S 2751APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING, -]ELECTRICAL
BUILDING DIVISION- APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
G J Q n�G�
J
BUILDING ADDRESS: .
SANITARY NO.
APPLICATION SU11h1I'fl'AL HATE
-
MAR
O NE`S PH
5
CO RACTOR'S NAME: LIC NO:
J
N/C
❑
CONTROL#
' AR HIl'ECT/EN 1NEER. IJC NO:
ADDRESS.
S
CONTACT: PHONE:dU1LDING
PERMIT INFO-'
-
❑ Consultant Fees Paid by Applicant (Initial) -
BLDG itLeC11PLUMB MECH
2
❑ ❑ ❑
LICENSED CON FRAC I OR:S DFCLARAI0
1 hereby affirm that 1 me licensed ander provisions of Chatue, 9 (commencing-
QTY .+ ELECTRICPERMIT' FEE
t
OB DESCRIPTION
PERMIT ISSUANCE, d
with Section7)of Di vision 3 of the Business and Professions Code, and my license is
in full farce undrfI
RESIDENTIAL:
❑SPUWL ❑PLUM K IT NGBMODBL
APPLIANCES -RHSIUBNTIAL,
Licetis lassl -lec.#
Dnre��l�-Contmctnr—?�jyt-ry--
PLUMBING
El ADDITION ❑PLUMBING RF PIPE
❑MUINFUNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑R REMODPIURITAIR El DEMOLITION
OTHER
ARCHITECT'S DECT-AlikI N
I understand my plans shall be used as public records-
-
PANELS
UP'f02A0 AMPS
Licensed Professional
OWNER -BUILDER m Ce Cian, ttN
for the
1 hereby a(Lrn onnt 11, exempt from the Contras Co License city
followinguires a 703 1,5, and Pmfmsians Coda. Any city nrenanrY
261-1000AMPS
OVER IBRO AMPS
SIGNS [?LL'CfkICAI.
,radon
t, alter,
which requires n permit m construct, eller, improve, demnlich, or repair any mmemre
14 a tit -
_I
SPECIAL CIRCUIT/MISC.
-
PC'i,no lisii,ammee,alsoremacesth,applicant forsuch permit to file aslgnedsmtentent
�I
,hot he is licensed pursuant td the Imvisians ofthe Cnntracmrs License Law (Chapter 9.
(crnnmencing wilh Stan.. 7000).1 Division 3 Cftbe Bueinefrand Professions Code) or
TEMP. METER ORPOLF. DST.
COMMERCIAL'
[hat he I,,xmnpt therefrom and rhe basis for the alleged exrnrplim,. Any violation of
❑ NEW BI.DG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 91315 by any applicant for x Permit eahjeels the applicant o it civil pendlynf
not more than five hundred dollars (S500), '
❑ Les owner Chub,property, or mycmplayecs with wages as their sola compensation.
will do the work, and the structure isnot intended or of erect for sale (Sec 9044, Business
❑TENANT ❑ FOOD SERVICE..
IMPROVEMENT .
❑ OTHER
SWIMMING POOL ELECT RIC
and Professions Code: The Contractor's License Law docs sat apply to ua owner, of
OUTLETS -SWITCHES -FI RBS
NEW RESIDENTIAL E R SQFI•.
property who builds or improves thereon, and who doer spch work himself or through
his own employees, provided [hal such improvements are not Intended or offered for
CHAREA $/SQ,FF..
sale, If, however, the building or impmvrm,ntissold within one year of completion, the
owner-bnilder will have the burden of proving that lie did not build or improve far Pur -le
f
Est f; lee f thep p rf m tela. lycontracting w'tl J t ml re t
AL:
constructl pr j t (S 7044 8 I P f :,' C de) Th C t t s L.-
-- -
cerise La d t apply l n f property h builds 'incentivesdherc d
whocontracts f such p jests w'th a cont ct rO licensed p scant to the Contractors
QTY, PLUMBING PE FEE
- -
p�
MAR 18 1939 �'I
PERMIT ISSUANCE
License Law
[:]I run exempt under Sec. ,B& P C for this reason
ALTER -DRAIN A, VENT -WATER(EA)
Owner Dale
VALUATION
��
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROT'EC1'. DEVICE.
