S 2781 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUM
NG-MECHANICAL. C O
BUILDING PROJECT IDENTIFICATION J o
BUILDING >Dftldi SANITARY N(l. APPLICATION SUIiMH"IAL DATE
OW . NF ME: �'.+� PHONE: CO fel LICryO.
J `lyclad' X1'1 fa,Bq NIC CON'1'ROLk
RLHTFECDF.NGINEER: !`+ LIC NO: ADDREIS '/� ❑
4
COM'AC7C PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HLDG ELECT PLUMB MECII
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC FERMI'I FEE
1herebyaffirmmal1mm�dicB ender povk6�nsof Chapmr 9tcnmmmaev. JOB DESCRIPTION
WOO with Section]gq)nf Uivision3of me Business, J' y d nd mylicense is RESIDENTIAL
F�+Op full forecandc pn a PERMIT ISSUANCE
W-
in _ !T , ❑SFDWL ❑KITCHEN REMODEL
a-L) License Liu.p API'LIANCIS-RI3IUFNI'IAI. ❑ADDITION ❑PLUMBING RE-PIPE
ZZW Date a— - Camtractor_ f
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
F m Z 1 undersand m I h II hu used ru blic recoNs PANELS MOI TION
ZOy0 YPunss n Pu UP It 200 AMPS
OZ-0 El INTERIOR HIMNI:Y REPAIR
I a4CW Licensed Pmfexionll 2014000AMPS IMPROVEMENT [3SWIMMING POOLS
OWNER-BUILDER DECLARATION
OC OVER 11100AMPS [I BATH REMODEfJREPAIR 0 DEMOLITION
Q 1 hereby atter.that 1 am exunpt from the Cnntrunor's License Law for the
u13O y V wmT,g masa..(Section]031.5. .Atur, and 1'r,,derns s r,a Any city or coumY SIGNS ELECTRICAL ❑OTHER
a which its issuance.
Permit requires
e chest a alineimprove,demolish.are a signed sa.mure f/kOCt/ I fAL SAN
ICC'�O'Q, that hes issuance.ak..11.r.,cre applicant for such Conerarmitmicense Law(Chapter
SPECIAL CIRCUIT/MISC. ��
2�} thin he is licensed pursuam lu thtu pnrvisinnx of me Comncmrs License Law(CM1epmr9
�g pC wmancencing with Section 700oof Division 3ofthe Bi,inensmd Proct,00ns Code)., 'TCMP.MEFER OR POLE INST F
RCIAL
Q.q o K that he is exempt Ihcrefrmn and me basis far the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any.,heart for a permit subjects the a,plicam rn a civil Pemll,of POWER DEVICES if FNANIT 71 FOODSERVICE
no a me thin five hundred ddle.($50). ROV
SSCC] EME Q
I.afthe sownern11o1my,ormy employees with wages as their role compensation. SWIMMING POOL EC1'RIC IT
C
9 will do the work,and the stmcmre is not intended oralfered Fortune(See.70,14.Business
W d Pofe"ma,Code:'The Convector's License Law does not apply m an owner of OUTLETS ITCHIis-FI%TURES ,..
3� anproperty who builds or improves thereon,and whodeves such work latiodfor through :JJJ
his own em ees,to provided that such ice mvinu nts am am intended or offered far NEW k' DEN'T1A1.ELEC:R SQ FT 4
sale.If,however,the building or improvement is sold within one yearofcompletion,the SQ. iFjsOORARFIA J.M� F1'.
owe
mer-hadder will have the harden of proving that he did not build or improve for pmr
Prove of sola). TOTAL:
❑ I,as owner of the propcny,nm exduxivdY contracting with licensed r mmdors m
m,tmet ane prnieat(sr.]Bu.Batmen and rmre,aiems canto The cnntmenara u- By
cense Low does not applym an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEF.
