S 2195 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY,OF CUPERTINO BUILDING.ELECTRICAL IT PE' NO.
.BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 2195
BUILDING PROJECkTENTIFTWTION
BUTLDINGA�DDRB.� '/�/p� W. Pd /S, 1, / �/, / syn/$ SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'/T' /Erol �H( C//`ON/'/f✓/,/' 'S NAME. C /� I
I l.`7 N/C CONTROL#
ARCHIT CT/F.NGINEER, LIC NO. qp ❑
CON'T'ACT PHONE: / BUILDING PERMIT INFO
EJConsultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
MU l l 6 L/ ❑ fg , ❑ 41
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
�0Z with Section 7003)or�eE
and Pr iPslosQade�ilBdz*Ylicensei, RESIDENTIAL-
PERMIT ISSUANCE
4UZU license Clan ❑SFDWL ❑KITCHEN REMODEL
vFi64 Dute r APPLIANCES-RESIDENTIAL ,ADDITION El PLUMBING RE-PIPE
CLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z C A.Zr I understand my plans shall be used as public me us MODIFICATION
OZ- UPT02MAMPS
H�,F]W Lmeraed Profesxionvl El INTERIOR EI CHIMNEY REPAIR
,,,T 201-IMOAMPS IMPROVEMENT SWIMMING POOLS
y�.�,4 OWNER-BUILDER m Ce Contractor.,
�6 I hereby affirm thin I um exempt from the Cnmomor's License Law India OVER 1000 AMPS [I BATH REMODHIIREPAIR ❑DEMOLITION
X 3�F following reason(Section 9031.5,Businae,road Prdessine,Cade:Any city or Umnty SIGNS ELECTRICAL - ❑OTHER
y which reyoires a formic to construct,alter,improve,demolish,or repair any simqure
Fpp"0�4 primmiDissuanw,ork.revenues theapplicant forsuch permit to ftleasigned smmment SPECIAL CIRCUIT/MISC (�
pr�y"I
that he is licensed pursuant it)the provisions of the Commuter's License Law(Chapter 9 z
Cu]�'00 (commencing with Section 7000)of Division Sof the Business road Professions Code)or TEMP.METER OR POLE INS F COMMERCIAL;
Y W e e1. that he is exempt therefrom and the heli,for the alleged use n.ption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
N Section 7131.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
not more man five hundred dollars($500). ❑TENANT C1 FOOD SERVICE
SQ I] I,as owner of the property, - IMPROVEMENT
or myemployeeswith pared foatheirece.compensation, SWIMMING POOL ELECTRIC ❑0'FHER
[� will dotResume,Code andtheao Commenceot intendedcomparedruule(ply I.44,B 'If
3m anderywho builds
The Commences doemf's License Lwdam,nmapplytolfownern( OUTLETS-SWITCHES-FIXTURES
his.,a who builds peamded the,
thereon,and who does such work himself or through
has own employees,provided mat tench improvements w am not intended nr offered for NEW RESIDENTIAL ELEC'I'R SQ PT.
smelLhoweveathe
veth burden
ileal yedur improvetbur mo SQ.FT.FLOOR AREA $ISQ.FT.
pa a of
will have the burden of proving thew he did not build rr improve far pur-
pose of sale.). .
❑ 1,as owner of the property,nm exclusively contorting with licensed ametmeeo It, At)
instruct the project(Sec.704q Business and Professions Code,)'The he Contractor's Lo-
cause Law does not apply to an ownerof property who builds or improves thereon,and QTY. PLUMBING P T FEE
who common for such anile is with I nmmacler(s)licensed puremal to the Contractors
License Law.
