S 2149 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILANGI'F. IT NO
BUILDING DIVISION APPLICATION/PERMIT PIAMIIING-MECIIANICAI. 2149
BUILDING PROJEC'[ADEN T'IFICAT'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI ITAL DAPI
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OW :K'S NAME' PHONE,4hCg 04 � CGNTItA :S MC: LIC NO'.
IIINIC CONTROL#
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ARCHITECTILNGINEER: LIC NO: ADDRESS: ❑
coNl'nCT: p,� � PHONE: ` BUILDING PERMIT INFO
7 s'�/ S/33 ❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUME MECH
❑ ❑ ®' ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FE17 JOB DESCRIPTION
I hereby mRr the I am loaned under provisions of Chapter 9(commencing
O d'Z th Stttinn 91KM11 of Division3 of the Business and Pml',ainnn Rdq and my licunsc ix R -I�$ D -N� TJAI
W O PERMIT ISSUANCE
FSB "lull lbrecandel t ❑SFOWI. ❑KITCHIiN RF.MODEI.
t U License"Loss
M77
APPLIANCES-RESIDENTIAL ❑AUDITION [I PLUMBING RE-PIPE
1-1u1 Date Contrmtnr An
-i a ARCIIITECPg DECLAR TION ❑MULTI-UNG' [I STRUCTURAL
Z Of°j 2 I understand my plans"hull he used us public records PANELS MODIFICATION
OZ,-,0 UPT0200AMPS ❑INTERIOR CI CHIMNEY REPAIR
{. W Licensed Professional 201-1000AMPS IMPROVEMENT C)SWIMMING POOLS
QS'
_9W=1
2 j OWNER-BUILDER DECIARA9'ION OVER IIXIO AMPS ❑HATH REMOD� RE AIR �DEMOLIT IJN
y 6'W Q 1 hereby alTom that I am exempt from the Contractor's License Law for the
W 3 W F following reason.(Section 7031.5,R.une.a and professions Calc:Any city or county SIGNS ELECTRICAL 11 OTHER
y which requires a permit to construct,alter,improve,demolish.or repair any structure,
CF uy'O� prions its issuance,also examines the applicant for such penal to file a signed statement SPBCIALCIRCUTUMISC.
WN datheis licensed pursuant a)the provi.me,.f the Conductor's License La,(Chapnv9
ti1�00 (commencing with Section91N)(0 of Division)ofthe Businessand Processions Cadc)or TEMP METER OR POLE INST. COMMERCIAL
d d o
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m'y Section 9031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
t more than Five hundred dollars(5500). IMPROVEMENT
O ❑I,asowearol'the pulart,or myempinyecs with wages a.uheirsole compensation, SNEWR
POOL ELECTRIC
will do the work,and the mmeure is am intended rnolTercd for sale(Sec.9044.Ensures El OTHER
tail and Professions Cale:The Commodes License Law does not apply to an owner of SWITCI IRS-FIXTURESproperty who builds ar improves thereon,and who does stab work himself m Ihrmgh
his own employe,,provided that such immvemenu arc not intnded or offered for FNTIAL ELEM R SQ IT.
sale.IL however•the building or improvement is sold within one ywr ofarmplerim.the SQ.IT FLOOR AREA ESQ.FE
awn
c,h.ilder will have the hurden of proving ohm he did.m build or improve(ar par-
poao of aalcJ.
❑ I,as owner of the property,am exclusively contracting with licensed contractors in 'TOTAL:
maslmm 0e project(See.1044,lousiness and Professions C do:)The Contractors Li-
lease Law does not apply to:m owner of property who builds or improves damson.and QT PLUMBING PERMIT FEE
who contracts for such protects with a contractors)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,R&P C fill this-awn
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORK(?R'S COMPENSATION UECLAR rRIN BACK FLOW PROTECT.DEVICE
1 hereby afar under penally or perjury one or the following declaratieu,
Ej I have and will maintain a Certificate of Consar to self-insure for Workers Compen- DRAINS-FLOOR.RODE AREA.GOND. STORIES TYPIiCONSTRULTlO.
