S 2581 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /� C O
BI111.DING PROJECT IDENTIFICATION G J o
BUILDINGADDRESS: SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
1950$ Hil"P n Coon 7 IFIQ van �0j k ' ) 2 -2 -
OWNER
-2 -
OWNER'SNAME: PIIUNE: CON'FRAC'DOES NAME: LIC NO:
RN� //w p Xi2 O why N/CCONTROL p
dC NGINEER: LLC NO: O ADDRESS: -
CIA&V C-=�2 0 / 7
COMPACT. ((,�.�� PHONe: BUILDING PERMIT INFO
MILC CHET✓ �e8-22r_z9�8 E2 Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
E- C;�- Hf-
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions ofChapter 9(commencing JOB DESCRIPTION
{OaZ with Section 9orObrDi men3ofee Busin,,tnd Irmfireions Cod,undmylaret,is RESIDENTIAL,
FOO in full fincuand effect. PERMIT ISSUANCE
CWF >WI. ❑KITCHEN REMODEL
GUU License Cloas Lic.M
yaw Date GmBactor APPLIANCES-RESIDENTIAL t ❑ADDITION ❑PLUMPING RF.-PIPE,
ARCHITECTS DECLARA'I'[ON PANELS ❑MULTI-UNIT El STRUCTURAL
zbh-Z I undeamndnry planseholl be coed as pubiicr..ords MODIFICATION
OZ-9Z UP TO 200 AMPS L1 INTERIOR L1 CHIMNEY REPAIR
F4. w Licensed Professional 201-IMOAMPS IMPROVEMENT
,,S4 ' E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODELTEPAIR El DEMOLITION
RM U I herehy affirm on 1 1.5 ctempl fmm the Gmtracmrs License Law roe the
W 3 2 FU+ rallnwing rens 1. (Section]IDI 5,,I,a1c, and Pndeemols Cade:Any city or returns SIGNS ELFLTRICAL ❑OTHIiR
F O r" wheM1 ...six u perm,no umsrun,alter,improve,demolish, fie a iir any structure
pdonoiu ossuance,alsn.eyuires the applicant for such permit PleusignN statement SPECIAL CIRCUITIMISC.
ythat hero licensed pursuant to the providars(if he Comracter's License Law(Chapter 9 _
0.IrI G1��0 fwmmencingwithSet,ton]paf)o1 Di,Won 3nf the Business end Prof cions Code)at TBME M I..'FNR OR POLE REST COMMERCIAL
dy a that he i.,exempt,haretrmn and,he hu,is roe the alleged exemption.Any vitiation of
x1a, Seri ED NEW BLDOIAUDI9'ION ❑DIiMOLITION
^m ion?031.5 by any applicantown permit subjects focapplicon,to v civil penalty ar POWER DEVICES []TENANT ❑FOOD SERVICE
F Z i o,morethan Use hundred dollars($incl).
C, ❑ I.as owner of the properly,or my employees with wagesas(heir sale connp,nsrion, SWIMMING POOL ELELTRI IMPROVEMENT
F wall do the work,and the structure is not intended or offered forsal,(See,91144,Basin- ❑OTHER
Wt.
3 m and frimessmns Code:The ContmefoPs License Lew does na,apply to an owner or OUTLETS-SWITCHES-FIXT ES
P• property who builds or improves therwn,and who doesiueh work himself().through
his own employees,provided tbar such improvements me not intended out offered I r NEW RESIDENTIAL ELECTR
sale,IF however.the building or improvement is sold within one year ofaontplc,ion,the SQIFf.FLOOR AREA $/SQ.PT
caner-huilder will have[lie burden of proving that he did net build or Improve for purtg
-
pnscoLsalcJ.
[ 1,as owner arthe properly,am exclusively contracting with licensed contractors to 'TOPAZ.
nnmrucr Ne pmjcc,(See.9fW,Rican.„and Profession,Cad.:)The Commerce,Li-
eLaw does not apply to an owner ofpre,n
ropeuy who builds or improves tbeand QTY. PL BING PERMIT FEE
calme[mama!,Or....In pr)eats with it c,n,amogs)licensed pursuant to the Canmeto.'s
License Law. PERMIT ISSI E N
❑I am exempt under Sec. &6P C for Illi,mason
ALTER-DRAIN& -WAT, (EA) VALUATION
Dam
alpWORK 'S COMP.. ON DECLARATION BACK FLOW PROT, '.
