S 2362 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
FBUILDNNG
CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
G DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL S 2362
BUILDING PROJECT IDENTIFICATION
DDRESS . SANITARY NO. APPLICATION SfIBMITI'AI.FAIL
OW il' AMG. - YHONL CONTRACTOR'S NAM- LIC NO: ` O D
N/C CON'I'SOL M
N7
�.ARCH ITECT/ENGISEEN: LIC O: A)UR...: ❑
/L
coNTnGF: PHolvt:: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB AT CH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT - FEP,
1 Barco,offrnl In.,I rain raeamea Ander pro.axiana or enrapmr v(commercial - JOB DESCRIPTION
"Zwith Sermon 9fN10)nfDivisionJ nllbo Busiaas,and Professions Cade,and my license is RESIDENTIAL
W p PERMIT ISSUANCE
ba W 0 in full force and p El SFDWI. El KITCHEN REMODEL6UU License Class Lio.a APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F�y W Date Conlmcmr
❑MULTI-UNIT ❑5I'Rl1CTURAL
Y A CUTLETS DECLARATION MODIFICATION
Z4- lunderswnd my pinnsshall be used it, .hire records UYT0200AMP$
C
OZ G ❑INTERIOR ❑CIIIMMINREPAIR
E.� Licensed Ynrfec,ionol 201-1000AMPS BAMRFddODE ElSWIMMINGPOOLS
c<cLL.� �.I OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODELIREPAIR DEMOLITION
G C ¢ 1 hereby affirm shot 1 am exempt floor the Cantracmr's License Law for the - -
iyyi((O y O []OTHER
following reason.(Scetion 7031.5.Business and Profession,Codu Any city Ur county SIGNS ELECTRICAL /I
LL13 W y which ocifires a luereat to construct, a p demolish,(it reP y:l uc,ure A
tial par t t aacquiresthe l suchParent, flsignedst mncrt SPECIAL CIRCUIT/MISC. 7 ��
�. End[act,fi :dp n W p `u Itl C t L L' (Cl t,oxe)
moC (conmenr ngwi,h Stlet on I O)n[D v'sm r3 flheR irmss and Poll ms Code),,, 1EMP.M1713R OR POLE IN. COMMERCIAL'
that he is exempt therefrom and Om basis for the alleged exemption.pnY vmlotion of [_1 NEW BI.DG/ADDITION ❑DEMOLITION
I-
so
p. Section 9031.5 by any applicant mi
for a pert subjec[s the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not mom than five hundred dollars(5500).
ad I,a,ownerofthe -Party, em to ceswiWwu es nstheirealeem lion, SWIMMING POOL EL EC'I'RIC IMPROVEMENT
Sq ❑ p-P y Y P Y l pensn L1 OTHER
II do the work,and the dracture is not i mended or on nine for sale(See7144,Business
4 a m and Professions Codc'.The Contractor's License Law does not apply¢r Ban owner,of OUTLETS-SW ITCHf'S-h 'I'
property who builds or improves Italian,and who dna,such work hlmse[f or though
his Awn employees,provided that such no,ovc nenls rate our amended nr nmemd for NEW RESIDIiMfIAI.Fl.BCTR
sale.Inhowever,the buildinlorionpmvemem b addwithirion,yearofcomtlletiou.Om SQ.FP.FLOOR AREA S/SQ.PF.
wner-builder will have the bunlen of proving tial he and not build or improve for pur-
pose of ache).
