S 2225 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING—ELECTRICAL PE fI NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2225
/ C
BUILDING PROJECT'IDENT'IF'ICATION L L J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.)ATT
Ilk
OWNER'S NAME: HONIi: Q� CONTRACTORS A P' LIC NO:
�Y hG 7 OG� . .p LAN N/C CON'IROLp
ARCII'fECT/IiNGING1iR: LIC NO: ADDRESS: C ❑
CON'I'AC'I': PHONE. BUILDING PERMIT INFO
,-r����2� ❑ Consultant Fees Paid by Applicanl(Initial) 21 ELECT PLUMB MGCH
0( ❑ ❑ Q� ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed miner provisions of chapter 9(Commencing JOB DESCRIPTION
WOO with Sectim,700Tof Division 3 afthe Busimessmnd PmlessimnsCde, m]mylicen..e is IT FRIDENTIAI•
F,�C in full Torre and egret PERMIT ISSUANCE
OL c34
❑SFUWL El KITCHEN REMODEL
FQ.UU LICr Cla. Lls'.H ❑ADDITION ❑PLUMBING RE-PIPIT
NQL Dam )! GCnmmcmr APPLIANCES-RESIDENTIAL
ARCHITECT-S DECLARATION PANELS ❑MUI:I'4UNII' ❑STRUCTUkAL
Z C)Z I unde,mi n l my plans nhull be used us puhhe mcards MODIFICATION
O Z- 0 UPI'O 2(X1 AMPS
F•a�Iqq'W Lic nscJ Pmfcssinnal El INTERIOR [I CHIMNEY REPAIR
Cao �, OWNER-BUILDERDF;CLARATION 281-1000AMPS IMPROVEMENT [D SWIMMING POOLS
W Q I hereby af4nn thin I am exempt from the Cnnw<torS License Law for the OVER IIXXIAMPS ❑BATH,REEMMODEDREEPPAIR ❑DEMOLITION
L 04 U following reason.(Section 7031.5,Business and Professions Cotte:Any city or county SIGNS ELECTRICAL OTIIY^li-s-rlr�
LL Us y which requires a permit in vtomomm alter,improve,demolish,or repair any structure
prior to itsissuance,also requires the applicant fsuch Permit file a signed statement SPECIAL CIRCU ITIMISC.
S1r�yY
that he Te:d postand t Into provisions of C tmcln License Low(Chapter 9
(commencing w ith Section'rWo ofDivii 3 ofth Business JP fe ins Code)or I EMP.METER OR POLE INS', COMMERCIAL:
G�
d 6 c that he is exempt therefrom and the basis for the alleged exemption,Any violation of
El NEW HLDGIADDITION 1:1 DEMOLITION
W'm"h Section)431.5 by any...loran,lbrapermitsohjuro meiy,fend ur a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
FZatit uthan live hundred dollars(351X).
Olmav m owner of the pmpeny.tar my employces with wages as thcirsnle mmpenwtinn, SWIMMING POOL ELECTRIC IMPROVEMENT
0 will do the work,andthe.anmture is not imended,nuffered for sale(Sce.7014,Business BOTHER
ad and Professions Code:'I he Commoner's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpcny who builds or improves thereon,and who docs such work himself or though
his non omployecs,provided nonsuch improvements arc not intended m otfered for NEW RESIDENT Al,ELECTR SQ FI'.
sale.If,however,the building or improvement issold within one year ofcnmpletion.the SQ.FT.FLUOR AREA WSQ.fT.
Wilder will have the burden of proving that he did not build or improve for par-
IF ��
tie of,ele. ).
