S 2037 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELI:CTRI1Ah PE UNO
BUILDING DIVISION APPLICATION/PERMITPLUM NG-MECHANICAL 2037
BUILDING PROJECT IDEN'T'IFICATION
BUILDING AUADDRESS: • ' v SANTLARY NO, APPIACAI'[ON SUBMITTAL DATE
OWNI!R' li' PHONE: ACTOR'S AME(III, / - IC (]r NIC CON'TR01.Of
AlCHI'1'T:Cf NGIN[ER: LIC NO. A Of /E V & 10/.deiOT�IIe��� LC_
❑
CONTACT. PHONE: aVV �/l��Il` BUILDING PERMIT INFO
��q_ ❑ Consultant Fees Paid by Applicant(Initial) BLDG 17LECIPLl1MB MECH
(//'—�Ad LICENSI!D CONT�ACTORTSS DDEECCLAA'RKTONN Jt7 QTY ELECTRIC PERMIT FHE
hcrcby ofam.thin I,m,licensed under provisions ofCharter 9(commencing JOB DESCRIPTION
pW Ga .,In Section 7000)of Dv lon3ofhe Rioaewsmnd mloabis Cud..rad 'Iieunsc is RESIDENTIAL;
Ia1 O z 1'I!RMI'1'ISSUANCE'
F-i- in force un elfe,lV �.�� ❑SFDWL ❑KITCHI?N kleMflDl!L
aUU License V Lie. APPLIANCES-RES I DUN'I'I AL ❑ADDI'HUN ❑PLUMBING RE-PIPE
Fzw DateIII FV Cnn(raclor
B,Dy AR 'HITECPS DECLARATIONI'ANI!IS ❑MIJl:fl-UNIT' ❑STRUCIEIRAL
I ZpInZ 1 understand my plane shall he used as public reands MODIFICATION
OZ—� OF'TO 2q1 AMPS []INTERIOR ❑CHI MNEY REPAIR
Fx�E'.u1 Licenced Nofeveinnt 201-IBINIAMPS INIVROVEMENT ❑SWIMMING POOLS
j OWNIiR-HUILUER DECLARATION OVER I0(K)AMPS ❑BATH RE.MODEUREPAIR ❑DEMOLITION
tae Q I hereby affirm that 1 am exempt from the Commemr's License Law for the
y U following tires. fg,mra 190 ILS,ILwincas and improve,
de ands Code:Any city o,ca htoy
um SIGNS F:LECTRICAI, ❑01'HI?k �j T
�w a cxry-
F-�O0 y¢ which xeyuisu n e,also to Cdres 11 L alter,improvg Jcmnlin t m repair any MmtloR A✓
J priunnin issuancealtentto res,heapplicant for eachpcnniuo Bkae Law Chamem SPECIAL CIkCU1T/MISC,
ythat hals lle,,bI,ursuvm mth).fD..inm�tolheStire racmr'mdPr.al.aw(Chapman
Immmcncing whb$mtinn]fN)ll)ofUvl.inn3nf,hc Busl,msnand l'rnlcvnimry C'alnp,f 'll,MP.MIllFR 014 POLI!IN"I', COMMERCIAL:
M., that C Lha he is cioard therefrom and the basis for,ha allege)exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X ea 4 Section 70315 by any applicant for a permit subjects the.pplicaa to a civil penalty of POWER DEVI
w ❑TIiNANT ❑FOOD SERVICE
nor more,hat f vu hundrrd dubm ISS W).
(✓Z S+ IMI'ItOVEMIiNT
6 ❑ Lo the work.the properly,or mycmntended wish wags asalei(Site 0TL13 ..ion, SWIMMING I'O OIC
will Jo the work,send the:vunure is not intended or offered for tale lSaJM4,Business ❑0'I'HIiR
F
W 3 w and ernfewhon.Code The oyes broach,
License Law dws nm apply to an owner al OUTLETS-S WIT 111!5- IRE$
a' properly who builds or improves thereon and who docs such work himself ol IMnugh
his own employees,e pmldid, that such improvements arc not intended or offered fir NEW kES1UliNT1Al.IiLEL.'It Q tn'.
sale.If,however,the building orimprovenmm is sold within one yeandc......hit the SQ.Ff.FLOOR AREA SSQ.Ief.
,weer-bullJer will hove the harden of proving than M1e dIA nal hinter ur improve fir pur-
yweormle.).
