S 2545 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-P:LP:CYRICAL PHRMIT NO.
IMITATING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL S 2545
WILDING PRQ Hies IDENTIFICATION
BUH.DINlA ESS: SANI'T'ARY NO. APPLICATION SUBMI'FIAL OAT
OWNER'S NAME: PHONE: CONFRACTOR:S NAM NO.
RI 6 OJ
1 p NIC COMI HOLp
A RCHI'fiCl'/, G IiIJt: LIC NO:•l N ADDIt:SS: -V ❑
ITJNMCT: PHONE: BUILDING PFRMI'IINFO
2-5-3 ❑'Consultant Fees Pail by Applicant(initial) BLDG ELECT PLUMB MECH
r_ IJa- ❑ ❑
LICENSED CON rRA(TI'OR'S DECLARATION Q'PY ELECTRIC I'C:RMIT FEF
I berenr reffimr that 1 am ficensc l ander,orchians of Cnapmm
r 9(crmendag JOB DESCRIP'T'ION
DOZ [h Satmr](1fIBTmn)ivisian9nnne Ha.inca.and l'mr i. c ane my B,enxe is t�7 RESIDENTIAL'
1- in force untie PERMIT ISSUANCE .J
Nu
J ❑SPDWL ri CH17N REMODEL
�UV Licrn. :Ims N AppL1ANCIiS-RIiSIDF.N'1'IAi. ❑ADDI'T'ION ❑1'hUM131NG kIiPll'R
��u] Dam_ ,r(
CC A I Cfti OitCLARAT ❑MULTIUNIT ❑STRUCTURAL.
N
4
F D m PANELS MODIFICATIO
Z p C—, I understand my plans shall be used os public records
OZO uPT02(N1AMPti ❑INTERIOR ❑CHIMNEY REPAIR
W Lleenxal Pndcs"ard.1 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DE?CLARAI'[ON
rY�j OVER I(NMAMPS �MCITI RF,MODEUREPAIR ❑DEMOLITION
a W G 1 hereby affirm that I am exempt form The Contractors License Law far the
51x p1,V following reason(Seclinn 71111,5,Business and Professions Code:Any city rr county SIGNS ELECTRICAL ❑OTHER
W a la•I- which reignite,a perms m cm ouacr,one,,improve,demolish.or remrir ary"income
Fpp,D.,OQ prior to its issuance,also marines The applicant fmsuch pemtitto File asi,dria,mcdoon SPECIAL CIRCUIT/MISC.
r js•] Ihat he In licensed laminator m meprovisinrsofthe Contractor',License Llw(Chnptor9
C 0C (armmaming with Section 7000)of Ulvinirn Sof the Business and Pmfesaimns Codc)or '1'I1MP.M11'I'II,OR POLIi INS'I'.
0,y o C that he is exempt therefmnt and the basis for the alleged eecniption.Any violation of ❑ F: BL I)DI'1'ION ❑DEMOLITION
'^ Section]011.5 by any applicant for apemidwhjects meapphianT Toa civil penally of POWER DEVICES
hot mom than five hundred dollars(1500). ❑IIMPROV ❑FOODSERVICE
z6 D I,asrwnerorthe pmp,ty,or my employees with wages us Their sale cotnpcnsation, SWIMMING POOL ELECTRIC IMPROVEMENT
0 will do lire work,andificarnmumisnol intindedoroB'erect frrsele(Sec.]LW4,Business El OTHER
and Podm,sirns Cade:'110c CnOrri License Law does nal apply m Int owner of OUTLI3'I:S-NWITGHES-FIX'T'URES O
propeny who builds or inTproves Ihercrn,;ord who does such work himself'or thnmgh
his own employees.provided that such improvements am nor intended or offered for NEW RESIDENTIAL ELEC!R SQ FE
sale.If.howcrn9 the huildingor impmentrat is sold wimirone yearof romplcdmrnme SQ.FT.FLOOR AREA SJSQ.IT.
owner will have the burden of proving that he did not build or improve for prm-
,we of xulcJ.
❑ I,m owner of the pmycty,um exclusively contracting with licensed cannumms E, Y i.'.
construct the project(Sec.]814,Business unit No asirm Code:)The Cen occ ia's Li-
u Law does nor apply in un owner of property who builds or improves Tbcreon.and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursranum the Contractor's rn
License Law, PERMIT ISSUANCE / v
❑ latncxonr,umdco Sce. ,B&PClinlhismrma
ACTER-DRAIN&VENT'-WATER(EA) VALUATION
Owner Dam /f /1
WUNKERnder PCOM PBNSA'DON DECLARATION BACK FLOW PROTECT.DEVICE / /, /, 1D
Thereby el maintain
ai under penalty of e PerjuryCnenemfinefollrwing Westontions: Gr (J lit
•� ❑ Ihave andwillforty Section 37ae of GmsemtoOut,wrefar Worker's Crmpen- DRAINS-Irl.(N1R,ROOF,AREA,COND. 5 RIES "I'YI'Ii CONSTRUCTION
sonar, t provided for by Section 9](Nl of the LaM[Calc,Ino the'cif nrmtmcc of the 3 Z r."