1 hereby sifrm under penally of periury one at the fallowing declum etas:
-
DRAINS- FLOOR. ROOF, AREA, COND,
❑ I have and will maintain o Certificate of Consent to self-iusum for Worker's G,mpen-
setion, as provided for by Section 3700 of Labor Code, for the performance of the
STORIES'I'YPH
CONSTRUCTION
work for which this permit is Issued.
FIXTURES -PER TRAP '
❑ I have and will maintain Worker's CCntpeasvtian Insurance, as required by Section
3900 of the Labor Code, for the pedormnnce of the work for which this form h is inured
CAS-EA.SYS'TEM-I INC.4OUTLE'TS
OCC. GROUP
APN
My W,rkc{" n li hrara ce ca rand Palk yy��CC G
Carrier'. Te Policy No.�ni �c'�%�
GAS - BA. SYSTEN4-OVER4CIA)
CERTIFICATE OF EXEMPTION FROM WORKF,RS'
COMPENSATION INSURANCE
GREASE/INDUSTRL WASTE INI' CIFIOR
,
S ` "-"BUB,DING DIVfSIbNNEF�S
(Thissectionpredict be completed ifthe neuritis forane hundred dollars($100)
or teasel
CREASE'I'RAP
PLANCHECK FEE
SEWER - SANITARY - ORM EA. 200 FT.
Icertify that in the perfonmmce ofthe work for Whiellthis permit is issued, [shall
nor employ any person in any mmmnerso as to became subject to the Workers'G,mpce-
ENERGY FEE -
WATER HEAT ER EN'ULLEMR
sationLawsofCelifomia.Date
Applicant I
GRAVING FEF.
NOTICE, TO APPLICANT: If, aper nmking this CcniMate of Exemption, yon should
bceome subjen ro the Workers Compcnsalinn Pmvisinns of the Luber Code, yon must
WATER SYST /TREATING
-
SOILS FTSE
WATERS VICE
forthwith comply with such provisions or this warmt,hall be dermedrmoked.
CONSTRUCTION LENDING AGENCY
I heebyaffnn that there is awnswcfan lendingagency battle performance of
NEW ESIDEN'IIALPLMU SQ. Er.
PAID
am Receipt If
the work for which this permit is issued (Set. 3097, Civ. C.) .
Lenders Name
- TOTAL.
Lenders Address
TOTAL:
HANNG FEE -
I costly that I have read this application and state that the above infmmmion is
correct . I agree to comply with all city and county ordinances and ail, laws mlming I,,
building construction, and hereby authorize representatives onhis city to enter upon the
QTY. , MECHANICAL PERMIT FEE
SEISMICFEE
TREAT ISSUANCE
ELECTRIC FEE
above-mentioned undesay far inspection purpo.ex
(We) agree m save, indemnify and keep harmless the City of Cupertino against
ALTER OR A DID TO M ECI I.
PLUMBING THE
liabilities, judgments, costs and expensex which may in any way accrue against said City
in asequence ofthe granting of this permit
AIR HANDLING UNIT TO IB,BOBCFM)
FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOLI EREC,G ONS,
AIR HANDLING UNIT (OVER IB,O(10 CPM
CONSTRUCTION TAX
CONSTRUCTION
b
SI,dFord ofA,plic.altContionam Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.00(1 RT
Willtheappheral nr fumrc building owuporn,ame or handle hazmdons material
as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Safety
21)
Code, Section 25532(x)°
HEATING UNIT (OVER go/P To Of
EJ Yet 0 N
Will the applicantor inants, building by the ¢y Area Mn which
emit hazardous sir camvminvnts as defined by the day Arca Air Quvlily Mamgemcnt
Air
Dis¢lm'1
❑Yes No
[y7
y�
PAID
are' Receipl#
TOTAL:
VENTILATION FAN (SI 'LERESID) -
BOILER -COMP( POR IW,WO BTU)
BOILER - CO (OVER 100,000 BfU)
AIR CON IONER
I have rend the hamNnas materials requirements ander Chapter 6.95 of the Cilli-
ISS ONCE DAT6
NE ESIDENTIAL MECH. SQ. Fn
forma Health & Safety Cade, Sections 25505, 25533 and 25534. 1 andualuad thus if the
building dues aCl correctly hour a terms, that it,, my resp urdleshuy m noriy the occupant
,
requireme hich must be met prior to issuance of a Cenlfin o!`Orrupmm.
'Dam
ISSUED I3Y:
?,,*For Curb zed age -�
TOTAL:r
OFFICE