S 2161 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE ITIS
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 2161
BUILDING PROJECT mhNOTCSOON
BUILDING ADDRESS: � � SANITARY NO. AI'PLICA'I'ION SUBMITTAL DATE
[vJ�'/aa 7777 �
OWN/F.R�J'YJ,AMP: PHONE: f RA�c 'S E: I,IC NO
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ARCHITECTO?HGINEF.R: _ e( TCO LIC NO: A /�KS: �/"I'l ❑
coNTncT: PHONES: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED COM'RACTDR'S DECLARATION QTY ELECPRICPERMIT FEE
I hereby affirm Ilial 1 con liv nrs,d under prookinm..f Chapter 9(commencing JOB DESCRIPTION
Omz IS ecti..n7 fDlVwl 3oflbc(tanine. dPnrlexsinnsCWc and myliccnuix RESIDENTIAL,
W O Q PERMIT ISSUANCE
F O n full farce a � I ❑SFDWL ❑KITCHEN REMODEL
t aUU Licen. lata Lic.I APPLIANCES-RESIDENT1AL ❑ADDITION C1 PLUMBING RE-PIPE
F z W DataConnect
F w4i ARCHITECTSD PnNELS MULTI-UNIT ❑STRUCTURAL
ODIFICAT[ON
zo-Z lyndammandmYplansxhall reused as public recon(///i/JD/� UP T02W AMP5
Oz4O ❑INTERIOR vINEY REPAIR
r 4.F.W Licensed Pmfcssituml 20I-l"RAMPS IMPROVEMENT E]SWIMMING POOLS
:gJ OWNER-BUILDER DECLARAI'(ONOVIiN IgN)AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
st I hereby infirm Ihm I am exempt Gum the Contractors License low for In.
Xtl O a U following reason.(Section]031.5.Business and probes.......Cale:Any city nr cnumY SIGNS ELECTRICAL ❑OTHER
1+14 as y which requires a permit m construct,idler,imp ova,demolish,or repair any strenurc
Cpm!{a
st prior t..its hemnca.Isoreimre,Ihcapplicaol farsucll permit o file asignedxmurnme SPECIAL CIRCUITIMISC.�
that he is li,eawdpuramat In the provistonsof the Contractors LicenceLaw(Chapter 9
ommen.ing
^p0 (cwhh Semien]INIfO of Division3mf the llminass and Pmfcsai.m,CodOm TFMP.MET'ERORPOLF,INST. COMMERCIAL:
6 y o tG tha he ix exempt therefrom and the hands for the alleged exemption.Any violation of ❑NEW BLDOIADDITION ElDEMOLITION
YX7 h•
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑'CENANT ❑FOOD SERVICE
F rn
I.,more than fvc hundred dollars($5(10).
p 6 1,u.owner of the norm In ccs with woes.,their.,,],cam Linn. SWIMMING POOL ELECTRIC IMPROVEMENT
d Q property, Yc�nP Y g Penna ❑OTHER
will do that work,and the structure is nal intended d Law d l for sol.(Sec.
9044 Buxincss
{mil m uad Professions Calc The Comments License o Law nm apply ev if owner of OUTLETS— ITCIIF.S—Fl%TU�Ii.S
F' property whobuild,or Impnweuthereon,andwho Jaw inch,inte ded.fordv..ugh
his own employees,provide) hot such impmven¢nIx um nal intended.,offered for NEW Rpal'('IAL ELECT,R SQ FC.
wit.H.howevcq the building or impmmurnat is sold within one year ofcmapletio..the SQ.FR FLOOR AREA &SQ.FC.
owner builder will have the harden of proving that he did not build or Inrpmve for par.
now ve sale.),
El 1,as owner of the pmpmy,am exclusively contracting with licensed contractors It,
TOTAL:
construct he pmkct(See.7Gt4,Business and Professions Cmlc:)'Ihe Contra em's Li-
neLawdoesnotapplyloanownerofpropertywnahnildsorimprovesthereon,and QTY. PLUMBING PERMIT FEE
who contmms for such projects with a romractor(s)Bcen.wd pursuant m the Contractors
License Law. PERMITISSUANCE
I am exempt under In, ,B&P C for this reason
AL'CER—TRAIN&VENT—WATER(EA) VALUATION
Owner Dm.
