S 2204 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO [full, -ELEC'YRICAI, Plitt T NO.
BUILDING DIVISION APPLICATION/IaERMIT PLUMIfING-h1ECHANICAL v 2204
BUILDING PR(IJEC'1'II1NN'1'IPIC'AT'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
� (;t,c Pr-fina
U 5 VC N E: F _ _^ 'OM1' CfOµ'S AM-/VWf/ NIC CONIROLp
ARCHITECUENGINF.ER: LIC NO: )91) S / ' I- ❑
CONTACT': PHONE: BUILDING PERMIT INFO
2 / ❑ Consultant Fees Paid by Applicant(Initial) HL❑DG ELECT LUMO MECH
hA CAW- V/qJ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE•
1 hereby All.that I am licensed under provisions of Chapter 9(c.mmemar, OB D'SCRIPTION
QQ ZZ with Scale.70gB of Di un.3 of the Business and Pmfessions Code,aml mylittnu is RESIDENTIAL'
�� PERMIT ISSUANCE
www in fall inhered effect ❑SFUWL [I KITCHEN RIiMOUEI.
<UU Ltccnu as Lic.p APPLIANCES-RESIDIiN'HAL ❑ADDITION ❑PLUMBING RE-PIPE
F Z W Datc Comrador
ARCHITECTS DECLARATION ❑MHLI I-UNIT ❑STRUCTURAL
IN„aj m PANEIS MODIFICATION
0Z vn K 1 understand my plans shell od used as public records
-CI UP TO 210 AMPS El INTERIOR El CHIMNEY REPAIR
t:Ed Liaised IsEficsinnal 201-1000AMPS IMPROVEMENT' E3SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IIXIAMPS BATH RE DU TA QDIi OLITI
GG C G 1 hereby affirm that I am exempt from the Commctor's License Law for the
a U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS IiLECfRICAL �f"ft
W 3 W N which requites a Pamir to comment.atter,improve,demolish,or repair any structure
� pins..it issmea,e.h.requires rheapplicanl for such permit to file o,oped smteman SPECIAL CIRCU IT/MISC.
W�ythat he is littrueJ punuanumM1e pmvision.%of the Contmdnh l.iecnau Law(Chuprer9
ty'0� (commencing with Section 7000 of Divi%ami of Ne Husiuea and Prefexdoo.s Code)(It TLMP.MEFERORPOLEINSIICOMMERCIAL,
(Y oq
that he is exempt domfimm and the basis for the alleged exemption Any vi.lmion of ❑NIiW 01,0E/ADDITION ❑DEMOLITION
W Section 1031 by xnyapplicaat fora pemritsubjects the npplinm PI a civil penalty of MWI7R DEVICES ❑TENANT ❑FOODSERVICE
t mom Nan five hundred chains($500). IMPROVE ENT
TSCL]1,as owner of the property,or my nnployces with wages as their sole compensation. SWI MMI NO POUT.ELECT RIC
will it,,the work,and the structure is not intended or offered far sale(Sec.70/4,Business ❑O'1'IIER
S 3 and Professions CWe:'TM1e Comtncwr's Lactose Law does nor apply ro as owner of OUTLI?TS-SWI'1 CHIS-ITXTURCS ✓�
proper who builds or intprovca thereon,and who does mcM1 work himxll'or Nmugb
Id,,own employees,pmvlded that such improvements are not mended or offered for NEW RESIDENTIAL ELECfR SQ FF.
sale.if,however.the building or Improvement is sold within one yemofcompletion,the SQ.FG FLUOR AREA $/SQ.IT.
owner,buidder will leave the burden of proving that he did not build or improve for pur-
I,as owner of the See Tw am exclusively amtmcdng with:)ph.licensed t. UVIUAT9 o e,La rho es nett(sec.71114,Bovwner of mildprop Pmfessions Cod:i The es therm',, lidveo,Lawdocsnorapplytoan ithaofpropeny who censedds marttovice Contri,m's QTY. PLUMBING PERMIT PEEwhocomuw.forsuchprojects with aconundot(g licensedpursuannntheCon.ucmiaLicense Law. I`ERMIT ISSUANCE Ej lam exempt under Sec. .0&PCfor this reason
ALTF,R-DRAIN&VENT F;R(IS)Owner Date WORKER'S COMPENSATION DECLARATION BACK FLOW I'ROEIiCI'.1 IC
• Ihereby o iren under pena]tyaf pequry.neof the following declarations:
❑I have and will mainmina Cenificaeof Consent m self-insure for Welkcr's Camper. DRAINS-FLOOR,ROOF ARBA.COND, S'I'OIRBS TRUCTION
.Ill.,as provided for by Section 3700of the Leber Code for the performance of rhe
fm which this permit is issued. FIXTURES-PER TRAP
I havesnd Lswilloadc.frhemean perf'n Comp en the
wrk for ce.as whihhis Per by Section
)of the l�6rt Code for the perlormnnce of the work for which rM1la permit is issued. GAS-1'A.SYSTEM-1 INCA t]Ul'L; (KC.GROUP APN
My Worker' alio, It'ser c dPolicy n t
Camlcc m s rt Policy No.: GAS-EA.SYSTGM-OVP.R4 U!