E] I lin which This permit is issued P1XT'URP.9-Pllli TRAP C'//
❑ I have and will maintain Worker's Compensation Inwruntt,az required by Section
3700afinelarMn Code.fn Ifo rfnmuncc of,beworkfin which mispc T' \sued. GAS-EA.SYSTEM-IINCAOUTLEfSROUT' APN
My WarkCl'FmureIIctien wand Parer �I 7 / - Sz
CanicrgJ/'�/'�� �� Policy Nn: ''9 9- GAS-EA.SYSTEM-OVER4 BiA) 3
CERI'IFICA'fH OF EXEMPTION FROM WORKERS' CNEASIUINUUS'TItI.WAB'I'111N'fI1kCBfT(IIt
COMPENSATION INSURANCE BUILDING DIVISION PINES
CI'his section need not M completed if the permit is forma,hundred dollars(SI W) _---" --
orless.) GREASE.TRAP PIANCI{T:CK FEE '
I cmify,hat in The Performanceaf the work far whichmis),omit is i...OF luturn SEWER-SANITARY-STORM EA.2W IrE
not mnploy any p.)a in any manned x,us to heerme whjeet m the Workers'Cooper- ENERGY FEE
Z ration Laws of Calif....a Date WATERHE;AfERW/VHN'T/I11.licFR
7� Applicant GRADING FEE
NOTICE:TO APPLICAN'P.11,afe,making this Certificate rl Exemption,you should WATER SYS'IHM?REAI'INC,
a , became sobject to the Worker's Compensation pmvisiom of The Lrbor Code,you mus, SOILS R
{>a fonhwith comply with such pmvislomomhis permit shall be deemed revoked. WATER SERVICE
Q
Z CONSTRUCTION IJ;NUING AGENCY NEW kESID13N'1'IAI.PI-MIL S0,It, PAID )m Recelp,if
1,)Q I herebyallirmlhal hereisacnnsulenpe
uctirn dirg.,rot,for therlhrnareerf
(~
the work for which Of,ischii,is issued(See 3097,Ci,C.)
Name
fnder's TOTAL:
) le
V Lender's Address OT
>a0Wi 1 rent,That 1 hove read this nppllcaion end stele that the above ialirmratinn is
I BUIL. 13E
0..1 TA mrrcck lugrccmmrmply with u0 cirytmJ crnnOyaNinunms and some bows rdmingm (TTV MECHANICAL PERMIT• FEE 2O
U Z building construction.and hereby authorize representatives of lhlsciry to cnmrulam the SETS IC Id7.
arose-mentioned Property for inspection Tomism s. PERMIT ISSUANCE
(WE)agree to save,indemnify and keep hmmless the City of Cupertino against ELECI'RI( FEE
liabilities,judgments.costs and expenses which may in any way accrtm against said City ALTER OR ADD TO MECH.
in consequence of the grunting of this p,rmh. PLUMBI FEE t
APPLICANT UNDERS'I'ANUS AND WILT,COMPLY WITH ALT.NON-POINT A I R HANDLING UNIT 001(T(NNt CPM
SOURCE REGULATIONS. Mf;CIIANI FEE
R HAND.Kj_(, NIT(O i Ith 1 CONSTRUCTION TAX
ow nIT
mem Dam F. HAUSI'E IQGD(W/DUM1 HOUSING MITIGATION FEE.
HAZARDOGS A'1'IiRIM S DISCLOSURE
Will micapplicantnr mind,building occupant store or handle hnzardians nmmrlalrAT 1 '1-1070j I
as defined by The Catania.Municipal Coale,Chapter 9.12,unit me...airand Safety
Code,Section 25532(x)] ALONG 11 11 UNIT(OVER IMAX)
❑Yes (SAO VIWILATION PAN(SINGLE RESHOT PAID
Dem Receipts
Will the air Haemo m fumed building by the Be,use coo Airnenl or tip urn tra.
mnit har.Wnus air mmaminams as TOP Ed by the BArea Air Quality Munngement - TO �
District?❑Yes [¢N/ BOILER-COMP(OVER 100,010 BTU)
O
I have mad the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER a�f ISSUANCE DATG
fomin Elmllth&Safety Gdc,Seducers 1.551.5,25519 and 25594.1 understand that If the NEW RESIDIINTIAL.MI!CH. SQ.PC
building does ort currently have a mnanT,th til ismymsgmsihilltylonnOifylhcoxcupant C_ r
of me requirement which must be met noismincecd CenificaTe of l]ccrlpiac,
efOrmitiff(iHOOETagent Date TIYI'AL: ISSUED BY.
OFFICE