S 2500 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL 7APPLICAI
BUILx�NG DIVISION APPLICATION/PERMIT .PLIIMRING-MECHANICAL. DQ{ _ Coo
BUILDING PROJECT IDENTIFICATION'' / J
'B��NGADDRESS: �� �� SANITARYN(/SSUBMITTAL DATE
V ' fOWN"S NAME: Wt T�T y0 96733 0�!IHCONI RACfORS NAME: LIC NO: NIC, ROI 8
AY
!CHITFCTIENGRI LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
C q ❑ ❑
LICENSED CON TRACTOR S DECLARATION QTy 'ELECTRIC PERMIT FEE =y
I herebyafr that I licensed Trp - of Chapter 9(commencing ._ JOB DESCRIPTION
MaZwhhsf vow) ro 'ion3onneBaa na Profur'on:e d,,anemylce.es RESIDENTIAL
WW 00 PERMIT ISSUANCE
NW.. infallf ceaddoff t. / ❑SNDWL _ EI KITCHEN REMODEL.
Md UU License Class Lick APPLIANCES-RESIDENTIAL ❑ADDITION- []PLUMBING RE-PIPE
F Z W Delc GmlRcmr
N6q ARCHIFFEC'I"S DECLARATION [I MULTI-UNIT El STRUCTURAL
FD.Vz lundect my plans shall be used as pubdcrecords PANELS MODIFICATION
y O14-Q UP'I'0200 AMPS TERIOR El CHIMNEY REPAIR
OZ^ .
Fv�FIy Lcensed Professional 201-I WOAMI'S IMPROVEMENT SWIMMING POOLS
-..1I OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BXIH REMODEUREPAIR LIDEMOLITION
1 hereby affirm thin I am exempt from the Comrucrers License Law for the
following reason.Need...n 70315,Business amt Pmfexsians Cade'.Any city of eounly SIGNS ELECTRICAL ❑OTHER
aW chi which require,a permit I Cunstect,alter,improve,demolish,or repair any,vada.. I
�.�4�dW pia
1.it,issuance,abnrequnes thcapplicant for such permit a file a signed statement SPECIAL CIRCUITIMISC.
that be is licensed pursuant in the provisions oflheContractors License Law(Chapler9 v
d (commncir,,ahSto..anlOIXpofDi,,im 3ofthe Businasnand Profession,Code) TEMP.METER OR POLE INST. COMMERCIAL'
q y o thnl he
e is exempt Elaborated the hosts for(be alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
W^y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t more than five hundred dollars($500).
H'ZY n'�o IMPROVEMENT
1,vs owner of the pmpedy,or my entployccs with wages.Heir sole emnponsmioq SWIMMING POOL ELECTRIC -
O all dmhewons Cade heCart ,ter, scemord.dosan,a ppy to 44,Business Q ❑OTHCR
N m and property
ahe b Cndo�.unp over Id roe I icetrve law docs not apply to an owner of i2 OUTLETS-SWITCHES-PIXTURES r Q O
Cr, his own
who huihts or ivided t s t such Land who noes are
wort:himself of though
his own employees,provided fbnl such intpmvomems arc sol intended or otforul for NEW RESIDENTIAL ELBCTR SQ FT:
sale.IT however,The building or improvement ie sold within one yearefcanTedon.the
SQ.FT.FLOOR ARRA $ISQ.FT.
er-hadder will have The burden of proving that be did not build or Improve for Pub
pose of sale.).
