S 2560 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMPING-MECHANICAL v
Q n CO
BUILDING PROJECT IDEN'GFIL'RI-ION J L
BUILDING ADDRESS: SANITARY NO. APPLICA'TIONSUBMITTALDATE
ao3s6 G
PHON?: Cpy1 RACFOR'S NAM 'Cr
LIC NO:
641 vt3 —'7 2 \ \.�.N.i N/C CONTROL.X
ARCHI'1'IiCr GINEER: LIC NO: VJ ADDRESS �- ❑
CONTACT: / 11 PHONE: q01.9 BUILDING PERMIT INFO
Pa s G \I C� Bbs
12-34
I] Consultant Pees Paid by Applicant(Initial) BLDG _ ELECT PLUMB, ECC 1
LICFNSF,D CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE Ire/
I hereby affirm that 1 am licensed under previsions of Chapter a(commencing JOB DESCRIPTION
aOZ with Section 710X8 or Division 3 ofthe Business and Professions code,and my license is RESIDENTIAL
F,= in full rorceandulfea, PERMIT ISSUANCE ❑ SIDE PSRfICIPEN REMODEL
�UU Date Clens Lice APPLIANCES-RESIDENTIAL ❑AUDITION E3 PLUMBING RE-PIPE
U`1� Doc GSDECr
ANCIIITECI"S DECLARATION El MULTI-UNIT ❑ST'HUCT'URAI.
F 7 to I'ANFI,S
ZOy„Z„ IundersnnW my plans shall he usW republic records • MODIFICATION
4Z,Q UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
F'�., Licensed Professikmd 201-10N0AMPS IMPROVEMENT [jSWIMMING POOLS
y OWNER-BUILDER DECLARATION OVER IfAM1AMPS ❑BATH REMODEUREPAIR EIDE OLITION
hereby affirm then 1 am exempt from the Contractor's License Low lir the
3 a U following mason.(See ien 7031.5.Business and Professions Code:Any city instancy SIGNS ELECTRICAL ❑OTHER
W R.N which.,arms a Mrmit to consumer.cher,improve,demolish,or repair any svumure
f"�q� prinrtn in iouance.oleo reyui¢s the appli.ant for such penninn fileasigned stmemet SPECIAL CIRCUITIMISC.
W W T Phot he is IiaenseJ pursmm Ik the pmvismns of the Cunuacmr4 License law IChapmr 9
W y'C�O (atmmcncing with Section 7gX))of Division 3ofNe Business and Pmfessirns Gx]cior TEMP.METER OR POLE INST COMMERCIAL'
1%.E e W that he is exempt dominant and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X^LL Section]031.5 by any applicant for a pnobut subjects Ne applicant to a civil penally of POWER DEVICES
W-y El TENANT ❑FOODSERVICE
not mum than five hundred dollars(2508). IMPROVEMENT
F_Za QL.....crof the propert,or my employes with wages as theirwle compensation, SWIMMING POOL ELECTRIC
O will do the work,and the smentre is not intended oroHered for sale(Sec.]�SW,Business ❑OTHER
4'3 se and Professions C(de:The Contractor's License Law does not apply to an miner or OUTLETS-SWITCHES-FIXTURES Z d O
property who bunds or improves thereon,and who does such work hinself kr through
his own employees,provided that such improvements arc not intended or offered far NEW RESIDENTIAL ELECTR SQ EL.
sale.If,hnwevee the huildingor improvement is sold within one year ofoompletion,the SQ.FT.FLOOR AREA VSQ.EL
owner-hudder will have the burden of reproving that he did not build or improve for pur-
se ol'snle.).
l,as owner ni the property, n exclusively contracting with licensed Utmmunns to O AL:7 5 "
instruct the project ISe.7094,Business and Professions CodcO The Contmnnr:s Li-
cense Law does not apply can owner of prepeny who builds or improves thereon and QTY PLUMBING PERMIT FEF.
whocommis for welt projectswith a cmuamons)licenced pum cent to the Contmemr's
Licenselaw.
