S 2447 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.FLF,CTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL S 2447
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O\ ,j'•{'S AME: IJ{ONla CONTRACTORS NAME1h M& TS41 :
a2S N/C CONTROL#
CHITEC'17HNGINEER: LIC NO: RA g ❑
CONTACT PHONE IBUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMft MECH
❑
LICENSED CONTRACTOR'SDECLARATION ❑ ❑QTY ELECTRIC PERMIT FEE
1 busby ida' mm l not licensed.neer pmvi.iI..orem pmra(commencingais JOB DESCRIPTION
=0 CZ) with SemioellW)MDivisimt3 of me Husiucss and Professions Cnde,and mylicvnse is NTIAL
F+W mfullforcevnd eBut APPLIA ISSUANCE DWL ❑KITCHEN REMODEL
RMIT
�UZV Llunsa Cla.. Lie#
tiQ0. Ume Cnmruao APPLIANCES-kESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F,pm ARCHITECTS DECLARATION PANELS E3 MULL-UNIT [I STRUCTURAL
Zoadz Iand ersmndmyplanssholl be usedanpnblic records MODIFICATION
OZ4q UP T02W AMPS
F[?,E-Ixl LrrcnsW Prnfesannul El INTERIOR ❑CHIMNEY REPAIR
� 201-IOW AMPS IMPROVEMENT
OWNER-B1111,DER DECLARATION ❑SWIMMING POOLS
y C 6 1 hereby affimr that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
%3 W, following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS P.hECfkICAL ❑OI HER
O, which roquircs a permit in unsmmt,ober,improve,dentnlish,or repair any swarm l
q m prior to its issuance,also requims the applicant for such pennitto file a signed statement SPECIAL CIRCUI'UMISC, / 6i✓ fe k?fte X
ads Ihmheislicensed pursuvnnotheprovtsinnsoftheConOamorsLioenseLaw(Chapter9
W�00 (ehnmten.ingwllh Senion7O(M)of Division3ttfthe Businessond Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
10�o yo Ihal he is exempt Iherefron,and the basis for the alleged exemption.Any violation or El NEW BLDG/ADDITION ❑DEMOLITION
Whym
Section IDDl7031.5hyanyapplu nl butopennil subjects dic,plu,not oadvil pannd,yof POWER DEVICES
Fq. not arc than five hundreddoliars(S500). ❑TENANT ❑FOOD SERVICE
z 0a ❑1,es ownerof tunpmpeny,or myemployeeswith wages us meirsnlewmpcnsotion. SWIMMING POOL ELECTRIC IMPROVEMENT
yy� will do fire work,a.d the smtamre is oat intendedor offered throttle(Sed.744,Business ❑OTHER
0. m and Pi-desvione Chdc The Cnntracmds License Law does.,it apply m va owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such Improvements am not intended or offend for NEW RESIDENTIAL ELF= SQ FT.
late.ll,however,the bullJing nrimprovemenl is sold within one yenro(completion,tiro SQ.FT.FLOOR AREA S/SQ.FT
owner-builder will have the burden of proving that he did nm build or improve for pur-
phvc m vola).
❑1,as owner of the Prepeny,um exclusively connecting with licensed contradicts to TOTAL:
mated the project(Sed.7044,Business and Pad doi0ns Code:)'Me Contractor,Li-
.e Law does not apply 10 an owner of property who builds or impulds morenn:Ind QTY PLUMBING PERMIT FEEwho wormers ou xtich moral,with a contmetor(s)licensed mratent to the Contractor's ffes�''
License Law. PERMIT ISSUANCEice+
El am exempt under Sec. ,B&P C for this reaam
drar DateALTER-DRAIN&VENT-WATER(EA) VALUATION
WOR KER'S COMPENSATION DECLARATION HACK PLOW PROTECT DEVICE.