he1'
weer l rehy nfltrm nndcr pmnalDn pc jury one of the following dcclamfion �Q
Q l have and will fee h,
eCion 37teof the Labor
Code
for Worker's Comp an- DRAINS-FLOOR,ROOP,A STORIES TYPE CONSTRUCTION
,;if d. r provided Corny$eo,inn 3]00 of the Labor Cando,for the perfnrnwme of,hc
work for when ill manicure
is issued. FIXTIIRF.g-PER TRAP
❑ 1 have and will mvinmin Wnrker'v Compensation Inanrun.e,M required by Section
3700 of the LuhnrCade,far the performance of Ne work toe which(his permit is famed GAS-EA.SYSTEM-I INC.4 DO I'LE'I S OCC.GROUP APN
My Worker,Compensation Ins,mno,caner and Policy number are:
Carrier: Policy Net: GAS-E.A.SYSTEM OVER 4(EA)
CFRTIFICA'I'U OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE.INTERCEPTOR
lee,)
(Thi„ec,innneednet hc.omdned ifthepenni,is for one hundondodam($100) BUILDING DIVISION FANS
nr GREASE TRAP
PLANCHf3C 1H
Toy an,the, an anyrmeeceorlhewmk Porwhich wenWork,ko,,und,[,hallCoopr- SEWER-SANI'T'ARY-STORM EA.200 FT.
mm�t Law ony person in any manner eo n,m become subjwt m the W,rk.rv'Cooper- ENERGY N:
,Z Applicant
Laws of Callfiania.Uale
z O Appliwm i WATER HEATER W/VGN"r/EL[CTR GRA( G P
h NOT]CE 10 APPLICAN'D If,alter making this Cerlfcate of Exemption,you should WA'ITiR SYSTEM TREATING
become euhject to the W.,ker,a Campno-fort provisions of,h()Labor Cadc.you nmsI SOI P
forthwith comply with such poo,mmons nr this pOrmb,hall he decmed re-ed. WATER SERVICE
Q
CO, SI here is.cars.LENDING
emna, ,nory NEW RF,SIDF.NTIAI.PLM H. SQ FT. PAID
U I far whihthithmthemio-ed Side.3097,
l'nrthe perrormmceof ---put, keceip,M
W the wa.k Por which this panni,is iswed(Sec.309].Civ.C.)
Q Lenders Name q TAL
Lender's Address TOTAL:
as I adif y the,1 huverend this.,ma umb and s,am,hanhe above infommem is BUILDIN FEE I kelj,6%A
TO
correct.(agm,mc,nnply whhall cityandcnumy ordinance,and state laws burning to QTY, MECHANICAL PERMIT FEE
~U Z nmmmg.,ns,mmi()n.and herehy amnod:er.pr.s.ma,fves,nnie dty,()emernp()n me SEISMIC E
nNoc-mcnfioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC D -
(We)agree to saw,indemnify and keep harmless the City of Cupetino against
Iiabildies,judgireme,costs and expenses which may many way accrue against said City ALTER OR ADD TO MECH. PLUMBING
in consequence of the scanning of this Imrnth.
APPLICANT UNDERSTA5AsND WILL COMPLY WITH ALL NON-PINT AIR HANDLING UNIT TO I Q(do CPM) MECHANIC V`�
SOURCE RE UI,A PIONS.
AIR HANDLING UNIT(OVER 111.000 CFM) CONSTRUCTI A
Siginiffire ofApplicand meter Dot. EXHAUST HOOD(W/DUCT)
HAZARDOUS TERIALS DISCL RE HOUSING MITIGATIO FEE
Willthen"Aheremorfteumh ' tesoc minarlchaeardousan,nand HEATING UNIT(TO 100,BIX)BTU)
as defined by,he Capetian,Municipal Cada,Chapter 9.12,and,he Health and Safety
Cal,Section 25532(x).^ HEATING UNIT(OVER 100,000 PTU)
❑Ye, ❑Nn PAID
VFNTILA'I'ION FAN(SINGhP.RESID) Date Record If
Will the applicant or future be(ding()madam use cqulpnmm or deviees which pO1LBR-COMP(3HP OIC 100,000 11 emit hazardous air em
mminab.aseclined ndby the Bay Area Air Quality Management TOTAL:
L]Yes nNo HOILER-CORE(OVER 100.000 BTU) "
I have read the hazardous ntmeriuls requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safefy Code,Senates 25505,25533 and 25534.1 undeamnd,hu,if the NEW RESIDENTIAL SUCH SQ.UT
building does not currently have u¢tem,that it is my responsibility to notify the escnpam
of the orquireiT&which ams,bT""'"to i...ence ata Cenitirse of Occupancy.
Owner t f authorized age Date I TOTAL: ISSUED BY:
OFFICE