S 2523 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. S 2523
BUILDING PROJECT II/ENTIFICIOIKEN
BUILDING ADORES S: SANITARY NO. APPLICATION SUBMITTAL
DATE
DUJILo �
OWNER'S NAML: PRONG: CO R OR'S ME: _ LIC NU:
NIC CONTROL If
ma
ARCHITEC'UENGINEER: LIC NO: At SS: El
CONTACT; PHONE: I fit, V BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
33- Sh'� ❑ ❑ �] ❑
LICENSED CONTRACT OR DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby afflria that 1 am llecnsed under provisions of Chapter 9(e.mmendng
D0Z with Section 0006)of Division 3 of the Business and Professions Cale,and my license is RESIDENTIAL,
1,100 wt PERMIT ISSUANCE
F n full force unit ea - �SFDWL ❑Kll'CHEN REMODEL
�UU License Clns �$ Coal APPLIANCIiS-RESIDENTIAL ❑ADDITION El PLUMBING RE-P[PE
F 2(y Ual¢ Contract.
w<aULTI-UNIT ❑STRUCTURAL
ARCHITECPS DEC,DECIA A ION
f-HZ lundcrsanJ my plans shall be use)as public remrdx PANELS MODIFICATION
OZ^� UP TO 200 AMPS C1 INTERIOR ❑CHIMNEY REPAIR
Q��u1 Licensed Prnteseionnl 201.1(HXIAMPS IMPROVEMENT SWIMMING POOLS
.j� OWNER-BUILDER DECLARATION OVER]"AMPS El HATH REMODEIBEPAIR El DEMOLITION
a 1X 1 hereby.Mfn than 1 on exempt from the C.mmcam's License Law fintM1e
ip5,O y U following reason.(Section 9031.5,Business and Professions Cale:Any city or county SIGNS ELECIRICAL ❑0"Tf ER I I-
ly 3 k.y which miluires a permit m strue,conalter,improve,demolish,or repair any structure —
F LL'Oa poor no its issuance,also requites the applicant for such gentian file a signedstatement SPECIAL CIRCUIT/M ISC.
} that he is licensed pursuantto the provisions of the Contractors License Law(Chapter 9 COMMERCIAL,
<Ey (commencing with Section-0ad of Division9of the lloxineseand Profession,Gail '1'11 MP.MCT IR OR P01.Ii 1NST.
iL LL than he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
w Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
n mere than five hundred dollars($51X1). IMPROVEMENT
=� MLuowner.f(be propenbmmy employees with wages as their sole annameanion, SWIMMING POOL ELECTRIC
will do the work.and the structure is not intended or offered torsade(Sec.)0D,Basin... ❑OTHER
3.. and Professions Code:The Contractorm s License Law does nappy to an owner of OUTLETS m
Property who huilds or improves thereon,and who does such work himselffm nhmogh
his own employees,provided that such improvements arc not intended.r.ffcred for NEW RESIDENTIAL ELECTR SQ tr.
sale.ILhowevec the l+uilJing or improvement is sold within one year of compleni....the SQ.FT.FLOOR AREA $ISO.FT
ter-lwildur will have the burden of pmving that he did not build or improve for pur,
,se.I smeJ.
