S 2769 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BE I LIVING-ELECT RICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPFRMIT PLUMBING-M?CHANICAL (� �]7C (1
BUILDING PROJECT WENT'IFICA'1'[ON J G U 9
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITIAL DA
o V S�`rtl 71, s s z_ 2�=
OWNER:SNAM PHONE. CnN�ACT( Ve.4 'i LIC N(l:
�1 NIC CON'll<cd
.ARCHITECT/ENGINEER: L 'NO: A❑DRESS: ❑
CONTACT PHONE: �S. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT P m nyI[-CII
ALA— El ❑ 11
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby afilrnt that 1 am licensed under mvision,of Chapter 9(commencing JOB DESCRIPTION
MW n'Z with Scot un70N1)olDivision 3onhe[laxness and PnTio,ion.Cale,snit my license i. RESIDENTIAL
Woo PERMIT ISSUANCE
W F in full force unJl E,rce eBs� Cl SFD ITL ❑PLUM LIN kEMODEI
GUU Lised a G Lic.M API'LIANCFS-RESIDENTIAL ❑ADDITION ❑KITC ENGRIi-I'IPIi
N6 D. c- ConlmClor
ARCHITECTS DBCLARAIION PANELS ❑MULTI-0;JIT ❑STkIJ(.TUItAh
ZOO1Z Imudercmid mydamdrall Is,used aspuble recnrdn MODIFICATION
�— UP OZ—� ❑IYfF3k10k ❑CHIN1NIiY REPAIR
a 1"JW Licensed Nole...r I 201-1000AMPS IMPROVE'MEN'T EISWIMMINGPoOLS
ce""� OWNER-I1111LDIiR IIECLNtAl10N OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
E C W Q I hereby offimt that I am exempt bom the Contra....'.License I,aw fur the
yx,3�F following reason (Section 7031.5.Business and Pro@axions Code:Any city or count' SIGNS ELEC I'RICAL ❑OTHER
W Q N which y . 1 I t t It -improve.J 1.h psi y fracture
1_'� Qt,for 1it, do, th,ii,ipfi,ault p i to file ''gdwtuou'n SPECIAL CIRCU rONE SC _
bar he Licensed l) to d l) h C n I F L Law'(Chapter 9
WC�� los nmmnbwiESecnn 7Nd)uI vteiuv3 n0hlbusinvssunJl mmss'otu Csde)..f DEMP METER OR POLE MMFR I I:
`Ly o C th,To is exempt Ihc.frnin um the breis for tic alleged ase prior.Any violation m NEW BLDG/ADDITION ❑DEMOLITION
W^m Section 70315 by any applicant for a permit wbjeantheappE,ammacM1 pendry 'I POWER DEVICES TENANT El LOGO SI?RVICIi
E=Cof more than live hundred dollars(S50B).
❑ 1.a.awnerofthe property,or my employees with wagesas their sole compensation, SWIMMING PMOL ELF RIC IVIAR 24 IMPROVEMENT
F+ will dothe work.and the suucwre snot intended or ofered mrsale(Sec.7034,Business ❑OTHER
W3 aa and Pofessions Code:The Cuntracmfc Liccose Law dons not apply m en owner of OU 11.17S-SW ITC71Bi -Is1X'NRES
property who builds or improves thereon,and who does such wink himself or though
Itis own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL CPA SQ FL
sale.If,hoverer,the buildingo, in,,nocusentk sold within one your of completion,the SQ.R ,O REA S/SQ.IT.
owner,bujider willhave mburden ofmusing M1th did nolo IJ p cf..r par-
Emscol:w1"), y^
C]1 -owner offlicproEtiscry,not exclusively contracting with I' J tractors n, TOTAL.: f
cont t the project(S 7(134 13 : J I 1.. Ct 1.l lir C t ato s I ` 7
w Law does not apply n, n
an owner of property who builds nmprove, hercon,and QTY, PLUMBING PERMIT FEE
who mntri fursuch projects with acontraclnr(x)licensed porwand to the Comrvemr's '�]]
hiccnw Law. PERMIT ISSUANCE alio
❑ I am exempt under Sec. ,B&PC for this rennin
Uwnor Date NET ER-DRAIN&VENT-WATER(BA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROT ECT.DEVICE
I hereby affirm under penalty of perjury ono of the following declarud...x:
❑ I have and will maintain aCenificate of Cameo towl6irovre for W'orkees Compcn- DRAINS-Il,OOR.ltOOF.ARI:A,CONII. STORIES TYPECONSTRIICfI(
pinion,as pmvidod for by Semon 37000 he Labra Code,for the performance of the
work for which this permit in issneJ. FIXTURES-PER IRAP
I have and will maintain Worker's Compensation Inmmnce,as required by Section
370mof tire 1ahor Curb, I he perlomn ea I the work for which this permit is issued GAS-EA.SYSTIAN I I NC.4 OUT ITTS
(ICC.GROUT' APN
My W s Cum nsution Ina cc r ('nlic n
Cum' 'n icy
Nr rA ? �51 GAS-EA.SYSTEM-(IV P.RaU?AI
CER IIICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANC17GREASOINDU.STRI.WASTE]NITER
MissaGnnnced no,hcanntpTeed it mr,,nnil ix foroneh Iodred dollars Of 1(10) BUILDING DIVISION FEES
nr Ems) GREASE TRAP CEPfOR PLANCHECK Fl?P.
