S 2875 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
/n CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO.
'� BUILDING DIVISION APPLICA'PIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDEN'11111CA'1'ION
BUILDING ADDRESS: SANITARY NO. A�PPjPPL�ICATION SUBMITQTAL DA'IL
%0\T1 t 1 a r/ p— ?�
OWN1iN:SNAMLs; PI[ONE CONI SAC]OR'S NAME: LIC NO.
Sk4%r%bF% • y. IF2 r, S- \,.Q - MAST• NIC CON'I'RUI.#
ARCHITECT/13JGINEER: LIC NO: ADDRESS F-1
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
❑ ❑ ❑
LICENSED CON'1'RAC'[OR'S UECLARA'I'IONozz QTy ELECTRIC PERMIT I'BE
1 hereby affirm that I am licensed ander provisions of chapter 9(commenting JOB DESCRIPTION
infill fameand elf O' isinnJnl'me Ha^�eC1 arnA Pmr�.ninnrCnJo,andmylicenseis RESIDENTIAL
O 2 ! o ( PERMIT ISSUANCE ❑SPDWL ❑KI'ICHENREMODEL
-Uajaj
Licenser�yy A .L. b4 APPLIANCES-RESIDEN IAL ❑ADDITION ❑PLUMBINGRE-PIPE
r�<,1 ARCHITECT'S DECLARATION ❑MULTI UNIT ❑STRUCTURAL.
Z O�z I makhOwnd my plans,hall be used os puhlic records PANELS
MODIFICATION
OZ— UPT0200AMPS [I INTERIOR ❑CHI.MNFY REPAIR
aIJ,ensed Prufroo nal 201-IINNIAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER LOIN)AMPS ❑BATH REMODEUREPAIR EIDEMOLI'HON
W C 6 I hereby afro that I am exempt from the Contractors License Luw for the
x O W U following reason.(Section 7Ill 1.5.Business and Professions Cod.:Any city or county SIGNS ELECTRICAL LJ OTHER
all ❑
which requires a Permit to condirma,altar,improre,demolish,or repair any strucwre
0 prim m'ns i"'clac,dscio, res]mete,irmlfur,tohpenninn file ao,mesl statenuent SPECIAL CIRCIII'I'/MISC. I r
Inthat he is licensed pursuantto the provisions of the Contractors License Law(Chapter Y
C (e"mmmncing with Section 71X10)uf llivisienJ nf,lies Business and Pnhlsei.ns Coda)or 'I EMP.METER OR POLE INST. COMMERCIAL:
a a o x than he is exempt therefrom W
and the basin for e alleged exemption.Any Gmflon of ❑NEW BLDG/ADDITION ❑DEMOLITION
m,•an Section 7031.5 by any applicant fora Nnuit subjects the applicantto acivil penalty of POWER DEVICES ❑TFiNANT El FOOD SERVICE
urn mom than five hundred dollurs($S01B.
IMPROVEMENT
wi Loownend me praperty.or
inuoremyemphsyees wimwages ar their Sec.
SWIMMING;'001.[LECI'NIC
� O will d.mewmk,Cort:The tmistmlnt ldvol;cense Law does
of apply toan.Bminess ❑OTHER
4 3 m and Professions Code:The Cnmtaconm License taws .i not apply s if owner st OUTLETS-SWI'fCHLS-PIX'fUNES
hispohneo,own who hated,nr impnwes then.,,end
po who does such work himself or tbrmgh
his own employeese holding that such,mal Nod nu ac n.,intended tor offered for NEW NESIUIiNTIAI.ELIiCTR SQ FT.
saleerNildevea ll have(di burden
;Out,he id n one round
or iegpsu tic fill the SQ.FT.FLOOR ARG SISQ.FT.
ervhulWer w111 have the harden of proving tent he did no,Fu11J nr interns,fn,'pur-
pomofsoleJ.