is him connotes for such projects with o canaamor(s)licensed pursuant o the Contrmmrx
License Law, PERMIT ISSUANCE
❑1 am exempt under See. .B&P C for this nous
ALTER-DRAIN&VENT-WATER(EA) /p VALUATIONDate 0—
WORKER S
—WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
I herebyandwill mai sends Cennfiof perjuryone ofthe fellsne for Workertions:
❑Ihave and will mainminaction300 ofConamn Lahou Code,for tho Workers Comped DRAINS-F1POft,ROOK AREA,CONE. S'TORI TYPE CONSTRUCTION
a,ak as provided for by Ss man 3]Ip of the lardsr Cola,for the perfnmmnce of the n p
work far which this pcnmh in i ori act' FIXTURES-PER'T kAP V�`
❑ 1 have and will maintain Worker's Compensation work
for Ie,As h1hia required by Section V
J]ql nftha 1. Cute.for the perfonnmce ofthe work hat wM1ich this pcnnil is issuM. GAS-EA.$YSTEM-I INC.,1 0Vf1.HT OCC.GROUP //1�
My Wo n lm ace conic mad Polcy Na,Policy
mle GAS-I?A.SYS'1'F?M.OVER4(EA ���� V�
Ca er:
CF:RTIPICAO DFEXEMPT SATION'[ON FRO DRKERS'^ GREASEJINDUSTRL WASTE TERCCI9'OR
COMPENSATION INSURANCE BUILDING DIVISION FRES
(This section need ern he cmnpined ifthe permit isfimone handout Dollars($IqB GREASE'TkAP
nr fees.) PLANCHECK FEE
Ic,nif,that in the perfonnamt,d"he work If,,whichmispermit is ismed,Ishalt SEWER-SANTA -STORM EA.200 FI.
not employ any pt in any manner so as to ben:me subjea to the Workers'Cnmpen- ENERGY FEE
Z
sulfur,Laws of California.Date WATEk I11A'I" WNIiNTIELF.CB GRADING FEE
Z O Applicant
N(YI'ICETO APPLICANT.If,after nmking this Ceniricale of Exemption,yI,.should WATERS TEMOTTATING SOILS FEEa ; become subject to be Worker's Conpen.evtion pmvieions of the Labor Code.you mem
LTI
Forthwith comply with such position.,anbi.,perms nhall he returned revoked. WA3' SIiRVIC1i
Q
z CONSTRUCTIONisacacoLENDINGAGENCY iW RESIDENTIAL PLM13. SQ.FT. PAID
I hereby af0nn that there on mwssion lending agency for the ped'ormvnce of Date ReceiptM
{U!a 2 the work for which his permit is issued(Sec.3097,Civ.C.) —_
O U Lender's Namid,mNny
TOTAL:
W Lenders Add TOTAL:
py 1 certiI have ret ¢inion and swat that the above information is BUILDING FEE Y
fn cancer.l agren .11 city and cmnmy oNinances mdslatc laws relining is QTY. MECHANICAL PERMIT FEE 7�
Uy, huilAing const ,and hereby authorise representatives of this city 1. me
SEISMIC FEE
aMvo-mentia far inspection purposes. PERMIT ISSUANCE.
(We)agate m save,indemnify and keep harmless the City of Cupenim against ELECTRIC PF:E
=ofApplici
Is,cases and expenses which may in any wuyamne......t.aid City ALTER OR ADD TO MECH.
the gmmin of this permir. PLUMBING FEC
EATEST DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10111001 CFMI
A'I'10 QMSCI{pNICAL FTG
eAIR HANDLING UNIT(OVER IO.gp M) CONSTRUCTION TAX
ic: Ucom...to, Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future ballding occupamstimem htnJla I....do.,natural HEATING UNI"F(TO I110TU)
as defined by the Cuptunino Municipal Code,Chapter 9.12,and the Health and S.10,
Coda Studio.25532(1)'1BEATING UNI'F(OVE ),org)13'1'U)
❑Yet VENTILATION I (SINGLE RISIO) PAI e(
ale ReceiptB
77
Will IM1e applicant or future building occupam use equipmem or device,which
mit hmammt
aus air caaromanls as defined by the Bay Arca Air Quality Management BOILER-c P(3111'(IH Itg1,IMN1 BTU)
TOTAL:
Dlsl°et1
C]Yes BOILB COMP(OVER 100.000 BTU)
I hove re)dlnu hsrmdous materials requirements under Chapter 695of the Cali- AI ONDITIONER ISSUANCE DATE
fomia Health 1" tety CWe.Satinns 25505,25533 and 25534.1 undersmnd that if me EW RESIDENTIAL MECH. SQ,ET.
huildingdoc Icureallyl r.tbut iti c nobility o notify the..Not
of there n' n is whit G fl vnftCe t f
a m ` �a��
Ow�la me TOTAI.e ISSUED BY:
OFFICE