S 2381 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING MECHANICAL S 2381
BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL Owl 1,
BUILDING ADDR'
l I
�R'SNAME' I'$O 1': CO RAC'I'OR'. NAME: N r hI NJj ^ NIC C(1NTROLp
R I I'. /6NGINEBR: LLLIIIC NO: ! DRES$R �I ,,1 I K �V ❑
CONTACL T/Il PHONE: D BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MUCH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 nerehy.fon„mm 1 an,l....ad underpro...ion,of chapter 9(commencing JOB DESCRIPTION
�aZ with Berlin.700(lofDivision set,he in Prole.....SCodd,andmylic1'F.RMIT ISSUANCE:aseis F TIAL'
W p p ZX�I1T
FaW In full G,co and effect IJVSFDWL ❑KI'fGIIEN REMODEL
dVUm
Lits, ��Ins Lic.p APPLIANCES-RESIDENTIAL, )DITION El PLUMBING RE-PIPIT
F z W Da { Contreeto
ARCHI'fFCT'S LOCAL MO❑MULTI-UNIT [I STRUCTURAL
PANELS MODIFICATION
Z p 1understand my plane sM1.II he used as public records
UI'TO 200 AMPS 0z4-G ❑INTERIOR Ll CHIMNEY REPAIR
Licensed Professional 201-IOOOAMPS ,- MPROVEMEN"P E)SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS BATH REMODEUREPAUZ DEMOLITION
1 hereby oducar that m I noxanpt from the Contractor's License Law ter the
following recent,(Series,70315,Business and Professions Code:Any city or county SIGNS IiI,ECTRICAL 17
41 a W y which requires a pectin to construct,alter,improve demolish,or repair any structure{pad prions ha lssuanw,aDa abqulres thenppllmm Breach permitm❑leasignwl secularism SPECIAL CIRCUITIMISC.
�9I `a ,hal he le licensed pursumlmme pmvieinm nrthe Cnntmtlors Liwnsc Luw(Chnptcr9
GAO
(commencing with Section 1000pdDivision3of the Businessandl'mfessions Codic TEMP.ALTER OR POLE INST COMMERCIAL
0.a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Way Schierl 7031.5 by say...learnt for a Perim xuhlcets the applicant or a civil pearly of POWER DEVICES ❑TENANT ❑FOOD SERVICE
�doil mase than Ove hundred dollars(8500). IMPROVEMENT
Lae hewrk,the n SWIMMING POOL ELECTRIC -
� � .rape y,ns,my employees with wages,s their sola compensation, []OTHER
will do th k.mdN 'I I lincluded ff IR 'I (See.1044,R
W m .red P f..- . Code The Connector's I'e La I ea 0 apply t nw oI' OUBTIPS-SWITCHES-FIXTURES
A' prop tY who builds or improvealluncon, 1 ohn does such work h m. If oil gh
his.,a employees,P vier d that such impro,calsocan,are n intended melficied for NEW RFSIUENTIAI.ELECTR SQ FC
sal If,h thebuilding' improvement ler 'thin Y f mpl i the j=7kF7FFIL0AREAj, $ISO.FTEller llh eth b d fp ,b(l tl der (bald p par-
po f: ).I f Ih p ertY 1 ly t "i 6 'l 1 ' 1 , t :to 'TOTAo a t in P 1 t(S 7044 B :" d P f .C 1 )'n C t I .Li- - ���
coast Law doe.not apply to an ownerol property who builds or ,proves ret, ,m QTY. PLUMBING PERMIT FEJIF
who contracts for such projects with a c mwamost licermal pursuant to the Curiosities
License Low. PERMIT ISSUANCE
Fl I an,exempt under Site ,B A,P C rnr this mason Y
ALTER-DRAIN&VENT-WATLR ,A)
Date
Pvnm WORKHR'B COMPENSA'T'ION DECLARATION HACK PLOW PROTECT'.DEVICE 11-7
r C_I1
1 hereby norm under.enalry of penury ono of me fallowing dedamtlons: F J M/
❑ Ihave rad will forbinection3me ofCe Labor Code,surere Woramece of
DRAINS-FLOOR,ItOOF.AREA,GOND. STORIES TYPE CONSTRUCTION
walk for
Eich this
for by Section 3]00 of the Ishnr Code,for the perfnnnm,ec of the
work for which ill maintain
ai ntai is Issued. FIXTURES-PER TRAP
❑I have end will oac a r Workers Compensation w rkfor ce,which
h his perm by Section
3100 of the L.bnr Cade,far the perfnnnence nrlhe work for which this permit is issued. CAS-EA.SYSTEM-1 INC 40l1TLETS C.GROUP APN
My Work s Crba,m mic In acro d Policy t � -I
Carrier:l�Eol in No.. `b `P{ ��I GAS-RA.SYSTEM-OVER 4IRA)
CERTIFICATE OF EX: PTION PROM WORKERS' GREASEIINDUSTRI.WAST E INTERCEPTOR
COMPENSATION INSURANCE - ,"BUILDINC4 sIONT Ipt
(This section need not be,completedifthaponnh is Tarns hundred dollars IS pp GREASRTRAP
or les..) PLANCHEF:CK PEE
Icenify that in lheperfurmanecefthe wtirkf..which butterinit is issued,Ishii SEWER-SANITARY-STORM EA.200 IT,
nm employ any person in any manner so it,to loco me adBe t cache Workers'Cooper- ENERGY PHP.