El 1,as owner of the property.am exclusively conlmaling still licea,cd con non
es to TOTAL
oaslxnct the par)eel(See.7064.Business and Professions,Code:)The Contractor,Li- '
Ase Law does not apply to an owner of property who bndds or improves thereon.and QTY. .PLUMBING PERMIT FEE
who umvoms for such projects with a contmelor(s)licensed Pumuan,m We Contractors
License Law. PERMIT ISSUANCE
I an,exempt under Sce. ,B&P C for im,peoun
ALTER-DRAIN&VENT-WAI ER IEA) EVALUATION
Owner Dram
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE /a�f 4'syn
I hereby illlivn under Penalty a ejprilanyCon one art the tonne Rn decWmdnm ES /L F '✓-fes
❑or,as polvidlnfarby eC,,.37leof Consemm Code,fareeperforrianCompeo- DRAINS-FLOOR,ROOF.AIt NA.COND. STORIES 'TYPP.CONSTRUCT]ON
wk for provided for ni Section 3900 of the Labor Coag for the perfnnnvnce of the
work for wM1icb this permit is Issued FIXTURES-PER'I'RAI'
�I have and will maintain Worker's Compensation Insurance,as required by Section
�j*NyJ
lithe Labor Code,for the perturmonce Of the work for which this permit is issued. GAS-CIA.SYSTEM-I INC,4 OUTLETS OCC,GROUP APN
My Werke' Qc tion lnsur dPndcya Airco' GAS-F.A.SYSTEM-OVER 4(EA)
y ��9 ys� opal /�
Corner (cols L.e/eS ON No.: &WL
CLRI'IFICCOMPE COMPENSATION
E KERS' CI<'ASE/INDUS'I'RI.WASTE INTERCEPTOR J,1
COM PENSATION INSURANCE I.H CDIVISION PF,F,S
(This sedinn need no,bewmpleed if the permit is for one hundred Jnllurs NI 00) GREASE9HAP
nr less.) 1JtaHNAq1. EH
Ify any teethat h lbs pertmannerool the work for suich ject this perthe W ikers'Curawnl SHWER-SANI'PARY-STORM En.?1X1 Ff
not employ any person In any manner xn as m banmo subject to lire Workers'Compcn_ 5NP.RGY FEE
,7. ation Lovsof Cadiremr.Dme WATER HEATER W/VENT/ELECTR
O GRADING",
FF.F.
NOTICE TO APPLICANT If,after making this Cerifcam of Exemption,you shaulJ WATER SYS'I'EM(fREATiNC �. ..
.� become subtitle,to the Wnn:u',COm,wall n provisions of the Labor Code,you must
WforhwiW comply with such Pmvisinns or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Irl'. PAID
I herehy allino shot there,,a condonerion lenWngegency I the perkrmanauof Dam ReceipiN
U 0 the work for which this permit i„zucd(See 3097,Cie C)
0Lender's Name TOI'AI:
ULender's Address 'TL:
OTA
a 1 artily that 1 hove read this appliulinn and state Thal tire above informalion is BUILDING NEE
rn corer.I agree m comply wall on city and county nnlinanms and score Inws rdafing m QTY. MECIIANICAL PERMIT r FEE
C..) Z funding eonctmaion,and hereby anthoriaenTe,coronals ofibis city tocater atlantic SEISMIC FEE
above mentioned property for inspec[ion purposes. PERMIT ISSUANCE
(We)agree m save,indemnity end keep harmless tiro City of Cupertino elitist ELECTRIC PEI's
I'mbilices,judgmerts.cosis andexpenves which may in any way accrue users,said City AL117RORADDTOM17CH. PLUMBING FEE
c
rmcqumma coal of Wier permit.
APPLICANT AND II COMPLY WITH ALL NON-YGIN"IAIR HANDLING UNIT('f0111,(IINICPM) MECHANICAL PEE
SOUR
SOURCE REGULATIONS.
` AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
7Sa,lro.
pplieanV Bat actor On".
me E.XI MUST FOOD(W/DUCT) HOUSING MITIGATION FEE
IIA.A DEUS MATERIALS DISCI.)SURE
anopplienn(1 arum hW[dingoccupomsare at handle hozmdea,manond HEATING UNI'F(I'O I00,000 BT U)
y We Cuperti r Municipal Code.Chapter 9.12,and the INeill,and Safety
n 25532(n)^. HEATING UNIT(OVER IOp,IgI111TU)t VENTILATION PAN(SINGLE RESID) PAIDpram Receipt#
lire opplicom or furore huilding amupmrc use equipnacnl art devices which BOILER-COMY(7HPOR 10(1,1100H'fU)
u,Air contearmuc a as defined by the Ray Amo Air Quality Mvnagemenl ( ABOILER-COMP(OVER 100,000 BTIJ)
0 Yes
I havemral the haeaMous mmcriaE rWuimmenis under Chapter 6.95cf,he Cod- AIR CONDITIONER ISSUANCE DATE
famia Health&Safety Cada S ria 5115,25533 anJ 25534.I understand drat il',he NEW RESIDENTIAL MUCH. SQ.Fr.
buildnl does colt ly ho l thutitlsm463m
myresge�1iIt ynoifythcocvpant
of tbemquirce sw mhin to riot m lssuanecaf u.f ifigleyf Oc
Owner or art cri ed gen, �/ /('�(•• Data GTA ISSUED BY:
OFFICE