S 2434 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 S 2434
BUILDING PROJECL'IDENPIFICATION
pU1LDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: COMRAMOR'S NAME: giiLIC ND:
U� r ur rJ C WC g tyr 6 L NIC C(lNl'ROI.p
RC HIFECUENGINEER: !� r LIC NO: f0 J ADDRESS: /+L i7 ❑
_11537S 4-Sv
N'1'ACI': PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HL❑ENG ELECT' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE IJOB DESCRIPT[Or
1 hereby af8on that I am licensed under provisions of Chapter 9(commencing IOIJ(
woz with Section 71)(Doof Division 3af dr Busineamid Prolvoirms Code,ane my heamen RESIDENTIAL' ,�"/
a100 ' PERMIT ISSUANCE
�F-Iy� in h+rec and effect. /_ S�pc OSFDWL PLUMBING
ZU License Class Lic.p 3l0?a1:7 � pPP1.lANCES-RESIDENTIAL. OADDITION ❑PI,IIMBING RE-PIPE
rFi�aa Date cnmrueumr
"AnHl DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
z Orr'z I understand my plans shall be used as public records PANELS MODIFICATION
Oz40 UPTO20DAMPS [DINTERIOR 0CHIMNEY REPAIR
[�aVlI^W Licensed 11...Ia Tonal 201-INDAMPS IMPROVEMENT E]SWIMMING POOLS
gig
OWNER-BUILDER DIiCLARATION OVER I(MXIAMPS ❑BATH REMODEUREPAIR ODEMOLITION
1 hereby affirm that I am exempt Iron the Common's License Law for the
0.�((O ,V following reumn.(Section]OJLS,Nosiness and Professions Cade:Any city nr county SIGNS F.LECTRICAI, ❑OTHER
IL s3 W I- which rupdre,a permit to construct,cher,improve,demolish,or repair any structure
I-'ci�O prions its issuance,also requires the applicant for such Permit o file a signed statement SP17CIALCIRCUIT/A11SC.
that he is licensed pu.uanttothe powisionsofthe CommcmrsLicense Law(Chapter 9
u)W C (a+..encing with Section 7000)of Division l ofthc Business and Profindams Code)or TEMP.MFT ER OR MIT INST COMMERCIAL:
daoy that he is exempt dumfm.and the basis for the alleged exemption.Any sin nium of ❑NEW BLDG/ADDITION C1 DEMOLITION
XmN Section 7071.5 by anyopplicant fora permit subjects the applicaonoa civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
W out more than rive hundred dollars($500).[-.Z Y IMPROVEMENT
O ❑ Lo the work,and
pmpeuc• r isnot mends withwages r talei(See 7ompcusines, SWIMMING H%)L ELECTRIC
will do the work,and the structured urn,Licand nr.me du for mole(Ree 7844,awria,msa [I OTHER
and property
wnions Code:The Contmemrs License Luo does not apply turn owner of OU'fLE'IS-SWITCIili9-FlX'I'11RIiS
pmpcny who builds or vided b thshah i,and who Ansa such work
te ided o,orthrough
his own owswoeea provided tfnn arch mens ismnems are not intended or o8ered lin NEW RBSIDEN'TIAf.1?LT:CTR SQ tT.
side,H.however,the building.,improvement is,old within one yea of conmpldinn.tbe SQ.FT.FLOOR AREA E/SQ.FT.
owner-hmlder will have the burden of proving that he did not build or improve for par-
,wv rf sale').
E]1,as owner of the property,ant exclusively contracting with licensed coons ms to TOTA2!.
