S 2442 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT Ill PERMITNO.
ISUILUINC DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL Q n /I
BUILDING PROJECT IDF.N'1'IFICAI'ION J L L•�
42
BUILDING ADDRESS: SANITARY IS APPLICATION SUBMITTAL DATE
2 2--
0
- 2G_¢
OWNER'S NAME: PH NE:O CO I'RACIOR' NA�1E: LIC NO�� N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO. AD gE55, L ❑
CONTACT: PHONE: Y/ I, BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT P1 MECH
❑ ❑ rrz� ❑
LICENSED a CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
0 W 1 nereny arum mm I am liwn,ad marker oras x..r ennpmr 9(commencing J06 DESCRIPTION
Z wishSection7000.1 Dtvision3oflhe Bixiect,ar l Prnfcs,lons Code,and onEchnscix -
1+10p ) y PERMIT ISSUANCE RF F T
FW infall aCl und effect. /6 SPDWI. ❑KITCHEN REMODEL
-t y License Cl' Lic# { APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
yW Dnte Convenor
G¢ ARCHITECT'S DECI.ARATI ❑MULTFUNIT ❑STRUCTURAL
F D w PANELS
Zy Z 1 understand my plans shall he used as public records MODIFICATION
UP T021A)AMPS
O z ❑INTERIOR El CHIMNEY REPAIR
F apEq�'OW Licensed Professional 2f)I-1000AMP5 IMPROVEMENT (]SWIMMING POOLS
�',,�,yOWNER-BUILDER DLCLARA'I[ON
((yy C C Q 1 hwoby infirm that I nm exempt from the Contractors License Law for the OVER I"AMPS ❑FIAT H RHMODEWREPAIR (]DEMOLITION
iC W V following creep,(Section 7091.5,Bnsinae,and Profession,Gdh:Any city or county SIGNS ELECTRICAL ❑OTH,
m B w y watch reywms n pertna m aonm.ner,ober,improve,demnfixn,nr mpnir any.taewm [JL U.GC� (itJp-Ky
Erie t t ': nix 1 'th ppltr tf a hp a tl 'g J.r¢nevi SPECIALCIRCUIT/MISC.
theft . tip esucial 1.the p n: f tire Contranna,Liters,Low(Chapter 9
mormarrimir,wilh Section 7000)of Dmusecon3 of the Has mss and Profession,Cale)nr I'13MP ME'fEN OR FOIE INST, COMMERCIAL:
that he is exempt tharefo nt and the basis for the alleged exemption.Any violation or ❑NI?W BLDG/ADDITION ❑DEVIOLI'I'ION
iCw footmn7031S by any applosm hail,ennit,anieets ba.,lieam n,a eml,aralty of POWER DEVICES
:2 footman El If()()[)I' SERVICE
�y not mora than five hand reddolla,($50H)' - IMPROVEMENT
C',
@
�I,ox awncr of the propery,onnyemployerx with wage a, cinco
ol, n'ra'ation, SWIMMING POOL ELECTRIC
� will du the work,nnA thestrm data is notaleneed onal...d franc 9044,Business ❑OTHER
3 m und Professions Code:The Ciniew o,License Law docs ant apply to an owner of OUTLETS-SWITCHES-FIXTURES
4i .. property who build,or improves thereon,and who does such work himself or Ihmugh
his own employees,provided Thal such impmvunents am not intended or offered for NEW RESIDENTIAL HLP.CTR SQ Fr
sale.If,however,the EmIllingorielprevemuntnanld wi0dn ,is yearoremnplcdogthe SQ.FL FLOOR AREA $/SQ.IN.
erFailder will have the burden or proving that ho did not build or improve for per-
p xe of sol..)
❑ 1,as owner of the property.Ito exclusively contracting with licensed survaen,rs to TOTAL:
ensu el the at(Sec WA4,Bauhaus,and Pndes,e mx Code:)The Conhanm's Li-
„e Low due,not apply to anownerafpraperty all,,milds or intprrars mereaa,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a coatractorb)IkanseA put aour to the Coulacmfs
License Low. PERMIT ISSUANCE
❑ Ism exempt under Sec. ,B&P C for this reason
-
Owner Das ALTER-DRAIN&VEIST-WATER(FLA) VALUATION
WORKER'S COMPENSATION DECLARA'T'ION BACK FLOW PR(ITELT.DEVICE
I hoeby under penalty of of(dra nueoflhefnllowmg declomtinn
Ihavo andwillfor by Se Cion 3700 of Co LaborCode,for
eie Worker's Cnmpen- DRAINS-I FLOOR,ROOP,ARBA,GOND.
