S 2366 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2366
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
o Cho b -"
OWNpE(sa'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
NIC CONfR(]LN
/Y i• ARCHITECUENGINEER: LTC NO: ADI RE. 1:1
CONTACTJ:rj fy �Na/n PHONE: BUILDING PERMIT INFO
�7�'yy�� ❑ Consultant Fees Paid by Applicant(Initial) BLDGlilrli�{p�� PLUMY MECH
❑
LICE SED C(INTRAC'I'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
C s Z I newt amrm(hat I am licensed order provisions of chapter 9(con nme^cng JOB DESCRIPTION
W with Section 70W)of Division J ofthe Business and Professions Cady and my license is RESIDENTIAL:
��
F �un
faro,a^ f+ PERMIT ISSUANCE
❑SFDWI. ❑KITCHEN REMODEL
i5U Locate Lic.p APPLIANCES-RESIDE ❑ADDITION [I PLUMBING RE PIPE
lit nate commnm
ARCl11TELTS DECLARATION ❑MULTI-UNIT ❑STRULTURAI.
Z O on z I understand Iny plans shall he used us public recaNs
PANELS MODIFICATION
O Z.- UI'TO 2011 AMPS
H fWj Licensed Pnsfess anal - - ❑INTERIOR [I CHIMNEY REPAIR
-4x76 OWNER-BUILDER DECLARATION 2p11(NXIAMPS IMPROVEMENT SWIMMING POOLS
I herehy affirm that 1 am csempt from the Comramnr's License Law for the OVER 1000AMPS ❑BATH REMODFUREPAIR ❑DEMOLITION
tiy5 06 U fallowing reason.(Section 7031 5,Business and Professions Cade:Any city or county SIGNS ELIiCfRICAI. El OTHER
w+31r�an which requires a permit to construct,cher,improve,demolish,or repair any sanctumF017111-1AC-It
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
It.,he is llcuR,d,.00nn ,,the pmvlsinnx of The Convenor's License Law(Chapte9
W 0G0�
(commencing with Section 7000)of Division 3 ofthe Huntress and Professions Code)or TEMP.METER OR POLE INST. I
d a e C
that he is estnua mlopefrom and eche basis far the alleged esempmies.Any violation of N LDG/ADDITION ❑DEMOLITION
�ySection]031.5 by any applicnm hnapennim subjem.v the opplicam macivil penalty of POWER DEVICES
Rot mare than live hundred dollar,($500). ANT ❑POOR SERVICE
=Q I,azawner ofthc ro norm Io res with we es us their eels n+m tion, SWIMMING POOL ELECTRIC IMP GYEMENB'
f D ❑ t pecture YemP Y g ,'cess ❑OTHER
f�F d Prone work,and :The Con is cbsea Lisemetended La.k.,ed a,,,apply to J,Business
DI and ennreshe build,Calc:The Cantmemar License Luo s sac con rk In to un r Ro rel' OUTLG I'S-SWITCfIES-FIXTURES
his.y whooy , or improves thereon,and who does such work himself or through
his own however
the provided trim such improvements are nom intended or plered for NEW RESIDENTIAI.FLECfR SQ Ff.
sale.If.M1nwever.the building or improvement is sold within one year of completion,eche SQ.FT.Fl.00R ARU SISQ.fT.
ins ter-hander will have the harden of proving that he did not Thai ld or improve la puts
,se of sale.).
EI I,as owner of the prufai a exclusively contracting with licensed contractors to TOTAL0
onstmcm the project(Sec 7044,Hminesn and Profcssinns Cale:)The Comm.....I.i-
mcLawJocsnoTupplymonownendpropenywm+hullds or ntpmves ffincor.one QTY. PLUMBING PERMIT FEE
who conwcu for such projects with a cammanr(s)licenved pursuart to the Contractor's
License Law. I'IiRMIT ISSUANCE O
lam csempt order Sec. ,H&P C for this reason
Owner Date ALTER-GRAIN&VENT-WATER(EA) VALUXI'ION
WORKER'S COMPENSATION DECLARA'ION BACK ROW PROTECT.DEVICE
I hereby vire^under pennhy of perjury one n1The rolleoso,dcelumtions: p►
F7 have and will maintain a Certificate of Consent in sclLre lin insuWorker's Compere- DRAINS-FLOOR,ROOF,ANI: OND. V STORIES TYPE CONSTRUCTION
smion,as provided for by Senior 37Bp of the Labor Code,for eche......mace of the
work for which this Pewit is issued. FIXTURES-PER TRAP
have ad or Code,
for
WnAc2s once ncialionofthew work for
which
his per by Second.