oz
anion Laws of Cclumaria.Dam WATER I(EATER WIVENI➢ELECTR GRADING FEF.
G 0 Applicant
f/, NOTICE TO APPLICANT.If,after making this CeniOcam of Exemption,you should WATFR SYSTEMITREA'DNG
H 5 heeumt subject local Worker's Compensation pmvisione of the Labor GXle, cannot SOILS FEEW forthwith comply wuh such Pre visions or this permit shall be daemsedrevoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW ItESIUENT1Al.PLMI3. SO.FT. PAID
I herchy allied that there ix aeo„swnton lending rgencyfortheperlmnm,oe of Dem - RcceiptN
the work far Morbid,permit is Issued(Sec 3097,Co.C.)
Q Lenders Nmne TOTAL:
Lenders Address TOTAL:
1 certify Nal 1 oavoread this applsation and sate tom the abuse inrormmish o BUILDING FEE.
-ii h correct,I agree to comply wire all city and ummy ordinances trod state Taws refining to QTY" MECHANICAL PERMIT FEE
V buldaramastmetion,and hereby ltuthorize repmsnnotivcs ofthis city or mutation the SEISMIC FEE
abovo-men0utmd pmi rnr inspection purposes, PERMIT ISSUANCE
(We)agree m save,indemnify and keep harinlres the City of Cupertino against ELECI'k IC FEE
Iiabiblies,judgmetns.costs and expenses which may in any way ucnueagainst said City ALTER OR ADDTO MECIL
PLUMBING FEE
qhc
maceof the RSTAgranting Sthispermit.
NDERSTANDS AND WII,I.COMPLY WITH ALL NON- OINT AIR HANDLING UNIT(TO III,OIN)CPM)
MF,CHANICAI.FF,F.
ULATIONS.
AIR HANDLING UNIT(OVER IO,IXO CFM) CONSTRUCTION TAX
p,eam/Comrncmr Dam HXHAUS'I 11001)IWIDUCT) HOUSING MITIGATION FHH
HAZARDOUS MATERIALS DISCLOSURE
r,pE...a or future building secupam ream e,handle matimeus material IHINTING UNIT(TO 110,00()BTU)
as 0elnul by he Cupertino Municipal Co.[,,Chapter 9.12,and the Health and Safety
Gide,Section 25532(.)! HEATING UNIT(OVER 100,00011'U)
�. E]yon, []No PAID
VENTILATION PAN(SINGLE RESID) Du - Receipt
Will the of,contra as,future building y the p use equipment Qm us, Micas which
it hazardous air amtaminanta as datincd by the pay Arco Nr Quality Management BOILER-COMP(3HP OR 100,000 BTU) TOTAL:
BOILER-COMP(OVP.R 100,000 BTU)
O Yes E3 No
AIR CONDITIONER
' u I read the Pounders materials requirements under Chapter 6.95 el the Coli- ISSUANCE DATE
G v ,&Sofcty Cafe Sedinm 25505,^ JJ and 25534.1 understand that if the NEW RESIDENTIAL MECII. SQ.Pr.
b Tide g n not currently havcamnvnt.that' myro"i,conbil'nymnntif Iheuec pant
o the minty which ,ost tnctp r enfa Con i"are so "pa y.
Ow Incugnnt Dam TOTAL: ISSUED BY.
OFFICE