S 2575 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF'CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
CITY
C.Df VISION APPWCATION/PERMITPLUMBING.MNCIIANICAL /� 5
11111LDING PROJF,LT IDIWI'IFICATION G J
75
BUILDING AI•DDDRFSS: SANITARY NO. APPLICATION SUBMIT/TAAL.DATE
OW ER'SNAMIi: � ' /e ZONE: CONTRACTOR'S NAME: LIC NO:
. yr NIC CONTROL#
AJECHITECTILNGINFER: LIC NO: ADDRESS ❑
CONTACT: PHONE: BUILDING PERMIT INFO
rickN /����0� ❑ Comed'ant Fees Paid by Applicant(Initial) n1.DG ELEcf PLUMB ME 11
„ e2I[ON oS�j �/ E-1 ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT' FEE
1 hereby affirm that 1 am IicemeJ under Provisions of Clutter 9(cormncncin
�1_ if lif ot]aM).nlivn;nt3.nne nasion.and prol;•ssi.nssous anJm I h JOB DESCRIPTION
ty0p yicenm is PERMIT ISSUANCE RESIDENTIAL'
Fq W F m full force and elft 2�Z/Q Cl SFDWI. ❑KITCHEN REMODEL
QUzU Licens Class LIC.#
H6S Dnlr ❑S r:mmr—/.4� APPLIANCIiS-RHSIDENI'IN. ❑ADDITION [I PLUMBING RF:-PIPE
pm ^ ARCHITECT'S UIiC1A lON ❑MULTFUNIT ❑STRUCTURAL.
Z O',l Z 1 understand my plans shall he used as public records PANELS MODIFICATION
0z4— UP TO 200 AMPS
FHF-W Lmmsed prolnsumal [I INTERIOR El CHIMNEY REPAIR
�XM,'j OWNER-GUILDER DECLARATION 201-IM)OAMPS IMPROVEMENT E]SWIMMING POOLS.
tY Q I hereby affirm'hit I am exempt from the Contractor's Livers,Law for the OVER HMOAMPS ❑BATH RENHIAELrktHPAIR 0 DEMOLITION
K 3 6 U�
following reason IScctinn]03 L5,Business and Professions CnJc A,ry city or county SIGNS IiLISCI'RICAI. (Yf11LR C4
YI W O y¢ which requires a permit to consimcl,unci,bnpmve,dcmuh,li,nr mpu:r any stmeuue
�rwJ prior to its issuance,alo,mi,im,theopplicnal lursuch pennies.lie aslgnedstmentenl SPECIAL CIRCUIT/MISC.
�;!(} that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
WCCO (commencing with Section 7")of Division 3 of the Business and professions Code)or TEMP.MET ER OR POLE INST. COMMERCIAL
d k c¢ that he is exempt therefrom and the basis for the alleged exemption.Any violation or N BLDG/ADDITION ❑DEMOLITION
�..y
Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES IiN NT ❑FOOD SERVICE
^ � not more than five hundred dollars($50).
01,vs owner nl the pr.pMy,nr my cnnployceS wiP wages nn thciraae mmpeneati.n SWIMMING POOL ELECTRIC .MEAT
will Jo the work,and the structure is not rotund W nrnlfere l for sale(Sec.7044,im,mrsx �)'I I IER
L3 m and Profession Code,The C.ntracto-License Law does nal apply to an owner of DO[1.17 I'S-SWITCHES-FIXTUR17S
Nearly who Nuldc or improves thereat,and who does such work himself or through
his own employers,provided Inas such improvements am nm intended or offered for NEW RESIDENTIAL ELECT,R SQ FT.
sale.IL however,the building.,impmm,n
vertiss.ld within nneycm.fcompletioa.Ihe SQ.FT.FLOOR AREA LSQ.FT,
s w r,buidder will have the hearten of proving that he did nm build or itn,owc for Pur-
Noe of sola).
❑ I,as owner of Ilse prnpeny.am exclnnively contracting wdh Iiecn.ced ennirannr.\n, TOTAL:
I n lmn.me pmjccl(Sec 7044,Bunincrs:seal Professions.......I..Cnntmmor's Lh
renese Law docs unapply to an owner ofpa,unty who builds or improves mencon,and QTY PLUMBING PERMIT FEE
who contrasts for such pmjcas with a contortions)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
El I am exempt under Sec. ,R&P C for this.",.I
Owner Date ALTER-BRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECP.DEVICE
I nereb)xllirnt under penally of Perjury one or the IiAlnwiug declareti.nn.