❑lam exempt �rsf .. ,B&PCrrnh�-son PERMIT ISSUANCE
n,..�• uXL Dam • r— ALTER-DRAIN&VE -WATER(EA) NT VALUATION
(
WORKERS COMPENSATION DECLARATION
BACKFLOW .C.DEVICE / Js
Imuch,affirm underperalty afpej.,ane ofdar following declarations: ` l/
I have and will maintain a Certificate or Consenuoself-inaum forWmkds Compen- DRAINS-F1 F,AREA.COND. SiDRIE.3 TYPECONSTIR CflON
smirk,as
work for which this fpoerrmi tSeetion 3]W of the labor Code,for the pertonnane<of the V/x///y(-/I
is i arka' FIXTURES-PER TRA
L]I have and will maintain Workds Compensation Insurance, h required by Section X
My Wittier,Corr Code.for theperformanceofthewlisymrthormhis Permit inissued. GAS-FA.SYSTEM-I INCA LETS OCC GROUP �a�APjs'
My Workers Compensation Insumnce canierand Policy numberort: 7 3
Cancer: Policy No.: GAS-EA.SYSTEM_ A7
CERTIFICATE OF EXEMPTION FROM WORKERS' O Z
COMPENSATION INSURANCE GREASMNDUSTRL IVATIllPOOR
BUILDING DIVISION RP'S
(This action need not be completed if the permit is for one hundred dollars IS 100) GREASETRAP
or less.) PLANCHECK FEE
Iov any outinthe tiny mannro as to become
for which this themitisiss Compn- SIiWER-SANITARY-S'IONM F,A.2
I shall
not employ any person at tiny manner so as to become subject m the Workcrv'Cnmpen- ENERGY FEE
,� satinn lows nl C:Jifnrnix.Dom WATER HEATER WIVENOVELECTR
Applicant GRADI FEE
Col, NOT'IC1711)APPLICANT:If,after making this Cenifcme of Exemption,you should WA'I'1iR SYSTEMn BEATING
a become subject to the Worker's Compensation provisions of the Labor Code.you must SOILS FB
Oilfonhwitbeomply with such pro visions to this permit shut]be deemedmo,ked. WATER SERVICE
as n
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID ptRi lX
1 hereby.ITml then there is a construction lending agency far the ecru no,ar.of Date ecep
the work for which this permit is issued(Sec 3097.Civ,C.)
0 F-' Lender's Num. TOTAL:
L) lender's Address XPERMITFEF
I.unify Ibar 1 have read this application and nte thabe aove information isB G FEE2- 0
0 correct.l agree to comply with all city and county ordinances and state laws re]ming t" QTY. MECHANICO
Zbuilding construction,and hereby authorize represetatives of Nis city m enter upon the IC FEEnbavbmemion<d prnpeny fur inspection pmgxas, s.(We)agree to save.indemnify and keep hafmless the City of Cupertino agolnst PERMITISSUANC�. EL RIC FEE Q
liabilities,judgments.costs and expenses which may in any way aceme against said City ALTER OR ADD TO MF.Cin asequence of the granting mf this permit. P MBING FEE
APPLICANT UNUERSTANUS AND WILL COMPLY WITH ALL NON-P(11NT AIH HANDLING UNIT(T�SOUN : E ,ULAPONB a � MF.CH NICAL FEE
M1AIR HANDLING UNIT(0
CONSTRUCTION TAX
Signamren Applicam/Contmcmr DoT— EXHAUST HOOD(W/ HOUSING MITIGATION FF.F.
HAZARDOUS MATERIALS DISCLOSURE
Will the uppllcant nr future bulldmg<acupomsmreor handle hazurdousnnncriel HEATING UNIT(TO I RTI)
us defined by lite Cupertino Munlulpul Coda,Chapter 9,12,and the Heallb and Snict,
Code,Section 25532(ai7 HEATING UNI'I'(OVER 100, T'IB hD)
❑Yes VIiNTILATION FAN(SINGLE RES , U
I - Dam Recipt X
Wndom,l the it commit
as building by
ay Ause rea
Air Qualitment y
viceswhlch BOILER-WMP(3HPOR IIIO,g108T'U)
'emit hazallous air nmmminunu as definal by the day Arca Air Quality Mmmgemcnl 0 r
DimrimT
❑Yesm BOILER-COME(OVER 10d,000 BTU)
I have brands,hazaNeusmaterials onEiremrnfc undef Chase 695 of the Culi- AIR CONDITIONER ISSUANCE DATE
(omio Health&Safety Code,Societe;25505.25533 and 25534.1 understand that if the NEN'RESIDENTIAL MECIL SQ.IT. 7 --?^y —9
building ally ltaveat ant,Out it is my ponsibilitymtwtify the cecuptm O
QLA I�em nym bmuu et ort a oCerffcam (]ecu
w0` �� lAf��
Ow er am orisd ugem TOTAL: ISSUED BY: j Aa
OFFICE 2_A=1