S 2027 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD NG-ELECTRICAL. PER`�11'1'NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �J 2027
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRL.SS/ � ) IVQ� I/ / _ r ,/ A A'O SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER' ME: //�,/ PHONE Y 'N/CfOT1N'fRACfOR'S 'nr,v hIC NO: ^T
r� _ O�� NIC COST'ROI.#
ARCH[ CT GINEagoadl
ER. ( LIC NO ADDRESS: ❑
to D ell 411
CONTACT: ..+. PHONE: + BUILDING PERMIT INFO
3-7?- 751 E:1 Consultant Fees Paid by Applicant(Initial) DG ELECT PLUMB MEQ
iO ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I em licensed under provisions of Chapter 9lcontmndng JOB DESCRIPTION
'a2 with Section 9000)of Division 3ofthe Business and Professions Code,andmy licene is RESIDENTIAL:
i. PERMIT ISSUANCE
FW" iter force and t. p 3.S ❑SFDWL El KITCHEN REMODEL
aUzU
Liters LicNv APPLIANCES-RESIDENI'I AI. [_1 ADDITION C1 PLUMBING RE-PIPE
I-d W Dme Cnntramr
at Z ail ARCHITECTS DECLARATION ElMULTI-UNIT ❑STRUCTURAL
zoit'lZ I underhand my plans shall be used as public records PANELS MODIFICATION
41_M UP TO 200 AMPS - ❑INTERIOR El CHIMNEY REPAIR
1F�I'.W Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
4Wa-i OWNHRTUILDER DECLARATION OVER IWOAMPS ❑RATH REMODEWREPAIR El DEMOLITION
R R a 1 hemhy offmt Thal I o,a exempt from the Contractor's License Law for the
x�0 W 0 following reason.(Section 9031.5,Business and Professions Code,Any city or county SIGNS ELECTRICAL ❑OTHER
which teyaitee n permit ,,consumed,alter,improve,demolish,m oTait any,emome
[❑❑.. priano it issuance,also w4uires me applicant for such farmit to File u.signed statement SPEC]AL CIRCUITIMISC.
is o that he is licensed pursuant to the provisions or the Cormadoe.a License Law(Chapter 9
CW O hdriouncing with Seed]on7000)of Division 3 ofthd Business nd Pmfessmns Code)or TEM P.ME'T'ER OR POLE LIST. COMMERCIAL'
d y o y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m Section 703 LS byany upplantnfor a permit nrucal,the applicant to a civil penalty of POWERDEVICES [-]TENANT ❑FOOD SERVICE
zp. of mad than five hundred deflars($5W). YAPROVEMENT
6 [D I,as owner of the property,or my employees with wages ae their into compensation, SWIMMING POOL ELECTRIC
0 will it,,the work,and the throure is not intended otnftrred Inside(Sar.9044'Business OTHER
d " and Professions Code:The Contractors License Law does not mpply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpeny who builds or improves thereon,and who docs such work himself or through
his own employaes,provided that such Improvement are nal intended or offered for NEW RESIDENTIAL.ELFCTR SQ IN'.