❑L as owner of the pmpeny,out exclusively contracting with licensed contractors is TOl'AL:
contraction the pruce,(Sec.9041.Business and Pndessions Code)The Contractors Li-
cense Low dw%riot apply to an owner of property who mulls or Imposes theresm,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a cammcton(s)licensed pursuannn the Cnnaumors
License Law, PIiRMII'ISSUANCE
ala exempt tinder Sec. ,B&P C fur this reason
Owner DereALTER-DRAIN&VENT-WATER(EA) VA LUAI'[ON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
• I hereby li irm under penalty of perjury one of the following declamtican:
l haveund willmainmi n a Coni Gcale of Consent to selG insure for Worker's Compen- DRAINS-FLOOR,ROMP.AREA,COND, STORMS TYPE CONSI'RUCTIUN
sation,as provided for by Section 3]1X)of the labor Code,for the performance of the
w k for which this permit is issud. FIXTURES-PER TRAP Q O
1 have and will maintain Worker's Compensation Insurance,as required by Section
Y 00 of the LaMar Code.for the formance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OUT
My Wmke. .oro n liunlmm acecamerand Policyl���,,JYYIkPP^��M are. (ICC.GROUP ARK
Carrico: sac Its, "they Nn: am:'3 GAti-EA.SYSTFM-OV HR 4(HA)
CUR TIFICATE OF EXEMPTION FROh WO K R GRIiASF/INDUSTkI.WASTE INTIiRCEI'IUR
COMPENSATION INSURANCE
U'hi,section overrun,INC nm Ietedl0he it fortune to olmddollurs $IW) 13U ODfVISION FEES panni I GRI?nSE'1'RAP _
or less.) PLANCHECK FEE
In,any that inthe derany.1
We fnr whicM1this The W o,rxd,Ishall SI7WER-SANITARY
no,employ any parson in tnny manner so vs mbecome sublccun the Workers'Colnpcn- STORM EA.201121' B Offtuo
Z sation Laws of California.Date
Applicant - W'A'TER BEATER WNENT/ELECfR GRADING IgiE
tiNO['ICE'1'0 APPLICANT:If,alter making this Certificate of Exentp ker,you should WATER SYSTEM/I'BEATING
a , become subject to the Worker's Compensation provisions of the"We Code,you most SOILS FEE
W lisnhwith comply with such provisions or this permit shall M deemed revoked WATER SERVICE
Q
UO
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
I hereby affirm that then is a construction lending agency lir the perfrnmuneeof Oa Neceip,p
U. F the work fnr which this permit is issued(Sec.3097,Civ,C.)
Q Leader',Name TO`FAL:
W Lenders Addrees
ky I cerady that I have read this application and state that the above information is BUILDING FE
LF. h ounce,l agree to comply with all city and county ordinances and state laws mlating to QTY. MECHANICAL PERMIT FEE
V Z huilding cnnswction,and hereby umhorize repmsematives of this city to enter upon the SEISMIC '
o III
above-mentioned pmpcny for inspection purposes.
(We)agree to save,indemnify and keep hannlesa the City of Cupertino again., PERMIT ISSUANCE ELECT C
liabilities.jud,ravol,cosd,t,$expenses which may in any wary accruc'uguinsl sail City ALTER OR ADD TO MECI I. O
onseyuence nim an of this permi PLUMBIZAEE
APPLICANT U St' NDS AN LL COMPLY WITH ALL N N-POINT AIR HANDLING UNIT GO 1),WU CPM)
SOIJRCG 'f'p IOi MECHAN ;AL PEIi
AIR HANDLING UNITfOVER 10.100 CPM) CONSTR PION TAX
Sig rc fA ,dcerd Cmrmc r Dam EXHAUSTHOODIW/DUCII HOUSING M (CATION FEE
HAZARDOUS MA DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I0100))BTU)
as defined by the Cuperti no Municipal Code,Chapter 9,12,and the Health and Safety
Code,Section 255J2pd? I� HEATING UNIT(OVER 100,(104 BTU)
E]Yc, W' VENTILATION PANISINOLE R551D) PAID -.
'10W II the applicant or future building occupant use equipment or devices which [)am Receipt N
emit hanvrdous tar contaminants as Jcfined by the Bey Areu Air Quality Management BOILER-COMP(3HP OR 100.001 BTU)
Fashion, - (O 11)1.00BILU
❑res �o BOILERCOMPVER (
�
I have read the locomotion,materials re a muric.ts under Cha tar R 95 of the Call- AIR CONDH TONER
.94 P ISSUANCE DATE
�f
fomla Health&Safety Cde,Scati�5MS335534.1 anJenmd that if the NEW RESIDENTIAL MECH. SQ.FT.building int only hvveasI'lli,y nr w'fy,h•rccupant
of hichmstcenilirm fF panne.
T raulhoriznl Igen!225 1, Doc TOTAL:
ISSUED BY:
OFFICE