1,as owner of the property,Am exclusively contmNng with licensed contractors ill
TO AL.
construct the project(Sec 7044,Business and professions Cou-)'Ihe Gmmmva's Li
-
nseLowdoexanapptyn,an owner of prapery who hn.dn or Improves(here i.and QTY. PLUMBING PERMIT PEE
who contracts for such projects with a conwamr(w)licensed punuam to the Contraemts
License Low, PERMIT ISSUANCE Y
❑ I nn,exemptunle'Sen ,B&I'Cfim thisrcamn
ALTER-DRAIN&VENT-WATER(HA) VALUATION
Owner Bac
WORnder COM aultyo!Nrj my m DECLARATION HACK PLOW 1'k(YI'ECT.DEVICE
I hereby ill mai under penalty oe perjury one of @a iallowing declaTerWorkers Ca
❑ Thew and will far
Se Cion 370cof,hc Labor
Codc,fuse fir WmknouCompete DRAINS-IB,OOR,ROOF,AREA,COND. STOMPS 'TYI'F.CONSTRUCTION
cation,u,providedhii for by Ss — 37(X1 of the Labor Cnle,for the perfonnvnco of the
work lar which,his permit is iewed. PIX'PI1RIi5-PER TRAP
❑ 1 have and will commamn Worker's Compensation Insurance,as ra,m,ed by Section
JT(p of the nMn Cok,fonhc Dona fnhe work for which this pemnit is issued GAS-tiA.SYSTF.kLI INC.40UTLE1:5 OCC.GROUP ANN
My Worker Co, Iry ca 'e- 1 Policy m r r
Carrier cm�ln„ n¢rP dlcy Nn: OAS-I!A.NYSTHM-OVER4(EA)
CCRTIFlCNFR( WORKIiRS'
COO MPENNSSATIOONNINSURANCE CREASF/INUUSTRh WAti I'I!INTERCEPTOR
BUILDING DIVISION FI31iti
CHJa scallop necA nil lnw,nnplctJ iOhc Pannil ix fnrone handled dol ha¢f$1001 GREASI3'1'RAP
or 1�.) PLANCIINCK I-P.0
I certify that in the performance ofthe work forwhich lhispOrnin isissoed.Ishall SEWER-SANITARY-STORM EA.NX,IZ
,tat employ any person in any mnnner.vn as to become eahjed to am Wofkeri Compen. ENERGY I'LL!
OZ sutler,Laws of Califrman.[)ate WATER HHATER W/VENT/ELECTR GRADING FEEZ Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMR BEATING
a hecomo s.hlcc,m the Worker's Comnsat
peion.....sinrs of hm
t ,he L, Cod
e,you mune SOILS TLE
W I'onhwi,h comply with such provisionsophis Perini(shall he Jemned revoked. WATER SERVICE
d A
CONSTRUCDON N.,andricalon NG AGENCY NEW RI!SIDENTIALI'hMI1. SQ.I'T. PAID
U l farwhich rmlhaundi inacd(Star i30lending agency firthe perlinnwnce of ❑. keceip,p
W Fthe work for which This pennil is issued(Sec.JIM)],Civ.C.)
Lenders Namc
U Lender'.Address TOT'
y1 certify Iha(I have real this upfiliation..it stem,hat the aMwc infonnvtion is IiUll FlOi
Fy cones.l agree in comply with all city and county ordinances and state Iowa relating to QTY, MECHANICAL VERMI'T FEE
UZ building tan.lmaion,and hereby mnhm..coO,rcwuntuivea nfmiw ci,ymemcr npon,he SEIS Er
above nreminned pmpeny lin inspecann purpneos' PERMIT'ISSUANCE
(We)agree cos.ve,indemnify and keep haandi,-the Coyof Cupenino.,airr,, ELI! ' IC Fir
liablla'ms,judgot bind expenses which maym any way accme againmwid City A LT ER OR ADD TO MECH.
en'" encenf �wming ol,his permi,. PLUI INO FEE
A PPIuNT I' D.i'IANDS AN WIL1. IPI
WITH AI .NON DINT' AIR HANDLING UNI'f(To I q(NIB um)
SOU .TIONS, MF. 1,® .AI.PCE
AIR HANDLING UNIT(OVER I n,(NNI CPM) CONSTRUCTION TAX
Signa c Appinan"mater ra Dx(e EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WIIItheupplican,nrI'u(urehuilAing na(gmm stn,'c nr h,mAlc hnzanlo„nn,a(cdal HEATING UNIT 1'IO 00,0k)BTU)
as defined by the Continua Municipal Cork,Chapter 9.12,and the Health and Safety
Cole,Section 25532(a)Y HEATING UNIT(OVER IOB(nift BTII)
Yes ❑No
VENTILAITON PAN(SINGLE RESID) PAID
Will Neu licam or future building t use equipment or devices which Da¢ Rccei (N
pp dby the
BOILER-COMP(JIIPOR 100.0001111D
emit h;rzalloux air cnnwmiwmw as Alined by the Buy Arca Air Qmllry M1Panugemem T( e
District? HOLLER-COMP(OVER IIIB,(X),B'1'EJ)
❑Yes ON.
1 Lavo tail tho.vwAnus nm,uriaB'rcrrymmonts under Chup,cr 6.95 nl AIR CONDITIONER the Cali- ISSUANCE DATEq
fain lltulth&Safety Coal.Sections 25505,Z533 and 25534.1 understand,hm if,he NEW RIcUDF.NTIAL MECH, SR PR
buiblingdoemm cuneny hveamnm,that it is myma,mibilo,m treaty lbececupint
.f th rc nae eme whi h nonan h tact prior to rm t,of n C nifie ate of oc tip ncy. �^
Owner or authorized!agent Dale TGTAL: 14:1ISSUED BY:
OFFICE