S 2455 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEcrrRICAL PERMI"INO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2455
BUILDING PROJECT IDEMPIFICATION
BUILDING ADDRESS: I 310 Z M :22 _ O 3 Z SANITARY NO. APP (CATION SUBMITTAL DATE
r - y^1l
OWSJUR'S NAME I PIONE: C TRA R'S NAME: LIC NO:
e p(�c SL" NIC CONTROL#
ARCHITECT/EN NEER: LIC NCO ADDRESS;p Y ! ❑
CONTACT: PHONE: 40
Y BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
^ u s
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF.
bunch,buby affirm that I inn licensed under provision,of Chapter(eonnnanchd£ JOB DESCRIPTION
CCz with. et p7 ))or Division 3 of the Bminessand Proessiom Codavndmy licerar, ^^
in full Tme a e
RESIDENT At,,
DO PERMIT ISSUANCE - V '0 SFDWL LI KITCHEN REMODEL
oB
CUF 1 APPLIANCES-RESIDEN'I'I Al. ❑ADDITION [I PLUMBING RE-PIPE
GF
A HI 'CT'n FCLARA'1'ION El MULTI-UNIT El STRUCTURAL
F� o PANF.1,5
ypy^ lunde:a d. Is h dos puMle remrda MODIFICATION
c'Z'-, UP TO 200 AMPS 94FITERIOR ❑CHIMNEY REPAIR
In cnsexl Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
{py,,BW Q I hereby affee that 1 am exempt from the Contractor's Lianee Law far the OVER Ugd AMPS ❑BATH REMODEWREPAIR El DEMOLITION
x 3 W Ufollowing reason.(Section 7031.5,Braine,and Professions Cade Any city ar county SIGNS ELECTRICAL ElOTHER
W tali b mcri..a pi,malm....t t Iter ney'ame,demolish, repair art,'Induct
FC�4Eanal t I: q .d pplicantl :uhpermit fl , daidearem SPECIAL CIRCUIT/MISC,
aa
m l licensed p i t l theprovisions oftheie t rob L' Law(Chapter 9
W1 (co nntc¢tn£wih Section 7000)afUvsion3 of[lie Business mrd Pmfmswnv Code)or '(GME METER OR('OLE(NST. COMMERCIAL
Y y M eG thud he is exempt Therefrom nntl he basis for ntc rnvged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^m Section 7031.5 by any appliean for`e pemut subjeels the applicant to u civil putally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five lam bed doll...($501).
CQ ❑ I,us awneroflhe pntpen.arm to th wv their sole coin minion. SWIMMING POOL ELECTRIC IMPROVEMENT
22 y vamp intended
tai gat as pe
will do Professions
and e The wreisnot rs License Lawe ed does
apply 7044,Business ❑OTHER
41"� and Pro who nt Code:The Coamcmrs License Law does not apply to if owner o OUTLETS-SWITCHES-I IXTURGS O
his o ny who Into his or Improves thInch i and who rni are n tante himself ff through
his awn employees,provided that such mentis uld a are on year of or offered for NEW RESIDENTIAL ELGC?R SQ FT
sole omilwev will
haveldi harden of
isat he lid non build or improve
the SQ.FT.FLOOR AREA 3/SQ.Pf,
row enhuilder will have me nrmen ar prestos inn[he dict not Hood or impm.e far prr-
p se ar anon[
❑ 1.a as owner je,a Sea 7041 vin exclusively contracting Cm1 licensed contractors m T
msmuct the es nor (Seo.]044,Business and property
fisswho ha Code')The Contractor thence, Li-
seLawdneenmapplymvnownerofpmpenywhobedpan lmprovcs Cortracand QTY. P BI RMIT PEE
who mnvoel.fnrsuch pr jecis with a commmngw)licenses pursmmno the Contractors10
License Law. 4'HRMI'I'I N
❑ Iron exempt undo Sec. ,B&PCfor this ren son
ALTER-DRAIN&VE (GA O VALUATION
Owner Data
/ WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.IIEVIC. D O O
1 hereby affrtm under penalty of pe jury one of the fallowing declamtiam,
❑ I have and will maintain aCenificamofConsentm sell-Insure For Workedw Gtmpeu- DRAINS-FLOOR,ROOF,AREA,CONI(. STORIES TYPE CONSTRUCTION
smion,as provided Fnr by Section 3700 of dte Lab o Cade,for the(RHnmmoce of the
work nor which this permit is loan . FIXTURES-PER LEAP
❑ I husband will maintain Worker's Compensation Inmtnnm,as rcxptimd by Seelig)(n
3700 ofthe Labor Car,for the performance ufthe work lilt which this permit is isseed ! GAS-P.A.SVSTGM-I INC.40UT'LETS [ O' .ROUP roAPN
y Walker's Comps n Insurance ent ierand Policy nuulerJj� - ` ZZ"
Carrier: I Policy No.: ZA- GAS-EA.SYSTEM OVER4(BA) 32
CERTIFICATE OF BXt?MPTION PROM WORKERS'
COMPENSATION INSURANCE GREASE)INDUSTRL WASTE INTERCEPTOR
BUILDING DTVI ION FEES
secedrn need not be mmplelexl tfNepermtl In Fnnmehundred dolhns l$1110) O
or less) GREASETRAP s PLANC EC FEE
1 cenify that in Iheperfnrmnnec of the work for which Nis permit is iswed I shall
nal employ to become SEWER-SANITARY-STORM P.A.200 FI'.