construct the Project(Sec.71144,Haut....and Pude Mona Code:)The Cominco..M-
cense Law does not apply toanowner of property who builds or inforwas thereon,and Q'I'Y. PLUMBING PERMIT FEE
who contracts fnrsuch projects with a commcmr@)licensed pursuant to the Contractor's /-�
License Law. PERMIT ISSUANCE 0
I am exempt under Sa. .B&P C fm mi,.00n
ALTER-DRAIN&VENT'-WA'U!R(ITA) VALUAI]ON
Owner Dote
WORKER'S COMP17NSA'1'ION DECLARATION HACK FLOW PROTECT.DEVICE
I herchy affirm under perisky of penury one of the Ibllmoing declanitions:
I h:nmmA wit aturnmr.Ccnilicaicol'Cn oanftoself-insure for Worker's Catagen. DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPI?C0 TRUCTION
dm provided for by Section 3700 of the labor Code,for the performance of the 1
lin which this permit is issued. FIXTURES-PER 'RAI' N
�(II have and will maintain Worker's Cnmlu'nsution Insurance,as required by Section
2-
Rol Lahr Code,for the performance mom work lnr which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker Com nUI on Insurance comer unA Policy number U EA.SYSFF OVER ,��
Cartier. 'T cu►I n PION FRO017M
CERTIFlCATEOE PTION FROM WORKERS' I%INI SIE -iRCF.I
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thisscelion acMnotbecompleted ifmcpetmit isfaronehundreddollaca(SIM) ( ASE TRAP
or lens.) ttth�s PLANCUECK FEE
candy that in the peKommnceoftho work fnr which this permit is issued,Isha1l FIT AANI' k - )R 00
not enmploy any person in any manner so as m becono subject to the Worked Camp.- ENERGY PEIi
Zz snLawaot'California.Data APER HEA'I'BIT W/VENT/III.FC'I'IT
O tion Applicant GRADING FEE
i
NOTICE TO APPLICANT.IL after making this Ceoilieate rf Exemption,you dumb ,. TEMIFREATIN(-i
(~ become subject to the Worker's Compensation provisions of the Labor Cale,you most SOILS FEE
Coilforthwith comply with such provisions or this pcomil shall lc deemed revoked. WATER SERVICE
4 0
CONSTRUCTION LENDING AGENCY NEW RESIDENT[Al.PLMB. SQ.EF. PA 11
V 0 Thereby aRrm that there isacnnswctiren]endia,.,.y farthe perfommanttof m Recei"I
Fthe work for which this permit is issued(Sec.3011 Civ.C.)
Lenders Name TOTAL:
0 V Lenders Address T T
aI ccnify that I have read this application and stale that the above infnmtathm is BUILEI N .E J
i-t N an rcct I ngrce QTY MECHANICAL P17RMIT FEE
U huilAing nnvwrudinn,and hereby amhoriae mprescnunives of this city In coat upon the SEISMIC F.E V
shave-monk ned propmty for inspection purlosea PERMIT ISSUANCH
(We)agree to save,indemnify and keep hornless the City of Cupeninn against r lil.[CTNIC E
liabilities,judgments.costs andespenses which may many way acemeagainntaaid City ALTER OR ADD TO MECH
in cmmegaeme of Ne graming.(this permit PLUMBING FE
APPLICANT UNDERSTANDS AND WILL Co1 PLY WITH ALL NON-POINT AIR HANDLING UNIT(IT)10.0010CFM) MECHANICAL FEE
SOURCE REGULATION.
6l ^ 1/I AIR HANDLING UNITIOVIiR IILtMtfICFM) CONSTRUCTION TAX
Signature(if Appli .rmcmdracter /r/ Dam EXHAUST HOOD(W/DUCI) V HOUSING MITIGATION EEC
HAZARDOUS M ERIAI S DISCLOSURE
Will the nppllead or furore building occupant More or handl,hazaNuus mmenal I]RATING UNIT(TD 100,000 B'I'U)
as defined by the Cupeninn Municipal Code,Chapter 912,and the I health and Safety
Cade,Seamon 25532(x)? HEATING UNIT(OVER Ise ORE BTU)
❑YesJct Vf?NTILATION FAN INGLE BITS 111) PAID
N Uate Recail,0
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(311POR 100.000 BB'I))
mit hi air contaminants as derined by the flay Area Air Quality Management T
.wrier]
11 Yes We
MOILER-COMP(OV FiR I(XI,INX)B'fU7
I have read the hasNrams mamaterialsrequiremerequirementsryrequirementunderuer Chapter 6.95 of the Cali. CONDITIONERi� ISSrrrU���ANCE ATF, � ^
hmmiu HwIN&Safety Code,Sutinns 25585.25577 and 2594.I uMcrstand that if the NEW RESIDENTIAL MECH. SQ.FC
buildingdoes not currently have a retool,the it is my rcspnnsihilify m.vify the tccupum ✓�1
rm
rtnc uireenu which. , met For :::Sl uance a Cenihea.af(lc uFancy.
Ownd or aumonmd a Dam ISSUED BY:
OFFICE
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