700 of the Labor Cmale,for mhdperformance rel the work for which this permit is issued. GAS-EA,SYSTEM-1 INCA OUTLEI:S OCC.GROUP APN
My)V .Coat cnmuon dna ca d Policy number are:
Cater: ^ace mer?hcyNGAS-F.A.SYST17M OVER 4(EA)
CER'I'IFI ATE 017 EIEMI'I(ON I+ICOM WG KERS'
COMPENSATION INSURANCE GREASUINDUSTRI,WASTE+K,
l9'OR
BUILDING DIVISION PEES
Mi, veliminced not fecomplael ODOR,psi int is nature hundredJnllan D Ifin GREASIiTRAP
or less.) PL N ECK FEE
I certify that in the Perfor^mace of the work lin which this permit is issued,l shall SEWER-SANITARY-STORM HIE .
not employ any person iR any manner so as s become subject m s'the Werke Compe^- fflEN R FEE
,Z sation Law.v of California.Dame WATER HEATER WNENT/ELE
Ch
Applicant GRWrt,FEE
N NOTICC'TO APPLICAN I:IL after making this Cctiliwm rel'Escmptine.you shouldWgTER SYSTEM/1'RIiATING
a ; become subject mo the Works',Co RK..alion provisions of the Lahr GNe,you must SOILS F E
(11 forthwith comply with such provisions or this permit shall be,created revoked. WATER SERVICE Y
�L Q
CONS
tthemRUCTION LENDING AGENCY NEW RIiSIDENTIAI.P[-MB. SQ.IT. PAID
U O Iforhereby which
that them issued( ec.ion lending agency for the perf+rtrantt of Dam Re ipmN
the work for which this permit is issued(Sea.9097,Civ.CJ
>' Lenders Name TOTAL:
U
0 U lendefx Address TOTAL�" 0. 1 ratify thin 1 have mad this application and same that the above information is BUILDING FEF, IN
IF-t h
correct.Iagree to complywithall city and county oninance.s and state laws misting to QTY. MECHANICAL PERMIT FEE
U `Z. building construction,and hereby toporim repre,,unnics of this city III th
enter upon e SEISMIC FEE
strove-unnumned pro,ty for inspection First PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamtles.the City of Cupertino against ELECTRIC
liabilities.judgment.,....¢andcspcmes which may In any waya' et,lim.wiA Ciry ALTER OR ADD
'IU MECH. PLUMBI CPEE
inconsequence ofine gratin I h'lummt.
APPLICANT I
s NT Nrio WILL COMPLY H,LL NON-POINT AIR HANDLING UNITG'O I0L000CFM1
APPLI Ii NT IS MECHANI .F:
AIRHANGI.IN .UNITUVER I0,0000IM) CONSTRUCT 'TAX
Si more of ApplicanUmr Uaa er EXHAUST HOOD(W/DUCT) HOUSING MITIG IGNITE
HA DOUS MATERIA DISCLOSURE
WitfitenEdic. IumrcboilJing«nupunt stns or handle hannNnus mamrinl' r/ HEATING UNIT(TO 100j)(MBTU) 2-
as
wa JehneJ by mM1e C ni^o Municipal Cale,Chapter 9.12,and the Health and Sonny
Code,Seeyes 25 2(a), HGTING UNIT(OVER 10i RTU)
❑Yw �No PAID
VENTILKI ION FAN(SINGLE RESID)
/ Date RmelpmM
Will the applicant or furore building use equipment or devices which
emit huzvNous air contaminants as
the B us defined by eche Bay Area Air Quality Management BOILER-COM!'p11P OR 10T(OT)BTU) TOT
Dllm"? BOILER-COMP(OVER 100,00)BTL
❑Yes zNo
R
AIR CONDITIONER
I have rend the hazardous materials requirements under Chapter 6.95 the Cali- ISSUANCE DATE
fume,11.11h&Safety Code,Se tions 255(15,25573 and 25594.I unJ' 'u A ham it I[,, NEW RESIDENTIAL MECH. SQ.FE
wilding does not cu mdy huv ti ym.po "limy moo f occupant
f c"mocmenz ich roue toe pd is aneeo aC etre e f spa y.
We nr uuthorizeJ agent Dute TOTAL: ISSUED BY:
OFFICE