❑ Ihave andwill for
ineCion 3700 of the Lmor sole,for the Wodmnce tate- BRAINS-I:LDOR,ROOF,AREA,C(INII, STORIES TYPE CONS'FRUCT10N
.,tint, r which
his
1nr by Section 3]1X1 of IM1e Labor Code,for the perlbrrmtn.m titer,
cork for whim rills permit i.issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Cnmpensmi.n Inrrnm,as required by Section
3700oflhe Labor Cole,fonheperfnrmnee of Pe work fitrwhich this permit isissued. GAS-EA.SYSTEM-1 INC.4 OUTLFTl OCC.GROUP
My Worker's Compensation Insurance carrier and Policy number am: ( v
Gorier: Toney No GAS-EA.SYSTEM OVER 4(IIA) j
CllGVICATE OF EXEMPTION PROM WORKERS' GREASI%IND115TRL WASTEIN'TERCEPfOR
COMPENSA'T'ION INSURANCE
(This sectionneed irmbemmplrled ifthe pcnsdl is nuone hunPBUILDING DIVISION FEESeldollarOS10B GREASH'BAP
or less) PLANCHECK FEE
Loy any that in be any
Peworkbmwhich his the Wisismeomfir . SEWER-SANITARY-STORM I:A.2(X1 FT.
not empiny,ny person in any manner so I become bjecnolhe W.rkcrs'Compcm ENERGY PGE
Oz nation lawsof GJilnmia.Date 7�� �I WATER TRADER WNENVELECTR
z O Applicant
W) NOTICE TO LIC ,onentmking Pin Cenifmtne a'Ilxempti.n,you shndA WATER SYSTI?M/1'RHATING -
a E become subject to the Workers Compensation pmsnsions of the Labor Code,you must SOH-S FEE
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE Vu I
Q
7
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMR. SQ.FR #SEESMI -EE
O I hereby affirm that them is a comtrcdon lending agency ter the performance of Re{LFhe work for which Pis Nma is issued Ner.3P)],Civ.C.)0ULenders Natne OTAL:
D.I Isnders Address TOTAL1r I certifyIsm 1 lose read this application and sate That the above infommion in H coomea 1 agree mcannply wire all dly and manly ominenecs and sate tows relatina' QTY MECHANICAL PERMIT PEE
zbuilding comiucdon,and hereby authorm representatives of this city to eater uponrhe abrwementioned property for inspection purpoes. PERM1IIT ISSUANCE(We)agree to save,indemnify and keep hard...me City of Cupeino again,Iiabilitin,judgments,costs and expensnwhich may in anyway accrue against said CitygLTER OR ADU'fO MECH.in ronscyucnmof thegnm,ingof Pspcnnit.
APPLICANT'UNDIIRSI'ANDS AND WILT,COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(DO IENNI CI'M)
SOURCE REGULATIONS. MPCHANINALFEE
AIR HANDLING UNIT(OVER 10.00"CFM) CONSTRUCTION TAX
Si of Applic..uncommem, L Om EXHAUM'HOOD IW/DUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will meapplicant nr future bui1dingoccupudI,l c or handle hazard.us material HENrING UNI T TO 10),000 RTIJ)
as defied by the CuPcn inn Municipal Code,Chapter 9.12,z the Health and Strict,
Code.Section 25532(aV - HEATING UNIT(OVER 10hola)if-[U)
❑yen �No
VENTILATION PAN(SINGLE RE Sl Of PAID
Dale Receipt M
Will'he applicant or a!wilding by the B use .Air enl.rdeviceswhich BOILER-COME OR 100.0X0 BTU)
,nit hayallous air unmaminantx as JefineJ by the Bay Area Air Quality Managemem L
Dis a?
❑Yee BOILER-GOMP(OVER IIXI,IXp 1{TU)
Ihove rnnl the hazand.alinitenals requirements under Chapter 6.95 of the Cali- AIR COMM ONER
1 r ISSUANCE DATE
fbria Health&Safety Com,Sections 255(15,35531and25514.1 to understand Patifthe NEw RESIDENTIAL MECH. SQ.Fr. ^ ^ -2 2 C
building d«:not cora:''tly "a,me,Poor it icmmum of.Cdirylowtifyve issue,reception L
.One rtqui xwhidn gbemet Prior res issuance ora Ceniticme ofoecupYh'y.
Owne rauthnrimA agent TOTAL: ISSUED BY
OFFICE