sale.IL however.the building or improvvmem is sold Widmann,yearefcmnpleJoq the S AREA $/SQ.PL
e
rFailder will have the burden of forcing that he did not build or improve for put- (1,
pe
a
of arae)
TOTAL'
❑ 1,as owner of the property,am exclusively contracting with licensed contractor,to
rnemm the p Jam(Sec.7044.Business and Pmfessmns Code)The Consortia L1- -
censeLawdoesnntapplytoanownerofprogenywhobuildsorimprovesmcrean.and QTY. PLUMBING PERMIT PEE
who wnuame Branch Fmjeces with o cantracnr(s)licensed pant anus the Comment's
LicenseLaw. PERMITISSUANCE
IDI am exempt under Sec. ,B&P C for this reason
Owner DateALTER-DRAIN&VENT-WATER(EA) , /,Ili VALUATION
WORKER'S COMPENSAI ION DECLARATION BACK FLOW PROTECT DEVICE YY/�D
_ Ilurobyaffine under pdookyof,serm,cre of lire following dedamtion
❑those and will inaimaina Certifcateof Consentto self-Insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. TYPECONS'TRULTION
STORIES
smion,as provided for by Banton 3]00 of the Labor Code,for the performance of the
k which this is issued. NIXTURF.S-PER TRAP
coo hove and will od (maintain Workers Compensation w Issuance, h rk,andf by$anion
3700 of lha Franc Code for the performance of the work for which lhie inormit is isaned. CAS-EA.SYSTEM-1 INC.40l1TLEIS OCC.GROUP APN
MyWorke��.'ii Campensatian Insurance mvrientnd Policy I -once:
GREASUINDUSTR
Canler�,] (Ty
CO O/A-- Policy No.. GAS-EA.SYSTEM-OVER
ERTIFICOF EXEMPTION FROM WORKERS' L WASTE INTERCEPTOR
COMPENSATION INSURANCEtlU1LDING DIVISION PEES
(Thissectioeneednot be eompWed ifthepermil is f ons hundred dallars($I00) GREASETRAP
or less.) PW NCHFAK FEE
I certify that In the perfannttnceofthework for which this permit is issucd,ishall SEWER-SANITARY-S'1'ORM EA.200 FP.
not employ any person in my marcor so as n become subject m the Workers Compen- ENERGY FEE
z ,Z union Laws of California.Date WATER HEATER W/VENT/ELECTR
O Applicant GRADING FEE
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMRREATING SOILS FEE
f~ 5 become object np
I.the Workers Cmcirsatirn provisions of the Labor Code,you mull
La$1 forthwith comply with such provision,.,this monasholl be deemed revoked. WATERSERVICE
Q
Z) Z CONS]RUCTIONis.c ONLENDING AGENCY NEW kF.SIDENTIALPLMB. SQ.t1'. PAID 6FEE
1 hereby uffinn Barnacle is n cnnhruminn lending agency for Iheper[onnvnec of
U he work fir which this pioned is issued(Sen.3097,Civ.C)
V .Lender's Name
Lenders Addross TOTAL:
} ISI BUILDING
[r I certify Nat 1 have read Ntsty and
oa and elate that the able laws r elating is
TZ correct.I agree ie comply with all city and rseumy read e,of and state laws relating to QTY. MECHANICAL PERMIT PEP.
V z huilding eonswetion,and hereby luthonze reprcsenunivw of this clly renter upon the SEISMICP
aMrve-drammncd property for inspection fmpoaes. PERMIT I.SSUANCP.
(We)agree to save,indemnify and kap handaw the City of Cspeniao against ELECTRICliabilities,judgments,costs and expenses which may in any way sector againsixaid City ALTER OR ADD TO MUCH.in cnnrequcna or the'Turing of this permit PLUMBIN
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ATR HANDLING UNIT(TO 10,(1110 CFM)
MECHANICAL FEU
SOUR :REGULA'TIONS. '
r Yf AIR HANDLING UNIT(OVER 10.(1(10 CFM) I CONS'I'RUM[ON TAX
Signature of Applicant vm
aor oC- Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
Z RDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocemfantsme or handle homrdrme material HEATING UNIT(TO 100,001)BTU)
as defined by the Cupenam Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)I HEATING UNIT(OVER 100j"RTU)
FYes [-1 No PAID
VENTILATION PAN(SINGLF.RESID) Dme Receipt It
Will the fir cmata or future building by the B use equipment or Maras which
emit hazsNous air contaminant vs defined by the Bay Area Air Quality Management BOILER-COME(THE OR I00.IXIII BTU) TOTAL:
Dennis?
❑Yes 7N BOILER-COMP(OVER 100,000 BTU)
, EQ
I have rend the bamtdous materials naluirements under Chapter 6,95 of the Cali- A I R CONDI'I'IONER ISSUANCE DATE
S mia Health&Safety Cade,Sections 25505,25533 tied 25534.1 undersand that If the NEW RESIDENTIAL MECH. SO,FT.
building dors nal .,,ntly have a Iona...,.hat it is my responsibility to artily the acin,and
oftb quiremcroswhadoust be met pros In tnsuanee ofa Certificate of u uncy. �/r`�yf T
OwneroraatherrTel a's's Dale TOTAL ISSUED BY • • -
OFFICE