S 2597 --APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C C
BUILDING PROJECT IDENTIFICATION J J
BUILDING ADDRESS: SAN] TT
TARY NO. [CAI SUBMITTAL DAE
��
OW 'R'S NA•M PHONE _ CONTR TOR'..NAME: �t LIC NO:
Q C i-IS.C� 'j Pj/;NA j rwA-/rte Q3 Y.?V,5 N/C CON'TROLa
t .• ARCHITECT/ENGINEER: LIC NOr ADDRESS: - ❑
r Cr O
CONTACT: PHONE: _ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ C� ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I ant licenced under provisions of Chapter 9(commencing JOB DESCRIPTION
COo'Z withSecom7NfNDi...in,3ofthe Bremessnnd Pn Esau,.,Cont,andmylicenxe is - RESIDENTIAL:
OO in fall force and rife PERMIT ISSUANCE
WF rt. 'Sr6 .3 ��/ _ ❑SFDWL [I KITCHEN REMODEL
aUpp License ClavLic.N APPLIANCES-RESIOF:M'IAI. []ADDITION �LUMBING RE-PIPE
yti] Dute �L + -t'�Gmlmcmr
1„Oy ARCHITECT'S DECLARAITON El MULTI-UNIT ❑STRUCTURAL
PANELS
Z O ZF I understand my plans shall be used as public records MODIFICATION
OZ O UP T0200nMP5
EI INTERIOR L1 CHIMNEY REPAIR
Q,N.I '"t-i Licensed Proona
fessil 201-1100AMPS IMPROVEMENT E]SWIMMING POOLS
�_..I1 OWNER-BUILDER DECLARATION OVER I(NN)AMPS ElBATH REMODEL/REPAIR ❑DEMOLITION
Q 1 hereby affirm that 1 am exempt from the Contractor's License Law make
314 F following reason,(Section 7031.5,Business and Professions Crall Any city or.onlySIGNS ELECTRICAL
❑OTHER
W!30<
m which requires a permit m structstructureconstruct,alter,improve,demolish,or repair any structure i" +�� prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
pppp ys In.,he is licensed pursuant In the pecomin,of the Cnmmter's License Law(Chapter 9
Apornamenting with Section'!000)of Division 3oftha Business and Professions Cede)nr 'PUMP METER OR POLE INST. COMMERCIAL:
11 c C that he is exempt therefrom and the basis badge alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m Section 7031.5 by any applicant fora permit subjects the applicant too civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Fi.
not more than five hundred della,,($500). 3"1IMPROVEMENT=0 ❑ I,ae owner of the pmpeny,mmy employee,wilM1 wnges.vhencNicontp.naninn, SWIMMING POOL ELECT
will dmhe work,and themmemmis forimended crofa.red auricle......9(W4,Busine.e ❑OILIER -
,Y a and Profession,Cade:The Cminewh dx License Law does nal apply to an owner of out LU I S-SWITCHES!`FIXTURES
properly who builds or improves Homan,and who dues such work himself or through
his own employees,provided that such improvements aro not intended or offered for NEW RESIDENTIAL ELF.CTR Q
sulo.If,however the building morapmveaenl iasold within nmcyemor,orepletim,the SQ.FT.FLOOR AREA WSIA FT.
owner-hinder will have the burden of pmving that he did not build or improve for pur-
,se of snle,7.