[-] perfectlyL an owner of she perfectly ata exclusively contracting with licensed contractors It) TAE:
omlrud the project(Sec.70,14.Badness and Professions Code:)The Connector's L,
throw Law does hot apply to an owner of property w1ho builds or improves braced,and QTY. PLUMBING PERMIT. FEE _
who eomores hashish prince's with u eenmac-an)licensed puremnT to the Contractor's
License L:hve P12RMI'IISSUANCE
1 ma exempt tin ecs sea. It&P C for this reason
owner Doe
ALTER-DRAIN&VE VALUATION
_ _
W TO 'R'S COMPEN A ION DECLARATION ' / BACK FLOW PROTECT C 000
I hereby nfOr t t def penolty of p r' sof the following declamtionc
I have and willmaictiana Certificate of Coneentnself-insurefr-Worker's Gtmpen- DRAINS-FLOOR,ROOPARE - - ¢TOR ES _ 'TYPE CONSTRUCTION
.alien,as provided for by Section 3700 of the Labor Code,for the pmlbrmance of The I / _
work for which this permit's issued FIXTURES-PER TRAP //N
❑ I have and will maintain Worker's Compensation Insurance,as required by Seclian (/
3700 fh Lb,Cod f the prf un flh is for wl-Id' perm'd is issued GAS LA SYS TEM I INC.4 OUTLETS GROUP APN
MyWorkersC nponsi I -an ePolicy nuinfer �
My P I' yN GAS GA $Y$fLM OVP.R4(EA)
CERTIFICATE OI EXEMPTION FROM WORKERS' WGRAMND -
COMPPNSATION INSURANCE DUSTRI.WASTE INTERCEPTOR EDIT lSJdISION QE tti$[ s
(I his section nmol not be complweA if lhepcnnnisfimmc hundrml dollors($I W) AP ,ror Less) PLANCHECK PEE
I certify that ineh,pefformvnecofda work forwhich tblspurmb is issued,lshallANITARY-STORM EA.200IT.not employany pleas In any mann.sovsTo becomesnbjecl m the Workor,Cenpen. Y PEE
soden LawsofCalifonda.Date TER WNENTIEIz0 Applicant ' LNG FEE
NOTICE TO APPLICANT:If,after necking This Certificate of Exemption,yaashuldTEM/TREATINGbecomommecl Iothe Worker's Compansvdon provisions ol'the Labor Code,youmust III
FEE
forthwith comply with ouch provlsions or lhixpemmIAall be demnedmvokee. VICEOCONSTRUCTIONLENDINGACENCV ENTIAL PLMH. SQ.PT' 1 Inn RecrimIf
1Mrw affimtthat There isawnstree 3 landing agency for the perfnmmnec of
he veUncle r,for which this permit is isxued(Sec 309],Ci¢C.)
Q CU.) Londe,,Name 'TOTAL:
Lessers Address
rY' Os 1 certify that I have read this nppliwlion and cram thus the above Information is , - rFEEL
HUIIAING. , s�
�.' In correct.I agree to comply with all city and county ordinances and store laws relating no QTY. MECHANICAL PERMIT V Z building denswction,and hereby auWmlze represonhnives of thin city to later open the SEISMICFEE
stu ve-menduchal pm,ar,far Inspection purposes. PERMIT ISSUANCE
(We)agree In save,Indemnify and keep harmless the City of ChIsern o egainst ELEC'T'RIC PEE'
liabilities,judgments,costs and expenses which may in any way atonic against said City ALTER ORADD TO MECH.
In consequence of the granting of This permit. PLUMBING P
APPLICAN UNDER STANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO 10,(100CFM)
SOURCE R.GULATIONS. 'MF.CHANICA FF.P.
AIR HANDLING UNIT(OVER 10,000 CPM) CONS'I'RUC'1'10 AX
Signature ofApp' T sComrador ole EXHAUST GOOD(WIDUC'T) HOUSING MITIGATION FEE
HAZARDOUS MA :I IALS DISCLOSURE
WillWcn lice.nrl'umre buildi ceupanl gore nr handle hozadous.radial I IHA'IINO UNIT(TO 10B,BBB BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25572(.)1 ' HEATING UNIT(OVER 100,000 B'I'G)
❑Yes - Nn PAID
V BN'PILATION PAN(SINGLE RB$ID) Dom Receipt M
Will The applicant or fuwre lhire occaped use equiphead in devices which
it huardom air contaminants as de mer by the Bay Area Air QualityManagommn BOILER-COMP(3HP OR 100.000 BTU) - -
TOTAL:
nsibid, BOILER-COMP(OVER 100,000 BTU)
E]Yes
AIR CONDITIONER
I have rand the hamrdnus memdalsreyuirentenu under Chapter e95 of lho Coli- - ISSUANCE DATE
fomin Ihealth Safety Cade,Sections 25505.25533 ane 25534.1 understand Nur if the - /� /�.
j NEW RESIDENTIAL MECH. SQ.FT. / _q'9
building does 1.1,mdfiadly have a tenant,that it my responsibility to notify the ottupard G� 1
oflcalmien Iswhich muvtbe me c of.Comfier.nI Oeeupancy.
Owner or au o age Date TOTAL: ISSUED BY:
OFFICE