I hereby affirm under penalty of p ,anchf the following declarations:
❑ Ihnvcandwillmnintainm Cvtifica¢of Consennnself-iuxure for Worker's Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND.
satinvided.,as pmfor by Section 3700 of the Labor Code,fonhe parlormance of the S'fOk1E5 TYPE CONSTRUCTION
work for which di,permit is issued FIXTURES-PER TRAP
I have and
will maintain Worker's Compensation Insurance,as required by Section
3700.fine lobar Code,fonhe perfummnceofthe work for which this pemdisissued. GAS-EA.SYSTEM-I INC.4 OUTLETS APE
My Work 's Com yt m Incey� r:mA Policy number urea
Canier���Rl/O/./��/Yl ePolicy Noe GAS-EA.SYS'I'EM�OVER 41yA) Q
CERTIPICAT�OR EXEMPTION FROM WORKEkS'
COMPENSATIONINSURANCF. GRIiASFJINDUSTRL WASTE INTERCEPTOR
(Thixsution nuJ nut d:uampleted if the permit isforonc hundred Dollars(SIIN)) GILDING DI VISI •S
nr less) GREASE TRAP PLA{{C}i f,K i• E
l unify mal in lire pelionnmace attire work forwldeh lhi.v permit is iaxued,lshall SEWER-SANITARY-STORM EA.2INl FT
not outplay any pernnn in any mm�ner so as m bacamo suM1ject to the Workers'Chattier ENERGY FEE
,� sntinn lstws of Cnlifomie.Dote
NOT[[em
'� WATER HF.ATEk WNENT/EL[CTk O, ADING FEE
OPICE'f0 APPLICANT:IL after making Ibis Cenificam of Exemption,you should WATER SYSTEM/!BEATING
a � heconte subjut to the Worker's Compensmion provision.of the L.Mr CoIM,you mull SOILS PEE
forthwith comply with inch provisinnsenhis permit Shull ba dcameJ revoked WATER SERVICE
Q Q
nom- z CONS"Ie is.amRUCTION LF leadING AGENCY NEW RESIDENTIAL PLMH. SQ.IT. PAID
UO kforewyaffimubatinti isaoonelrue.30 leading agency Ponheper(onnunw of Data keceipt# i
W the work for which Otls Pennil is ismN(Sec.JW9,Civ.G)
o Lender's NantaIn
a Innde,Address TOTAL: S TOTAL.
u
I unify fail I have Iced this appuco ust and statictum Ibe above information i. - BUILDING PEE
A church l agmc lir comply with all city and county ordinances and state laws renting to QTY. MECHANICAL PERMIT FEE
L) Z building construction,and hereby authorize representatives oflhis city theater upon the SEISMIC LEE
above-mentioned familiarly]or inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep nvmlesv Ile City of Cupertino ag.iast ELECTRIC PEE
Iiobildies,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
mw
nsequcnu of the grami ng of Ibis permit PLUMBING PER
APPLICANT UNDERSTANDS AND WILL COMPLY WITII AL1.NON-POIN"I' AIR HANDLING IINI'C(TO 10,000 CPM)
SOURCy81%y�/C�'1-��JTIONS. •� MECHANICAL FEE
/ieieJil/i� /.;)1 � AIk HANDLING UNIT(OVyk IO.IAMI CPM) CONSTRUCTION
/gnnaatu�re aL(Ap�pllcan AIrdclor I'Dvte EXHAUST HOOD(WMUC'q HOUSING MITIGATIO FE6
AZAROLLS MATERIALS DISCLOSURE
Will the applicant hr mar,building occultism ohm or bundle hazardar,acucrial HEATING ON]'T(TO 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Seeti m 25532(a)I HEATING UNIT(OVER 100,1100 R'Hl)
r7 Ye,, ❑Nh
VENTILATION VAN(SINGLE RES ID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt#
mil hazardous air contaminants a..defined by the Bay Area Air Quality Management BOILER-COMP CIHP OR I00p011 BTU)
Dishicfl TOTAL:
❑Yes E]NO BOILER-COM P(OVER I co,1%1)BTU)
I have read the h ode,Sections
materials 5,25533 a under .1 understand
of the Ceti-e AIR CONDITIONER ISSUANCE ATE
Tornio g ahs a.Safety Cela,have
x25505,25533 and 25534. I ndcrsmnd Ihal if the NEW RESIDENTIAL MECH SQ.frT.
building does not currently have to met flid(it isua responsibility In notify the owatpam
of mer ich run M:met priormissuanceofa Coni iwf f � •+f�/ �If/
oromamiodd em I Date TOTAL:
ISSUED BY: ( T
OFFICE