❑ I am exmri.,Idea Son,
BNPCfor this reason PERMIT ISSUANCE
ALTER-DRAIN& IE
VENT-WATER A
Owner Dan, VALUATION
I hereby affirm under penalty of perjury one of the Gillowing declarations:
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I] I have and will maintain a Certificate of Consent to self-insure for Worker's Compe,I- DRAINS-FLOOR,ROOF.AREA,CO STORIES TYPE CONSTRUCTION
xytimn,as provided for by Semicn 370 of the Latim Cade,I the peifarmnoce of the
weak far which this permit is issued. FIXTURES-PER TRAP
❑I have and will mountain Worker's Compensation InImence,vs trammed by Section
37Woftha Lrolfof Cade,form ,f arei,§ieµ.rform ichthls tlsis d. OAS-P.A.SYSTEM-I IN 40 LETS
V IJY�I OCC.GROUP APN
MY W�l lacy
Carne NO GAS-EA.SYSTEM-OVER4 )
CF,RTIFIC O PE SATIONIIN FROM WORKERS'
COMPENSATION INSURANCE GREASEJINDUSTRL WASTE INTER CPETER BUILDING DIVISION EBBS
(This section need not bewmplete4ifihe permit M1unthedJnllws($lap
ur le".) GRBASE TRAP PLANCHECK FEE
I certify that in Wo peaam'mante of the weak for which this permit,,issued,I shall SEWER-SANITARY-STORM EA.200 FI:
not employ any parson in any manner so as to become subject to the Workers'Gumpert- ENERGY PEE
O Z sution Laws of California.Date WATER HEATER W/VEN'1'/ELECTR
Apportion GRADING FEE to
r~Ni
NOTICE TO APPLICANT:11,after muking this Ceniticate of Exemption,you should Wq Yy HEATING
(r >
become subject the Worker's Compensation provisions of the Lohor Code,yon must SOILS FEE
w-r
forthwith comply wish suchpowtiomorthisparoul,,hall bedeemed revoked. W 'ERVIC
'Z CONSTRUCTION LENDING AGENCY W ESIDENTIAL B. PAID
Ihereh,.M.that there iso construction lending agenoy fan he peframtance of D Rainapt#
Q the work for which this permit is issued(See.30 7,Civ.C.)
WLenders Name TOTAL
Lenders Address //r#/AL:
y 1 votary but I have read this applumme and sem them the above inlormation is BUILDING FEE
r h eoteer.I agree to comply with all city and county entrances and stme laws!elating to QT MECHANICAL PERM FEE C.) Zi buildna,mmsraction.and nearby authorize re sentatives of this city to en ter upon the SEISMIC FEE
above mentioned property for inspection p e ec
PERMIT ISSU Q
(We)agree t.save,indetn to harmless the City mfg agiduinragainst ELECTRIC PEE
liabilities,' d"I'mocnss ands en n hicq may in anyway accme ngvnst said City ALTERORADDTOMECH. -
- Inc celflagmmingo this5e reit PLUMBING PEE
A L AN UNDERSTAND. AN W .LC MPLY WIT N -POINT AIR HANDLING UNIT 10,a#ICFM)
S U ;R GULATIONS, �� MECHANICAL FEE
/ AIR HANDLING UNIT I(I,Wn CFM) CONSTRUCTION TAX
agmwreo Ap win Comer Bu -.EXHAUST HOOD
(W/DUCT) HOUSING MITIGATION PBB
HAZARDOUS NUO ERIALS DISCLOSURE
Will the applicant or future building occupant sore or handle hazardous material I IPEATING UNIT(TO 100,003 BTU)
as defined by the Camera.Municipal Code,Chapter 9.12,and the Health and Safety -
Code,Section 2553200 HEATING UNIT(OVER 100,000 BTU)
El Ye., ❑No
VENTILATION FAN(SINGLE RESID) PAID
Will the u licant or future hulldin Date Receipt#
pp g by the Bay Arab
Air snaky,devices BOILER-COMP(3HPOR IpFflWBTU)
omit hazaneus air cnnmminanu as defined by the Buy Area Air Quality Management OTAL.
DismicY!
❑Yes (]No BOILER-COMP(OVER I00,1100 BTU)
1
1 have real the hazardous materials requirements under Chapter home orate Cali-e Alk CONDITIONER ISSUA CE DATEF
forma Healths&Safety Code.Sections 25505.25533 and 25534.I tomaderomed
many the
thin If the NEW RESIDENTIAL MECH. SQ.FT. ✓//]
building doesrteres not whicentlyh
have of mettthmir isua res of a Cilitymnmifyecagon pee
of the reyuirementx which must Fz met prior it)issuance ora Cenilwte of Occupancy.
Owner or endorsed agent hateBb L: ll Z)pyq / j�
ISSUED BY:
OFFICE