lion,as provided for by Section 3700 of the Labor Code,for the Performance of the
r for which this Perm it is issued. FIXTURES-PERTRAP
have enJ will mainwin Worker's Compensation trimer,as required M1y Section
J (Nlofthe laor Colle,fteche perroradvoDhe work forwhich thispermit is issued. GAS-FA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker"Crnnpc tion Insumngelr�icr and Policy um � .�4e�.p,
Caricaffl1P S / Policy No.: VJA GAS-EA.SYSTEM OVER 4IEA)
CER FTCATEOPEXEMITION FROM WORKERS' GREASE/INUUS'IRL WASTE INT'IiRCEI'fl1R
COMPENSATION INSURANCE BUILDING DIVISION FRES _
('Thisseclion need not becodideed ifthepermit is forone hundred dollars($100)
GREASE TRAP
nr lerx) PLANCHECK FEE
I certify that in the perraranccofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM PA.203 IT.
not employ any person in any manner so as to becmne subject to the Workers'Cnmpery ENERGY PIiF,
O Z satin.Law,of CaliIford..Date r WATER HEATER WNENI'/ELECM
� Applicant ' GRADING IEE
y NOTICE TO APPLICANT.If,after making this Cenificate of Exemption,you should WATER SYSTEM/BEA'I'INO
a ; become subject to the Worker's Compensation provisions of the labor Code,you must SOILS PRL
[TJfoMwith comply with such powisionsn this permit shall be deemed revoked. WATER SERVICE
0. 0CONSTRUCTION LENDING AGENCY NEW RISIDEN ISAL PLMB. SQ,PL PAID Out eceipty
V0. 1 hereby infirm that them is a construed""Itur ing agency for the per emwmce of
W [~ the work fur which this peril is issued(Sec.3099,Cls.C.) O TOTAL,
O L) lender's Name
(T-I Ledil sAddrs BUILDING it..
I
f�.tt y I certify that I have read this application and state that the above info n is
corm.I agree it)comply with at[city and county ordinances and slate lows reating to QTY i (ANI IT BE SEISMIC
V z huildin6 comwdinn,and herchy umhodra nTresentmiv,of this citymenmr upon the
move-mentioned property for inspection purposes. PERMIT IS. E ELECTRIC
(We)agree mmove,indemnify and keep harless the city u(Cupenina mgairut
lishilitieajudgments•casts and expenses whichmay in any w.,.ccmm againstxuid City ALT ER OR TO PLUMBINGFEE
in consequence ofthe granting of this permit.
APPLICANT UNDEtSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDL UNIT r(To inoig,CFM) MECHANICAL E
SOU R-(a ATI)NS.
y D AIR HANDL( ( IT(OVRR 1110 CONSTRUCTION TA
' Sig Cmdramor Dae IEXHAUN I In /DUCT) HOUSING MITIGAIIONFEE
HAZARDOUS MATERIALS DISCLOSUR:
Will the applicamor dome building oellvername to handle hazaNwn material HEATING UNIT(70 100,00)BTU)
as defined by the Cupertino Municipal Coe,Chapel 9.12,and the Heallh and Safety HEATING UNIT(OVER 100.001)BTU)
Cale.Section 25532(,)1
E3 Vies [I No V17NI ILATION FAN ISI NGLE RESID) PAID
Doc Receipts
Will the applicant or future hooking reception use equipment or devices which BOILER-COMP(3NP OR 110.0010BIT)emit hazardous air contaminants as defined by the Bay Arca Air Quality Managclnenl 'DDIAL:
District' BOILER-COM('(OVER IOq(N10 BTU)
El Yes E]No
I have real the limitations matedds requirements under Chapter 6.95 of the Cali- AIR CONDITIONER p ISSUANCE DAT•
- found Health&Safety Cade,Sauons 25505,255]3 and 255]4.I understand Rot lithe NEW RESIDIiNfIAL MECH. SQ.FT. / "�
building does not currently have a Roam,that it is my responsibility m notify the occupant ( !/ (((///
of the nequiremems which must he met prior to issuance of a Cenifrcam of Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE