S 2265 APPLICANTTO FILL IN INFORMATION WITHINAED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEI IT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMxwC,-nlecxn7lcnL 2265
BUILDING PROJECT'IDF.NT14'ICAI'ION
ODILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAII7
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OWNF " ML PHONE: COM ACTOR'S NAMG: LIC NO:
C'' i I /r " —AI //� /w' NIC CON'TROLN
ARC ECT JNCn INEv II: ` n '.I NO: S JJ J ///C / f ❑ �O
c( Ci A //I I e CIM 4 O
CONTACT MONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG/ ELEM ' PLUMB MECH
LICENSED CONTRACTOR'S DECLARAT[ON
S6QT•y FLEC7RIC PERMIT FEE {rel/ (p�nY/ IrLN-nX/ IrJ�
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�geZ with Scene.7")of Division 3 ofthe amines,and Porexsions Code,and my license in R
�00 . PERMIT ISSUANCE
W 1- m full force and c cc D ❑KITCHEN REMODEL
RUL) License Class Lia it APPLIANCES-RESIDENTIAL DITION El PLUMBING RE-PIPE
in<� Oele CI aamr
RCIHrECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
zo,,nZ Iunrm
dc :mdmyplar ,c
ssahallbeusedaspublicords PANELS MODIFICATION
BZ4p UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�.F.W Licensed Prubsciunal 201-100AMPS IMPROV17MENT 0SWIMMING POOLS
ay$; OWNER-BUILOIIR DECLARATIONOVER aNN1AM1'S ❑BATH REMODEIIREPAIR ❑DEMOLITION
Ccald 1 hereby affien that 1 am exempt from the Conlracmis License Law for the
OEU 1.1
xS�dowing rcasoa(Seedon 7031.5,Bminessand Pndv,,dixs Gude:Any city or county SIGNS ELECTRICAL ❑OTHER �-f
which reqa permit to construct,alter.improve,demolish,or repair any structure //8 N
uires
I- priarm'ns ismence.alho requiresme appllcantforsuch permit to file a signed statement SPECIAL CIRCUIGNUSC. 0r .1F�/iJ
F,tr�yy IM1al M1e is licensed pu Law lChapter9
��a00 (commencing with5F711)"�,�ll yIs 3ofthe olio, sninns Cwlc)or TEMP METER OR POLE INST.
aq that he is exempt th bb�rn rme allyyqm .eny violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
fstencSceion]031.5 bYauh)ec¢Yhllapplic t civil Penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
nmmcrhan fnah (SY IMPROVEMENT
❑I,aowneroflhrntptqYcr)' s`i it aemnpensmion, SWIMMING POOL ELECTRIC
p. wdl do the work,unJ 11j," lurelstlut intJndedor � I 1' .]044.Bmires, ❑OTHER
L3 and Pmc,,ions iL e Cnmmmors Liceme law Jsns no 1 to as evmcr of VfLEI'S-SWITCHES-FIXTURES / 0
.. property who buildsDrnves thereon,and who drcs such w m,elf or Ihmugb
his own employees, r 'ded that such improvements are not intend Jor oficom for NEW RESIDENTIAL ELECT R SQ FT.
sale.If.however,the uP,Qg or Improvement is sold within one year, 'completion,thc SQ.FT.FLUOR AREA pSQ.PI.
mer-builder will hivti.Ale l:.!dSIrH1`Dmt11'= dmmwa io'e,
pose of ruled.
❑'1,as owner of the property,am exclusively contracting with licensed cnmmemls to OfAI.'
