S 2530 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING:MECHANICAL S 2530
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRE SANITARY NO. APPLICA'T'ION SUBMITTAL DATE
aD3 7 bpej v $q
M��OW "SNAME: PHONF;: CO TR OR' AME: LIC NO:
&vsrn q09 N/C CONTROL of
ARCHITECT/ENGINEER: LIC NO, ADORE w`� ❑
CONTACT: - PHONE:
BUILDING PERMIT INFO
❑ COnsilltard Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
az LICENSED CONTRACTOR DECLARATION QTY, ELECTRIC PERMIT FEES
1 baraby affirm that 1 am Ilc raved under provNions of Cornier 9(Commencing
JOB DESCRIPTION
F�� with Section of Division 3of the Business and Prof..or,Code,had my license is PERMIT ISSUANCP,
in full farce and elFeq_ yr RESIDENTIAL,
�UV License a^. Lich ❑SFDWL ❑KITCHEN REMODEL
Pzw )me Contractor APPLIANCES-
RESIDENTIAL ❑ADDFHON El PLUMBING REPIPE
ARCHI'1'ECr'S UECL A N PANELS El MULTI-UNIT ❑SI RUCTURAL
z p y zz. 1 understand my plans shall he rotates public records MODIFICATION
O z UP TO 2M AMPS
F4L'W Licensed Professional ❑INTERIOR ❑CIIIMNP.Y REPAIR
J
..I 201-IWOAMPS - IMPROVEMENT SWIMMING POOLS
�� OWNER-BUILDER DECLARATION ❑
I hereby affirm that 1 nm exmmu from the Cimarron.,License Law fnr the OVER 100CAMPS W a ❑BATH RF DF.1./REPAIR DEA10LITION ,
'3 4 U following rmsaa(Section 9onstr t.alnns and Roles-cions nae:Any city stroomy SIGNS ELECTRICAL 59 OTHER E/��{-',-lAl,r661s�t,',/r„—
which requires a permit to cmnarun,alter,improve,demolish or repairany structure
prior to its issuance,also requires theapplicent bar such Pumit to file a signed statement SPECIAL CIRCUIT/M TSC.
amat he is licensed Pursuvnt to the provisions of the Cmntram s License Law(Chapter 9
W (commencing with Section 7000)of Division 3 oft he Business and Prbfesslnns Care)tor TEMP ME TER OR POLE INST. COMMERCIAL,
d it n e' that he is exempt therefrom and the basis fnr the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Secd.n7031.5 byanyapplicam fnr.permitsubjcetstheappli...I to.civil penalty or POWERDEVICES
not more than five hundred doll...($500). ❑TENANT El FOOD SERVICE
pQ� I,m owner of the IMPROVEMENT
❑ property,or my oiNwagesmthei(vele compensation, SWIMMING POOL ELEC'T'RIC
S mwill Prdo the work anile The Cmuchnota Licensmoffered for sale(SecAf144,Business ❑OTHER
and Professions Cade:The Cnmractora License Law Joel not apply m an owner of OUTLETS-SWITCHES-FIXTURES
ti property who)builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered fair NEW RESIDENTIAL.P.LEC'CR SQ FT.
sale.IL however,the building or improvement is sold within ane year of completiim.the A(IA)
.FLOOR AREA $/SQ.FT.