WORKER'S COMPENSAI
PerjurI on DECLARATION PACK PLOW PROTT:Cf.DEVICE
G3
1 hereby affirm under PenaltyCant n,perjury one ofthe following Worker's
Cs a
�Ihave and will maintain CenifimmnfCon.cntto sell-insure for Worker's Compen- DRAINS—FLOOR.BOOR AREA,COND. ORIES TY CONSTNUCCION
salion,a provided for by Soudan 3700 of the Lahr Code,for the performance of the
far which this permit is issusal. FI%'CURES—PFR TRAP
1 hove unJ will maintain Workers Compensation Insurance,as required by Section ,
ofthe Lahr Code,f... morioneal the work for which this permit is issued GAS—EA.SYS] INC.4 OUTLETS OCC. ROUP APN
My Wa 'nl tree rr d 1bicynlL1111YflrI:�C�f GAS—EA.SYSTEM-OVER4(EA)
Camcrr I Vi'olicy Na.:
CBRTIFIC IS OF EXEMPTION FROM WORKERS' GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This section need nor he conrpl.ted lithe permit is loran,hundred dollars($100, GREASETRAP
or less.) PLANCNECK PEE
[eemOMalin lh.perfnnname.ftbe work(nwhichthi,Nmant is iamal.[,hall SEWER—SANITARY—S'CORM EA,200 IT.
not employ any person in any manner so as to become subject the Workers Compen- ENERGY PEE
an,
cation laws of California.Date WATER HEAT FR WNENTniLECTR
zApplicant GRADING[:I.[;
y NOTICE TO APPLICANT:If,after tusking thin Certilic.1 of Exenrptinn,you should WATER SYSTENUTREATING
(—' become xuhyre,m Worker's Compensation WoCompensation pmvisinns of the Labor Cale,you must SOILS FEB
fanhwith comply with such provisions or this permit shall be deemed mvaked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMII. SQ.FT. PAID Dare Reccipl p
G 0 I hereby affirm rhatthem is a conmmctina lending agency for the performance of
the work for which this permit is issued(Sea 3097,Civ.C) TOTAL:
1" lenders Name
Lender's Addles.. TOTAL:
Lr.1 BUILDING Pfili
W nee drat 1 have mod this city
and coup and dram ces the sMwe i%s mining is
[A rodding agreemcomply
and weeny ciry and countyordinances and smtelawsr,orri c QTY, MECHANICAL PERMIT PEE
V z budding contraction.and hereby aiN.riac representatives of this city mercer upon rhe SEISMIC ITE
allove-mentioned property for inspection purposes. WSSUANCF SUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep to rmlass rhe City..f Cupertino against
Iiahilirics,judgments,costs and expenses which may in any way accme against said CityADD TO MECIL PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTLING UNIT(To R"'CFM) MECHANICAL FEE
SOURCE REGULATIONS.
LING UNIT(OVER 8,000 CFM) CONSTRUCTION TAX
Sigmwre of Applicanr/Cnmrmmr Dat. HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lna.lidicint or future building rmcupmtsmre nr handle hazardous materialNIT(TO 110,000 BT'U)as Jcfnest by rhe Cupeninu Mu al Code,Chapter 9.12,;cod the Health onsSafetyCode,Section 25532(.)7 UNI"r(OVER lifl. )B BTU)
0YOf VENfILATION PAN(SINGLE RISID) PAID Uare ReceiplN
Will the aliphrem or ture building occupant use ryuipmem or devices which ROILER (3111'OR 100,00 BTU)
coubt4vvdmomi-comunin Ia ns defined by the Bay Area Air Qmlity Manage.., TOT
In,bict7 BOILER—COMP(OVER 100,000 BTU)
❑Ya, t
I[I. be ha rd'us rx, ria( cinder Cha(H.:r 6.95 of rhe Cali- AIR CONDITIONER ISSUANCE DATE
-reyorremcn
tion a belts I Cale,. ti x 3505.25533 and 25534.1 undcnrwd than if rhe NEN'RESIDENTIAL MECH. SQ.FT. `���(0 Q
buil rg Jr nnl�Uhmms1cono, 1pmribiUym tify th mutant L LJ t
of c c t hon st mel prior to iauonc ofeC f
<�
Owner or unlh..rieN agent Da¢ TOTAL: ISSUED BY:
OFFICE