anlinn,us provided for by Swoon P011 of Ne Labor Code,far the perfonnnnce of the STORIES TYPP.CONSTRUCTION
huh no, umamt d FIX HIRES PER TRAP
su rhas uulwllma t War k Compensation Insurance, bySeclnn
'Icl l he Lubar Code,far lh fotmanee of We wnokt rw hv(h lbs permit is i"Llot GAS CA.SYS I'FM-I INC 4 OUT LETS OCC GROUP APN
Canier:Worker nm msatinl surance aortic pol yNo. m"! D GAS-EA.SYSTEM-OVER 4(EA) 6 , Q
/�Ca
CERTIFICATE EXEMPTION FROM W KERS'
COMPENSATIONINSURANCE GRBASVINDUS'rRL WAS'N IN'r13RCBPl'OR r13I111A1N0 DLVI�ION PBE,S ' '
(This section need not M1cenntEleted ifthc permit l.lorono hundred cellars($100) GREASE TRAP
or Ies.J PLANCI IECK FEE
I curtly that in the perfom,ance oflhe work for which this permit is xnum.i shall SIEVER SANITARY-S'I ORM EA.200 FI'.
not employ any person in any manner sn a,10 became nuhjeed m the Workers'Cnmpen- ENERGY PEE
Z ',Z ..tion laws of Culifnrms.Data WA'I'Rk IENTER W/VFNI/EITCI'R
Applicant v GRADING FEE
NOTICE TO APPLICANT:If,after cooking this Ccnifired,of Exemption,yen should WATER SYS'IENVIREA'1'ING
become snbjed to the Workers Compensation provisions ol'the LoMorGlde,you must SOILS FEE
Wforthwith comply with such provisions or this permit shell be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL,PLFT
Mq. SQ. . PAID
UO hate Receipt I hlDov
ereby ethat there is n reinsert lending ngmmy rm
be the,wrea .ncc of p
LTJ the work for which this permit is issued(See 3097,Civ.C.)
QLender's Name _ - TOTAL,
U
Lender's Address 0 OTAL:
Icerifyflat l have read thisoppliwlion and stale that the autos infnnudnn is r BUILDING F -
F rn a uroa.I agree m comply with all city and county ordinances and sttue laws rotating to QTY. MECHA lµ'. .PERMIT FEE I
building construction,and hereby authorize representatives of this city to enter upon the SEISMICH ?
Alive-mentioned propeny far um,,Iina purpose.. FFR
(We)agree m save,Indemnify and keep harmless the City of Cupen'ma against PERMIT ISSUANCE C D P.LECTRI F.
liabilities,judgmars.cessonlexpenss,which nmy in any way seeme against said City ALTER OR ADD TOM CH. -
cnnscyucaceofthegrepingo[,his permit. PLUMBWi rE
APPLICANT UNDERST !DS AND WILL COMPLY Win ALL NON-POINT AIR HANDLING UNIT<'DO 111,000CFM)
- SOUh EI Y 'llONS. PEE
� AIR HANDLING UNIT(OVBR CONSTRI . ION TAX
Sigarme ofvpPlicalit/Contriefor Daw `I EXHAUST HOOD(W/DUCH HOUSINGITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant.store or handle hazardous material I HIM INO UNIT'IT 100100111'U)
as defined by(lie Cupertino Municipal Cade,Chapter fl.12,and the Health and Safety -
Code,Section 25532(m? HEATING UNIT(OVER 100,000 BTU)
❑Yes 0N VENTILATION FANS INGLE RESID) PAID
Will he lasumorI abulldia-na,mi nluxacin for dcviws wbicb Data Receipt#
pp g e y Air
BOILHIt-COMP OR IlO,Olx1 N1'U)
mit hazardous air conmminems as defined by the Bay Area An Quality Management 'I'OT'A;
Di.vlctp BOILER-COME(OVER 100,100111 U)
El Yet, ON.
1 have read the hazardous materials re its ruche Chdr t 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
yui pu
Carnia Health&Sarcty Gd Se4inre 25505,25533 and 25534.I undemamd that If the NEW RESIDENT IAL MPCI1. SQ.PL '7 --Z/ ,�
building m illy haentenant,Nmit ix my responsibility to notifythe occupant zi
of the rcyuir e fi ran t be mG prior la issuance of u Calf E
-
Owner or aulboole agent UDt TOTAL: ISSUED BY
OFFICE �