Iceaily the in the Isenhnnanceofthc work for w'hichlhis peridd i--rd,Ichall SEWER-SANITARY-STORM EA.201 IT.
nal mnploy any perssm In any manner ,,ac Iu Mon x,th ext m the Worked Curbed- ENERGY FEE
C) sminn law"d GJifumia rude WATER HEATER W/VENTIFLEMR
O Applicant0 Q GRADING FEE
y
NOT 10 APPLICAN'E If,alter making this Cenificalre of Exemption,you ebnuld WATER SYS'I ENITREA'TING
hecmne subjal In be Workee's Conlpenwdnn ,,,vi,io is of she Labor Crdt,you most SOH.S FEE
I1-) forthwith comply with such pmvi.sinm or ths.permit shall he deemed revoked WATER SERVICE
0.
itis z CONSTRUCT'[ON LENDING AGENCY NEW RESIDENT IAL PCMB, SQ,IT PAID
U O (hereby afrosthn't hen isaconslmeumt lending aganey moths perforimuee.f Wm It"vilns
the work for which this peemit is issued(Sec.3(m7,Civ.C.)
C) U Lender's Name TOTAL:
r D..I Lender's Address T(IT f
r FL 1 sonify Ihm I huvc rand this application and ,are that the above mormwion is BUILDING FEE
V1 cotrc<n.1 agree to comply wile.n city and manly ommamea ant a:ne I;Iws romdng w QTY MECHANICAL PERMIT FEE
U Z building construction.and hemby anthumu reprewmmtives of this city to enter upon lire M"ECIANICAL
al sentinel mPvoy rnrlm,Giou pmpuscs.
(W.)a t n indcnmif keep hamdecsthe Cit fCu linos PERMIT ISSUANCE
gree o yore p y.. Cupertino gains ELECTRICE
ImIn itim,jul,inves.costs and expense,which may in any w:myacerae agninsl said City AL'I ER OR AILD TOMECH.
in mxve r mscc of the'noting of this permit. EE
AI'PLIC ')Ii 16T'ANDS ANDWILT.COMPLY WIT' ALL NON-P(IINT AIR HANDLING UNIT(TO IILINq CFM)
Eri� Sr P R A'I'ION.' FT;EAIR HANDLING UNI'r(OVER 10,000 CITU ION TAXSign, neo Appianl/Contmaor Data EXHAUST GOOD(W/DUC19 TIGATION FEE
IIAZARDOIIS MATI!R1A1 S DISCLOSEIRE
Will the applicant or future Buildingweeleard aomorbandle hrianlaus'material HEATING UNIT(TO 100a)(0 BTU)
as delined by the Cum,nino Municipal Code.Chapter 9.12,and the Health and Surety
Cala Se I 25532(a)? I1HAI NG UNIT(OVER 100.000 B'TU)
El yes ❑No
VENTILATION FAN(SINGLE.RESIDE PAID
Will the applicum or future building ovvupum use P
O
BOILER-CM
miaquipnor devices which Date Racist if
Air
Qu
et ham
rardnus sir coamnl
inap as def ncA by rho&iy Arca Au nliry Managumm�l (31111 OR 100.000 BTU)
Uislrim? BOILER-COMP(OVER 100.000BTU) ,T
❑Yes �1JNn
I M1ave mad the haardmrs marerial re ' is under Chapter 6.95 of the Cali- AIR CONDI'fIUNER ISSUANCE DATE
ymmniw 'I
fault.Ile. Safe'y Gyle Sections 25505,25533 and 25534.1 underswnd That if the NEW RE,SIDEN'TIAL MECH_ SQ.FT.
p al entre ly haveufenam. or"'is my responsibilhymn..lify the recaps
et ui ua rte lnel prior n,iss sofa Cenifivumuf Occupancy_
OwI litre' 62mud Rgcm, Da¢ 'TOTAL_ ISSUED BY:
OFFICE