E] 1,as owner of the pri,o,um exclusively cunhashin,with licensed contractors to TOTAL
cnnstow,the proje„Not,70,4Q Business and 1'nde,oam ChdeO'1 he Contractors Li-
censeLow does hot apply manowser of property who build,or moons.there., ad QTY, PLUMBING PERMIT FEE
who mowers f'.r such projects with a conouetorts)licensed purauanuo the Contrnc,ors
License Law. PERMIT ISSUANCE
❑I am excmpl under Sce. ,1{&i'C fur,hisrr,cn
AFTER-TRAIN&VENT-WATER(EA VALUATION
Owner Date �r
WORKER'SrperalMPENSATION UECGRlowing BACK FLOW PRDIGCI'.DEVICE
I hereby a0 imh under penalty of pc jury one of the following Worker's Co:
❑Ilius,and will maintain aCertilicate of Consent wBelt-nonuse for Worker's Cn,npen- DRAINS-Iq.(rl4H1rRE)HYrAR1iAsGGp1DS'1"DRIES TYPECtIN�CTION
smion,as provided for by Section 3/00 of the Ichor Code,for the perfrroutwe n1 ube ^ /
work lira which this permit is issued. FIXTURES- ' RAP n JC/r
I have and will maintain W'orker's Compensmion Insurance,as required by Section
3701hffme Labor otic rform:mce,of,he work for which this per.Iisiss ted GAS-EA.S I, -I INC.4 OUTLETS (lC GROUP ��/ M •
My Worker •nsa, I umne,Gamer unJ Policy n �, Y L
Cannier: Policy No.: 1q`.tg/3 2� GAS-EA.S . :M-�`�I?JS RA 1999
CIIRTIFICAI'EOI'LXIlMFTIUNPKOMW RKliRS' J V
COMPENSATION INSURANCE. GR 'TItL WASTEINTENCEPTON
BUILDING DIVISION FEES
(Thi,section need nrn be cnmplipe
erod it rmit is form,ahundred dohm,S 1 W)
m less.) GREASE IR "PIA PLANCHECK FEE
I certify that in the perfommnce ofine work forwhich this penmit is footed,ishali SFV'r R-II
not employ any person in any manner sn os t.become subject n,the Worker;Cmtpen. ENERGY PRO,Z, smion Laws of Calif nam Dae WATER HEATER WNEN1/IiI=R
F.
z O Applicant GRADING Wi
N NOTICE TO APPLICANT:IL attar making this Certificate of Exemption,you should WATER SYSTEM?RIiATING
a ;
become subject to the Worker's Cnmpensminn Pr.viniuna of the Labor Cnde,you most SOILS FEE
fonhwim comply with such pmvininn.r nr this permit shall MJeemeJ revukeJ. WAFER S17RVICI?
0.
CONSTRUCTION LEN DING AG17NCY NEW RES IIIENG 1 A L PLMB. SQ.FT. PAID
U Z I herehwthrow
ydBalin.I,. nsction lending agency forthe performance of ate Receipt
"s toss V O ten wink for which dons permit i,;sered(Seo.7099,civ.C.)
Lenders Name 'POTAL
L) Lenders Address "rOTAI.: .
1 certify mre
at I have ad this application and state that hhe ld ov,mfarmar �
on is B .ILIAC I'EE
17
CA cartl l agree to comply with all city and county ordinances and state laws reemingto QTY. MECHANICAL PERMIT FETE
C) z builAing cons,sultan,enA hereby uulhnriee reprenentmiver nt min cloy manner ulmnthe SIS IC I'GF.
aMwe-meminned Property for inspection proposes. PERMIT ISSUANCE
(We)agree.h save,indemnify and keep hmmless the City of Cupertiuo agents, EEE[TRIC PEE.
H.bilides.Bolloontz,econtnd expenses which may in any way accmeaguinosaiol City ALTER OR ADD'TO MECH.
in coo,, aoc hurdegmafngof this Permit. PLU LNG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR DANDLING UNII'(TO 10.000 CFM)
MECHANICAL HE
SOURCE REGULATIONS. �'''''����� /� p
. -)'i=�=� ,- Cm e AIR HANDLING ONI'I'HIVP.R I gINIOCFMI CONSTRUCHONTAX
J
Signamre(il'Applilanvc"nn.mnr Date EKHAUNI'GOOD(W/DUCT) HOUSING MITIGATION FEE
HA%ARDOUS MATERIALS DISCLOSURE
Will the applicamor fatme hard,.,.,.,an,sasre or handle hazardous morm.1 HEATING UNIT(TO 100.000 H'IV)
as defined by the Capetian Municipal Cade,Chapter 9.12,and dm Heal,Ili and S.fcty
Cale,Section 25532(x)^ HEATING ON]l'(OVEIt 1 W,00d H'I'U)
El Year 11 No PAID
VENTIG'fl(lN PAN(SINGLE H&$IU)
Date Receipt#
em
Will the applicant m furore b fitnedted I,<upma use equipments devices which
it hazardous air commninanta ns de,fiby the Itey Arca Air Quality ManagementROILIiR-COMP(3HP OR 100,000 IF TO)
E]Yea ED No O
Dixtrim l BOILER-COMP(OVER 100,000 RTU)
I have reml the byord.usT,nenaesresp,iren,cntsunder Chaptcr6.95 ofthc Cali- AIRCONDITIONER ISSUANCE DATE
fmmia Health&Safety Code.Sections 25505.8577 and 25534.1 undersmmi than,if the NEW RESIDENTIAL MFCH. SQ.F1'. / A �— Qe
holding doer mm cmrendy have a mnam,ma,it is my mm sp.nsibility notify the occupant (T//�
n of the yuire a which th temp ttuf.Cerin mo 0c ncy.
Own roro�ut mr, agent Dale TOTAL: ISSUIiD BY:
OFFICE