I,as ownor of the properly,am exclusively contracting with licensed'emmtms m 'IYY Air
onmrut the project(Sec.7044,Business and Pmfe,sjoes Code)The Contractors Li-
neLawdoesnotappytoanownerofpmperlywhobuildsoiimprovesthereon,and QTY. PLUMBING PERMIT FEE
who rtm rmts torsion projects with a,mor tors)licensed areamtn ,,the Contractor's
Liece,e Lw. PERMIT ISSUANCE > , / v
❑ I am exempt under Sec. ',R&PC Pimm,rea,on
Owner Dam AIA'Ek-IIRAIN&VENT-WATER(EA) VALUATION
.made,WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
have
andwatrirmtain a penalty of o(Coneneofinefnsure forvid,declaWorkmtion,Co -
❑ shove andwill for
Sousse 3calic7M o(Consent self-Code,for
of the
IlRA1N5-FLOOR,ROOP,AREA,GOND. STORIES TYPE CONSTRUCTION
sminn,as hick led for mi Section 3]W of the Labor Cole,for the Performance of the
work forwhichthis airom is sacred. FIXTURES-PER TRAP
❑ 1 have and will maimain Workers ante o thew rkfisr chi as requiredbySection
3900 of the Lehor GNe,fanhe performance of the work for which this grant.le iscu.d. GAS-EA.SYS'1'HM-I INC.40U'1'LETS OCC CROUP APN
My Warkor' p. onlnsurancercanl.r and Policy nu — GAS-P,A.SYSTEM OVER 4(FA)
Caniee 11ff00 n iL�w
if icy Nor:
CERI'I FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PHRS
(Thi....tion need not be computed thepermit is Caere atahundred dollar,Stop)
or loss.) GREASB'I'RAP PLANCHECK FEE
I verity that mina permarn enoflM1e work far which this permit is issued,INall SEWER-SANITARY-STORM EA.200 FT.
not employ coy grown in any mnnnerso m to became.abject to the Workers'Coal ENERGY FEE
Z sminn Laws of Cclifnrnia.Dare WATER HEATERW/VEN'VELECTR
O Applicata Z RADING FEE
H NOTICE TO APPLICANT.If,after making this OcnIDcalc of Exemption,you should
y SWATER SYSTEM/fRENTING 1SOILS FEE a become subject m the Worker's Compensation provisions of the Labor Cede,you must
W forthwith comply with such provisions or pirron,holl be dwmn.drevok.A. WATER SERVICE,
Q
CONSTRUCTION LENDING le AGENCY NEW RESIDENTIAL PLMB. SQ,FT PAID
V Q Ihereby affirmf..which ki nwh isued(Scedonlending agency for the performance of Date ceipt#
the work for which thi,Irnnit Ix issued(Sw.3099.Civ,CJ
O ULenders Name TOTAL:
Lenders ly t TOTAL
con :
I oenify the I have read this application and state the the above information is BUILDING F' -
.F.t lZ1 correct.1 agree to comply with all city and county ordinances and state laws ofarjng to QTY. MECHANICAL PERMIT FEE
U z building constructed,and hereby authorize representatives of this city to enter upon the SEISMIC FP.F.
above-mentioned propooyforinspection porposcs.
(We)agree Ica save,rude mnif J kee harmless the Cit f Cu t PERMIT ISSUANCE LLECTRI PEE
yes p yo peost again,
liabilities,judgments,eoomoand expenses which any in any way acerve againm said City ALTER OR ADD TO MECH.
in consequence of the graining oft 's permit. IT
F
APPLICANT UNDERSTA AND WILL COMPLY WITH ALL NONPOINTAIR HANDLING UNIT(TO 10,000
SOURCEREGUL/yT MECHANICAL FE
Alft HANDLING UNIT(OVER 10 1 ) NM) CI ION TAX
Signntdr of ApplicaAZARAZAR Dme EXHAUST HOOTS(W/DUCT)
HMITIGATION FEE
IfDOU9MATERIALS DISCLO HOhandl
Will the applicant or future nhandle ure building occupu
store or e hasurdous material HEATING UNIT(TO I00,000 BT 4
us defined by the Culwhino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)'1 �/ HEATING UNIT(OVER 100(00 t
EJ Yes jjamw P _
`t VENTILATION FAN(SINGLE U DJ Dam Receipt
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR IN, ^
District? TAU. V
L]Yes BOILER-COME(OVER I00,000 BTU)
1 have readthe hazardousmienill,requjrentem,under Chapter 6,95 of the Cut- AIR CONDITIONER ISSUANCE DATE
forma Health&Sam e,Section,251503,L5533 and 25534.1 understand that if the NEW RESIDENTIAL MECIL - SQ.FT. Q
building does not retry haven tantss sibility,to notify the accuptmt
of the regp' ants w net wf a Crniftea� c unoy
23 +9
F)c Owner or authorized but Dole s TOTAL: ISSUED BY.
OFFICE