroRaredf sole(Sec,9044,Batemess HER
ul`� and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWI'ICHE,S-FIXTURES
property who builds or improves thereon,and who does such work himself or through ,
his own employees,lameided that such infamernand are not imendeor offered for NEW RESIDENTIAL ELECTS SQ ET.
sale.ILhowever,The building or improvement is sold within onsyeniAtconLie
lron,the SQ.FT FLOOR AREA S/SQ,FT.
cooter-builder will have the burden of proving that he did nen build or.imprme for pur-
prew.fsvlcJ.
❑1,as owner of the property,am exclusively contracting with licensed eommctors to 9'OTAL:
our srtuct the pmjwt(Sec.9044,Boniness and Prof,sionc Cale)The Commetors cruse Law does not apply it)ad owner of property who builds or improves therear,Emil QTY. PLUMBINOPERMIT FEE
who contacts ter such projects with a commemr(s)licensed pursuant o the commences
License Law. PERMIT ISSUANCE
E] I antexempt under Sec ,B&P C far this reason
Owner pate ALTER-DRAIN&VENT-WATER EDO VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE LYI�/1
Ibe[cby affirm ander penalty oftwrjury one of the following declumtionp ✓ J U/
I have and will maintain a Certificate of Consenuo self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'LNPF CONS'BUCTION
union,as provided for by Section 3700 of the Labor Code,for the psur nehanee of the
walk for which this permit is Issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Inwmnce,as required by Section
37M of the Labor Code,for performance of the work for which this permit is issued GAS-EA.SYSTEM-I INCA OUTLETS OCGGROUP APN
My Work omplasm,o sarance ca d Policy nm b• a
Cu[Hee Policy Na.: GAB-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(This section need not he completed If the permit is forme hundred dollars($I0p BUILDING DIVISION FEES
or lax) GREASE TRAP
PLANCHECK FEF.
leenify that the pa,rommonf,1.becthe work foe which this permitisco'Conpon-ssued,I shall SEWER-SANITARY-STORM PA. FT.
not employ any Demon in any mannwmvstohwmma smbjacuo me Wnders'Compen- ENERGY FEE
Zsation Laws of Califomis,Date y�
0 O Applicant WATER[]HATER WNENT/ELECTR !J GRADING FEE
y NOTICE TO APPLICANT,If,afro[making this Ceniucem of Exemption,you should WATER SYSTEMG`REATING
become subject to the Worker's Compensation provisions of the Labor Cade,you nmst SOILS FHL
nothwuhcomply with such previsionsorthis permitshall be deemed[evoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELSE. SQ,ET. PAID
U0 I hereby affirm mailmen,isar...drum lending agency for they commerce of Dam Receipt#
4G .-T the work for which this permit is issudd(Sec 3099,Cie.C)
o U Lenders Name TOTAL:
U Lenders Address TOTAL:
1 certify that I have read this application and state that the above information is BUILDING FEE
ra h correct.I agree to comply with all city and county ordinances and Stam laws miming to QTY. MECHANIC
L) z huilJing umswctinn,unJ hereby amhorize rcpresenmtives of this city renter upon the Y ISMIC FEE
ahnve-mentioned property for inspection mrp-es, e_.
(We)agree nc euve' door F`and keep harmless the City of Cartoon.againn PERMIT IAUNIT
ECTRIC FEE
liabilities,judgments, andexpenws which may in any way accrue against said City ALTER RAUJov'equence of Ih permh P UMBING FEE
APPLICANTU a $AND 1 LY HH ALL NON-POINT AIR HANI0d0r0CFM) ECHANICAL FEE
$OUST A NS.
J AIR HANDLING UNIT( IkRIB,INM)CFM) NSI'RUCTION TAX
azure ofAp ,7, . Co tact auto EXHAUST HOOD(W/D '�
HAZA OUS MATERIALS DISCLOSU USING MITIGATION FEE
Will the applicant or future building occupant store or handle hazoodurs material HEATING UNIT(TO 100,000BTU)
ac defined by the Cupertino Municipal Cade,Conrad,912,and the Health and Safety
Code Section 25532(a)'! HEATING UNIT(OVER I00,000 BTU)
E-]yes 7N PAN
p VENTILATION PAN(SINGLE RBSID) Date Receipt#
Will the applicant or Imam buildingoccupantthe B use ea Air Qu or devices which BOILER-COMP(3HP OR 100,0(10 BTU)
not M1azdnlnuv air contaminants as defined by me Boy Area Air Quality Management T
District"
XL
❑Yes No BOILER-COMP(OVER 100,000 BTU)
I have read the brow ous materials requirements under Chapter 6.95 of the Call- AIR CONDITIONER - ISSUANCE DATE
round Heulth&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT. �
building does not currently have ateenmh that it is my responsibility eh army the w pont �_ <7
of the oximeamentc which an theme ono madraof it Comfierpo ey. (((
Owner or auto orizedii,di Date J TOTAL: ISSUED BY:
OFFICE