S 2175 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE1{`L4IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, v 2175
} BUILDING PROJECT IDENTIFICATION '
BUILOINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
kNERSNdE: PHONE, CONI'RACTOR:S NAME - LIC NO:
NIC CONT L#
PrRCHIFECTIENGINEER7LIC NO: ADDRESS ❑
/ S S Y5ry
CONT'nC'r. pxONF.: - BUI NG VRMIT INFO__ '
N - ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MP,CII
LICENSED CONTRACTORS DECLARATION QTY ' ELECTRIC PERMIT FEE ❑ ❑
l nereny arnr m thin l licensed e e p nr Pa Cher 9 Ri made g _ B DESCRIPTION
ooz wish Savem.9W0)nf P DM1 Busi dP f sion,Code,and a,lcetee is RESIDE A '
O in full force and 0 feat .spy PERMITISSUANCE.
Z V U License Cl urs Lia#.--�eIG4�' ❑SFD ❑KITCHEN REMODEL.
yQL Date Connacmr—_C'QO7 j({T�✓ APPLIANCES-RESIDENTIAL. DA TION El PLUMBING RE-PIPri
1„]2N2 ARCHITECTS DECLARATION ❑ UFFUNIT ❑STRUCTURAL
zC) z I understand my plans shall be used us blit records PANELS
trust public MODIFICATION
rz� M UP T020UAMPS -
�rNl❑'--'u] Lmcnsad Pade.annal INTERIOR ❑CHIMNEY REPAIR
PDOU
OWNER-BUIIAER DECLARA'T'ION 201-I MWAMPS IMPROVEMENT SWIMMING POOLS
yy C I hereby affirm that 1 am exempt from the Contractor's License Law far the -OVER 1000 AMPS _ ❑BATH REMODEWREPAI ❑DEMOLITION
ee 3,F following reason.(Swtlmn 703 L5,13usinecs and Professions Gdc:Any city or county SIGNS BI-L'CI'RICAL ❑O'fHER
O N which requires n parent m wngrueL also,improve,dcalollsM1,nr repair any stm elle
pdnna us issuance,assn cables,lbaappllcans(such pennilm fileasiSnW_etatemant SPECIAL CIRCUIT/MISC.
{��y Jur'he is licensers pnrsounuo the phavainras oCme Canlmaor,License 1, (C'a"' a
41[.LitO (comrmning with Secaon 0000)nfPositive 3oflhe Basincss unit Professions Cadeprr M L:
TF.Mp METER OR POLE INST.
W W o C Ih:n he is exempt IhereRom unJ the basis for IHe alleged exemption,Any violation of ❑NEW BLDGIADDITION ❑IlF:M01.IT10N
W.m-a 0.N, Section]0315 by any applicant for a permit subjects the applicant In a civil finally of POWER DEVICES
not mora than five hundred dollars($500). - ❑TENANT" ❑FOOD SERVICE
❑1,as owner of the pmpetly,onny employees with wages ns lhcirsnlc armpensysia , RIC IMPROVEMENT
will do the work,and the structure is not intended nroffued for sale(Sea.7044.Bnalness ❑OTHER
gal all and Perfessmw Code:The Conti Inns License Law docs nor apply to on owner of OUTLETS-SW ITCIIES-FIXTUItH -
r property who bunds tar improves thereon,and who does such work himself or shmugh
his own employees,provided that such improvements am mol intended or olrcred for NR 'RE E R
sale.IL however,she building or improvement is sold within one year ofenmpleron.she SQ.Fr FLOOR AREA S/SQ.P.
enbuilder will have she burden of proving that he did not bull([or improve for per- _
p saof sale).
❑ L as owner ol'the pE,ftyp am oreltivVely cur menti,wnM licensed euro res le TOTAL'.
construct she project(Sec.9044,Business and Professions Code)I lie Contractors I i-
o 'e Law does not apply to an owner ofpropery who builds a improves theram,and -
wh
License
Lace projects such proleewith n eommnor(x)licensed pursuant m the Cnmmtar's
License Law: I❑ m PERMIT ISSU CE \\J
1 aexempt under Sec. ,R&P C fonlds reason
"ER- N VENT-WY
D (E
r am VALUATION
WORKER'S COMPENSATION DECLARATION- B C O L HICT.DEVICP
I hereby affirm ender penalty of pcfury one of she fallowing dechn'adim.