'Ec IFIC TH OP EXEMPTION FROM W KERS'
COMFENSATION INSURANCE GREASIIINDUS"fRL WAS- INTERCEPIOR BUILDING DIVISION FRES
O'hl%section lived not becompleted ifthe permit is f.ronchundrW dollars($100) GREASETRAP
or IcsaJ PLANCI IECK FEE
Iccnify that in theperfomtanceofthe work for which this permit is issued,],,hot] SEWER-SAN RY-S'FORM VA.2(XIIT.
not employ any person m any manner se m th
to become.mhj.I to e Wmkeni Cahill- ENERGY FEC
O Z .,tell Laws of Culiforrou Date WATER 1- <ER WNENTIELEC IR GRADING 4Ef;
7 O Applicant
C. NOTICE TO APPLICANT.If,atter making this Cerilicom of Exemption,you should Wp';µSVSTBM/1'RIiATING
h h beanne subject to the Workers Compensatimt provisions of the Labor Cede.you mus, sons PEC
finbwith venally withsuch lonsoas m this permildell he the cal revoked. ATER S17RVICE
Q
CONSTRUCTION LENDING AGENCY NEW RFSIDFNI'IAL PLMN. SQ.P7. PAID
U 0 l hereby afford that Nen,is a construction lending agency far the performance of em µeceiptp
rhe work for which this perms is issued(Sec.3097,_Cl,C.) TOTAL:
U Us&,'.,Name
Lenders Address - TOYTAL:
I only that 1 have read Nin application and nm¢drat the shave information is =ERh1IMI,)
BUILDING FEF.
tF.Vat carred.I age,to amply with un city and oouory ordinance%nnJ stem laws relating m QTY. HANICAL PERA11'P FF;E
U Z buildilemotrvctam.send herehy authon,representativesefthin city toentcrugm the SEISMIC PEIi
above-tacardor d Property for Inspection purposes. NCE /(We)agree to save,indemnify and keep harmless the City mf Cupertino againstELECTRIC PIiE
Imbilitie,judgmrme..s,xund cxpunscs which may in any way accrue ugainsr said City "TOMECII. 1'IAMBING IEIi
of of ICANTe NDERSIf the TAN Sthinp WILAPPLICANT'UNDERS'1'ANOS AND WILL COh1PLY WITH ALL NON-1'UIN'1' UNI'1'(Trmit
If 111dKKICl>M) MGCHANICALFEESOURCE REGULATIONS.
G UNIT(OVER 10,000 CFM) CONSTRUCTIONTAXSignmum rAppsion/Comesom Date D(W/DUC`G HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theopphismorfumm building occupant stureor handle hvnNou,nernill HEAPING UNIT To Innina R'N)
as defined by the Cupenina Municipal Cole.Chapter 9.12.and the I h ahh and Safe,y
Cede,Section 25533(x)^ HEATING UNIT(OVER IofoW it rut
❑Yes C1 No VENT[LAI ION PAN(SINGLE RE SID) PAID
Un Recolpt M
. Ij
e Will the applicant or fume,building occupant me equipment or Mona which BOILER-COMP(3HP OR 100.0,X1 RTIJ)
mit huardous air dmmmiwnb as ddincd by tM1c Bay Area Air Quality Manugemcm TOTAL:
Di%vin' BOILER-COMP(OVER I(XI,IXq BTU)
E3 Yes [I No
I have read the hamrdous materials mgonancers under Chapter 6.95 of the Cali- T
AIR CONDITIONER ISSUANCE DATFtl
fomi.Health&Safety CIA,,Sections 25505,25533 and 25534.1 unlemane that if he NEW RESIDENTIAL M1',CIL SQ.IT.
buddingdrcsnmcurnally havem to nI,bui It is my aesptmsibility mnotify the occupant
of Ne re tet which ..ince.(a Celli of u '
1 1
Owner lir um ieJ Dat TOTAL' ISSUED BY:
OFFICE