construct the project(Sm.NN4,nosiness and Professions Coi The Congas or's Li. ('
most,Ww does not apply m an owner of progeny who builds or improves throme,anl QTY, PLUMBING PERMIT FEE 7f �s��
Wh,cormaces Ro,mhpmjecNixim ucontramor(al licensed parewuntm the Contractors yy.tSO�C L/0
`-:-
License law. PERMIT'ISSUANCE �I'I
❑Imnexemptundersec. .R&PCfor mix reason 1 �,
ALTER-DRAIN&VE.NT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE GO Q d�
I hercbY'nffrto under penalty of perjury one of the fug having declarations: 6
rl I have and will maintain a Carl of Cousern to selGinsum for Wudwex Cooper- AINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
sation,m provided for by Section 3710 of the Iahm(Gdo,for the performance of the A
work ler whichmpe
is rmit is issued. PI%TURE$3R -PF.RTRAP G / SFObC..L
1 have and Bill maintain Worker's Conlpcosation Insurance,as required by Section
370o1'thc Lobar Code.fnnhepe / ypofthewarkY/f�nrwbhich�thls tis issued GAS-EA.SYSTEM-IINC.40UTLE'FS OCCGROUP APN
Camccr I ^ ✓ and NAZI
Y GAS-F.A.SYS71iNTOVER 4(HA) YJ
CERTIFlCATE(lF IiXEMI'fION 4R M WORKERS' GRI?ASFIINDUSTRI.WASTE INTERCEPTOR /G
COMPENSATION INSURANCE BUILDING DIVISION
(This section need not W completed new permit is for one hundred dollars(S I W)
tit less) GRPASIiTRAP PLANCHECK HE s
Imnifydat in the pclfroamcenfthe work far whichauspcnnil is issued,i shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as Io become subject m the Workers Compen- ENERGY IEE
Z satins Law,of California.Data WATER HEATER W/VENT/ELECR
Applicant GRADING FE
.^N. NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should WATER SYSTEMfIREATING SOILS IEE
hmmo a subject o the Workers Compcmatinn provisions of the Labor Cade,you most
fonhwim,ompiy with such pnAkimx,m this parmt,hall be deemed revoked. WATER SERVICE
C1. CONS'IRUCI ION LENDING AGENCY NEW RESIDENTIAL PLMO. SQ.PC. PATO �,•�.�/
,z ate 'R`Receipt Of
I hereby athm that mere i,a commission leading agency for the perfarmorm of O/a y 0
the walk for which this permit is eased(Sec.3097,Civ.C.)
QF"' Lenders Name TOl Q TOTAL:
r IUSI Lenders Addres, _ 0
1 certify mat 1 have read min appliwlinn and state Ihm the aMve infonnmion is BUIL N TE
F N correct.I agree w aaeoply with allelly and county ordinances and slam laws eclating'm QTY. MECHANICAL PERMIT FEE O
U building construction.and hereby authorizereprmenodves of this city to enter upon the SEI EE
etwex-mentioned propeny far inspection pmposel. ERMIT ISSUANCE
EL W li
(We)agree to rave,indemnify and keep harmless the City of Cupertino against ��
babilities,judgmems,costs and expenses which may in any way accrue ugumusaid Cit pITER ISSUANCE
TO METH. PLUMB NG FEE
in cnnscquentt M the Granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.t00 CFM) MEC NICAL FEE
SOUR ' T;GUTATI ti. ^_
AIR HANDLING UNIT(OVER 10,INO CFM) CONST R TION TAX
Signa o Applican b clor me EXHAUST GOOD(W/DUCT) HOUSINGM 'IGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Willfle applicant.,future buddingrxclecal score nr handle hixiammsmalerial HEATING UNIT(TO HNopo B'ru)
a,defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
code Sc don 25532m)v HEATING UNIT(OVER Fannon BTU)
❑Yes ON. VENII LATION FANS I NGLE RESIDI PAID
Date Reeeipt N
Will the applicant or furore building occupant use equipment or deilms which BOILER-COMP LIAP OR I ONt,gO BTU)
,in,,haurdous air mot m erea,as defined by he Bay Area Air Quality Manageme9l O
District! BOILER-COMP(OVER 100.00d BTU)
L]yes No
I have read the haossuba.s materials requirement,under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
hernia Health&Safely C de.Sections 25505,25533 it 25534.1 understand Ibal if the NEW RESIDENTIAL MECH. SQ.FF.
building does run runandy have a tenant,that it is my respomibility to notify me occupant
of dm rcquiremenis which must be mel Poor I,imuance of a Ccnlficate of Occupancy.
Owner or authorized agent Dale TOTAL: ISSUED BY:
OFFICE
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