caner-harder will have the burden of proving that he did not hot ld or improve for put-pose of sale)- a❑ 1,as owner of the property,am exclusively ennatio ns with licensed amanintors to onstruct the project(Sec.]044,Business and Professions Code:)The Contractors Li-cense Law does not apply to an owner of property who build..,or improves theren,:rod QTY. PLUMBING PERMIOwhocontmets for'uch projects with a eontracmrn)licensed pur'nant touseComuchr's 1999License law. PERMIT ISSUANCE9x99❑I am exempt under Sea. ,R&P C for this reasonALTER-DRAIN&VENT-WATEROwner Date VALUATION
WORKER'S COMPENSATION DECLARATION PACK PLOW PROTECT.DEVICE
I hand w affirm under penalty ll perjury one of the insure ing declarations
❑Ihave and will lair bytain eCion 37m.fCe Labora to code,for
Warers rformace of the
DRAINS-FLOOR,ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
work(r provided liar by Section 3](Nl of the Labor Coda fnr the performance of the -
VI for which this permit is issued. FIXTURES-PER TRAP
37 have and will Lode,for
he performance
anceothe Compensation work
for which
h required by Section
3900.(the Labor Coda forth¢perfnrmnnca oftho work fircwhich this permit is issue]. OAS-EA.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
My Works ., oro ensati Insure one carrier and Policy au
Carrier: - _Policy No.: re GAS-EA,SYSTEM OVER 4(EA)
CERTIFICATE EXEMFUON FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(ThisIecti.n need not he completed Hobe permit is for onohundreddollarsSIts)) GREASETRAP
or less,) BUILDING
FEE
I cenify that in the pertmntwnce nDhe work fnrwhich this mi
pert is ies.ch,lshall SEWER-SANITARY-STORM EA.200 FT.
neldy any person in any man s :•m e subjem t.the Workus'C.mpmn- - ENERGY PEE
no"
cnnp
zi '.tionLaws
O O Applicant WATER HEATER WNENT/ELF.CfR GRADING FEE
s'Zi r�/I N O ICE'I�A�'llL1CA1 €r'mak tg ilii'Cenifcate of Exemption,yoo should '�VA713B SYSTIiMITREATING
bear.subject to the Worker's Compensation provision of the Lola Code,you amid SOILS 17EE
Lkl G forthwith comply with such provisions or permit shall be deemed revoked. WATER SERVICE
Q '
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID
U 0 1hercbyaffirm that the. lendingageney for the Pe,frrmuncum' Date looramlit
Lis H the work for which this permit is issued(Sec.3097,Civ.C.)
Lenders Namef _ TOTAL:
benders Address TOTAL: b.5T ,
1 certify that 1 have read this application and state that the above information is V BUILDING FEE
Z) correct.l agreeur comply with all city and county ordinances and state laws refiring to QTY, MECHANICAL.PERMIT
U z haddingconstructioq and hereby authorize tepresentativeso(this cityt.enferupn the PEE SEISMIC FEF.
w+
.Nice mentioned property foriapecticn purptrse'.
(We)agree to save,indemnify and keep harmless the City of Captain.against PERMIT ISSUANCE
ELECTRIC PEE
Iiabilities,judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNI'((TO 10,(X1!)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
/ �) AIR HANDLING UNIT(OVER 10,008 CFM) CONSTRUCTION TAX
Siga� (Applicli`ant/Cum r {r/�•(�T/bytdr— EXHAUST FOOD(W/DUCT) HOUSING MITIGA'T'ION FEB.
MATERIALS DISCLOSURE
Will theomdram ar furore hulldiog microform smmnr handle hmardnus material BEATING UNIT(TO 1(X1,0010 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health rand Safety
Cock,Sermon 25532(a)? HEATING UNIT(OVER 100,003 BTU),
❑Yes E]No VENTILATION PANS INGLE RESIDI PAID --
Date Receipt of
Will nf then,cont m or inure building by the B use ea Air Qua or devices which BOILER-COMP CHP OR 100,(100 BTU)
emit hazardous air cmntuminunts as defined by the Bay Area Air Quality Management TTA
Di.dricfr -
❑Ym., I]No BOILER-COMP(OVER I0I000 BTU),
1 have read the inzvrdnts materieLcAIR CONDITIONER
requirements under Chapter 6.93 of the Cali- ISSUANCE DATE
4tmi.Health no Safety Cede,Sections]5505,25533 and 25534.1 understand that if rho NEW RESIDEN'CIAL MECH. SQ.Ff.
building dmev not cummly hevm tenant.that it is my mspnnsibil'ny myyp notify Oto occupant T f
of 1perc9ui�remryeJn7u w•hldI tbem, rte,to issumcanf.Cer ori -
OtL«2F6iauC-t ort? ¢eof.,h uy !� Date TOTAL: ISSUED BY:
OFFICE