C]1,ox towner of the property,on exclusively contracting with licensed contractors to TOTAL:
.mantet the project(Sec.7044,Rosiness and Professions Code:)The Cnnlowla's Li-
se Law does not apply to an owner of progeny who builds or improves thereon,and QTY YLUMBING PERMIT FEE
wit.cornet,f.....h pr.jeeta with a coommon(s)licensed parsuanIr.the Contractor,
License Law. I'1 IT SDANCE
❑1 am exempt cork,Sec. .B&P C for this reason
AI. &VEST-WATER(EA) / VALUATION
Owner Uvm 01
�3 WORKER'S COMPENSATION DECLARATION HACK PLO PR '1+ .1 VICIi
I hereby group under penalty of perjury one of the following ing de rear's o
IM1ave and will maimaina Cenifcam nfConsenuo sof-insure for Worker's C.mfem DRAINS- RO OAU. $T(1R1E5 TYPE CON$'TRUCI'ION
militia,ns.....ded far by Section 3700ot'the Luber Code,for the perfornancu of the
work for which this permil is issued. FIXTURE -P P
1 have and will maintain Workers Compensation Insurance,as required by Section
37M ofthe Labor Code,forthe performance ofthe work for which this prmil is issued. GAS-EA.SYSTEM IN Ers OCC.GROUP APN
My Worker' pens ',a to tate.ono.or and Policy nuam,1�/ /�+,) R
Carrier:�IL_Policy No.:VY-13�S*.°r el GAS-EA.SYSTEM.OVE7i 4(I:A)
CERT ICATE OF EXEMPTION FROM WORKERS' GREAsr/INDUSTRL WASTE IN'I'ERCEI"1
COMPENSATION INSURANCE t ILDING DIVISION_FEES
Trhis swti.nneed nm he complecd i f the permit is for one handful dollars($1 W) GREASE'IRAP orlwsl PLANCHEC I+
Icertifynhat in the perfommnceofthe work for which thispcmtin isi.vsond.ishall SEWER-SANITARY-STORM EA.200 F.
El" FE
nm employ any Person in day manners a co to subject the Workers'Comped.
,`� ehfion tare'' Clili+mia.D tYt 1 Y 19Y WATER fIIiKI'ER W/VIiNT/fiLIiCTR
z atimApplium �t�JIl N'L GRADING F '
NOTICE TO AP .1(CANT:IL nRer tnTking this Certificate of T:xempti.n,you should WATER SYSTIiA1/fREATING
twenew subject to the Workers Compensation provisions of the Labor Calc,you most V SOILS FEE
forthwith comply whit such Pnwivion,in the,permit xmll he deemed revoked WATER S17RVICE J
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID V M l hereby affirm that there is a construction lending agency for the performance of Dae Receipt If
LI. the work forwfielt this ,.it is i...of(Sec.3097.Civ.CJ
U901AL.
Lenders Name
Lenders Address TOTAL: •'-
1 certify that I have read this application endemic that he above information is BUILDING PT:E
FrIIA correct.)agree to comply with all city and county ordinances unit state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE Z Wildingeonstrueion,and hereby amhoriecreprettntalives ofthis city roemerupon the
abovo-memioned property for inspection purposes. PERMIT ISSUANCE
ELECTRIC FEE(We)agree it)save,indemnify and keep harmless the City of Cupertino against
habilinies,judgmenls.cons and expenses which may in any way axon,against said City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of the groming.f this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY W1'ril ALL NON-POINT AIR HANDLING UNIT(TO LBO(XI CFSD MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNI'T(OVER L(fid CFM) CONSTRUCT ION TAX
&gra of ppl¢anUC.mradne 1�� < / EXHAUST HOOD(W/DUCr) HOUSING MITIGATION FEE
HAZARDOUS MKIERIALS DISCLOSURE
Will theapplicant or future buildingoocupunlemre orhandle hazmdnus..(oriel HEATING UNIT(TO Ild,find Erl l)
as defined by to Cupertino Municipal Code,Chapter 9.12,and the Heahh and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
E]Yet P1No VENTILATION PAN SINGLE RESID) Date Receipt N
PAID
Will the applicant furore building occupant use equipment or devices which BOILER-COMP AHP OR 100,000 BTU)
emir bnzmJoue airir c.nmmiamns ns defined by the Bay Area Air Quality ManagementTOTA:
District! BOILER-COMP(OVER 100,000 RTU)
❑Yes ❑N.
Ihanemal the bactoomeem,requirent
mes cover Chapter fi.95of the Cali AIR CONDITIONER ISSOAN
as mDATE•(
forma Health&Safety CMe,Sections 25505,25533 and 25534.I undersand that if the NEW RESIDENTIAL.MECH. SQ.14. in Y
Wilding does non currently have a anent,Nat it is my responsibility to notify the occupant G
o the requimmenu wh'h must el pounn issuance ofd Cenitice m
of apay.
u rued.gem m TOTAL: ISSUED BY'
�to
OFFICE