7_]
Ihvve and will mainmim Caaificmo o[Cnncent to selGinsure far Wodars Cnmpan- D INS-PLOOR, STORIES TYPE CONSTRUCTION
ion,as provided for by Section 3700 of the Labor Code,for the perfommrce of the
ork for which this permit is issued. '1 STU R ES-PER TRAY
1 have and will ra imhin Worker's Compensation Insurance.as required by Selion
%)or the Labor Code,for t he performance of the work Errwhich this permi t is issued. OAS-BA.SYSTEM-I ING40UT IUS OCC.GROUP APN
y Widend Policy numrrier: peiryNo.'. GAS-F.A.SYSTEM OVER 4(EA)
CP,RfIFICATE OF EXEMPTION FROM WORKERS' p�
COMPENSATION INSURANCE GRE ASFJINDUS'rRL STEIN IIIER -
' BUILIANG DIVISION 11731
("rhiaaealion need nnthecomplaeJifihepermiGs fiancee hnndmd Jnllur T
or IessJ UU) CREASE TRAP
I certify that is she performance ofthe work for,hich this per misisns adf shall .ANCHECKPEE
nos employ any pervun in any mm�ner.w ns sad becnmesuhjecsmthe Wn. s'Comtem SEWFIR-SANITARY-S' E -
Z cation Lawsof GdifornG.Dare fERGV FEE
� O Applicant WATER HI..A'IIER WIVEN' ,f--CTR GIi DING FEE
NOTICE TO APPLICANT:If,after making This CeniMvm of Exe nice,you_should WATERSYSIENVI'READ
re vine subject sa she Wader's Compea, map
of the or Co.,.you muss pp`1 SOILS FEE -
aIimhwith comply with tach pmvaxinns or thispamit shall bed redrevoked. WATER SERVICE GJ -
Q
z CONSTRUCTION LENDING AG r Y NEW RESIDENUAL PL U1. SQ.FI'. PND
U O 1 hereby affirm that there is it construction lending icy far the performance of I Reactor
LL H the work far which this penitis is issued(Sec.3197,Civ J _
Lender's Name
O V :
Cil Lender s Address TOTAL
TOTAL:
In 1 certify o c I have read thaw,and alnn an mm IM1et the abode information to BUILDING FEE
F..t m corent.I egret ct comply with all city and ooanty hminiaturesivof and sunt laws reacting e QTY. MECHANICAL PERMIT FEE
U huilding cnnsfinesimn,and hereby auNoriu rcpt thrives of this city to enter upon the SEISMIC FEE '
vhmve-mee)aned property indemnify
an Ice -s
(We)agree to save,an,ennar and kc es,an ss the City of Cupertino against PERMIT'ISSUANCE ELECTRIC PEE
Ilnbilidos,jaJgmenis,cony and expenses cel may in any way aceuroagoiretsaiA City ALI'ERORADDTOMECH.
onseyuencc of dm granting m d"Rer PLUMBING FEE
APPLICANT UNDERSTANDS AND LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(7010,000 CFM)
SOURCE REG IL.ATI INS MECHANICAL THE
AIR HANDLING UNIT(OVER 10,000 CPM)
CONSTRUCTION TAX
Signal eaApplicam -onsrvesr ate EXHAUST HOOD(WHJUCT)
HAZARDOI, MATERIALS DISCLOSURE y HOUSING MITIGATION FEE
Will the applicant memo building occupant stare orllaadlc hazardous materiel HEATING UNIT GO 100,000 BTU)
as defined by be Cupasina icipal Code,Chapter 9.12,end the I leehh hall Safety
Cale,Section 25532D)R .. BEAT'ING UNIT(OVER I00,00O BTU)
L-]Yes No
VENTILATIONPAN(SINGLE RESID) PAID
Will the puce Recaps#
hppincun rfuuve buildinK occupant use eynlpmom or devices whlcb
snit hazardous air tum nnmtw as defined by the Bay Area Air Quality Management BOILER-CAMP(Affs OR 100,000 BTU)
District^
.E]yes Cryo BOILER-COMP(OVER 100,000 BTU) �AI-
I have read the brand n.smaerihlsretureareals under Chapter 695 of the Cai- AIR CONDITIONER ISSUANCE DATE
fourth Health&Safely Calc,Seattle,,25505,8533 rad ders
25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.Ff. /)
building dorm not currently have a tenant.that it is illy mspersibility to notify silo occupant
flhe I enmen,as ham lila sp e�ecfa CsrificmkllfO pa p
stir g4lar
-1I1trPnrnhoaiclagmm Ir dam TDTAI: ISSUED Btu
OFFICE