p yany person in any manner so as a jcteo the Workers G .E
QZ aaeion Laws of California.Date WATER HEALER W/VENT/GLECTR
0 Applicant - G A G FEE
Uj NOTICE TO APPLICANT:If,after making this CeniGcvm of Hxemption,you should WATER SYSTEXIC REATING
a hecomestinced m the Worker's Compensation provision of the Lubar Code you move 1'EE
4TJ forthwith comply whh such provisions or this permit shall bedeemed revoked. WATER SERVICE
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL TIME. SQ.FT PA
U I for by which this
that there isaeotnmm30rD,lending C.) tyfar Ccperformnnceof Date ceip
w the work for which this permit is Ixsncd(Sm.309],Clv.C.)
OULender's Name OTA
Lenders Address 'TOTAL.
Ha 1 cplil'y that 1 huvc rwd Chic application and rune that the above information is - � BUILDING PF O
r.w A correct.l agreemcomply with all city and countyominmtcesand state law.relatingm QTY. MECHANICAL PERMIT FEE
U Z buildingmm0uction,and hereby authorize roprauentativas cd Ec,ily m emerrpan the SEISMIC FTE / !I p
above-mentioned pmpony far In,eedual purryrses. PERMIT ISSUANCE
(We)vgrc o.. indemnify and keep harmless the City of Cupmrino against ELECT Z
liabilitles,j g rats.eostsa pensee which may in any way uccme against said Cit ACfFR OR ADD TO MECIL
in c
..roily end the of this permit PLUMB G EP.
APP IC T UND S OS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQ000C ND
SOUR :R[GUI If MGC( AL F'GH
AIR HANDLI NO UNIT(OVER 10jR0 CPM) (� CONST UCTION TAX
HAZARDOUS MATERIALS DISCLOSURE,
Signuwrc n[ ppllcaData EXHAUST HOOD(W/DUCT) a HOU NGMITIGATIONFEE
HAZAR
Will Cc npplievm nr finum huilJing rmenpvm still..nr bundle hazvrdousmaurial HEATING UNIT(1'0100.0!X1 B'1'U)
as red tied by he Cupenino Municipal Code,Chapter 9.12,and rho Health and Safety
Code,Section 25532(x)'! HEATING UNI P(OVER 100,1100 BTU)
❑Yce L]No OPAID
VHN'I'ILA'TION FAN(SINGLIi RESIDI Data Recti #
Will the applicant it future building acenpnB use cit Air Qu or Marts which
emit hamNom sir mmnminumc us defined by the Itny Area Air Quality Managcmm�[ BOILER-COMP(311P OR 100,000 B'i'U)
❑Yin E]No
BOILER-COMP(OVER 1(10,1X10 BTU)
AIR CONDITIONER
'e tribal" materials reryirememx under Chapter 695 of the Cali- ISSUANC=ATE
mI.H a &Snfe ,actions 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
buildi res nate ento eani[list it is my respommilily to notify the decnpart -Z (�
olth v,md e brubemc[pnnrso,arancenf aCrtificate of Occupancy. o
O n nn[horized a£em Uam T 4L: ISSUED BY:
OFFICE