S 2666 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-ELRCfRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT1'LU]1111NG-MECHANICAL S 2666
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: I :SANITARY NO. APPLICATION SUBMITTAL DATE
>S 33 �?
OWNF 'S NAMIi: PHONE: , kACTOR'SN I LIC SIC CONTROL
1
ZZ
ARCHYTECUtGINEER: LIC NO: ADD SS: EDCONTACT: • PHONE: BUILDING PERMIT INFO
T ED Consultant Fces Paid by Applicant(initial) BLDG ELECT' PLUMB MECH
d -o E] ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby off ms that I an licensed under provisions of Chapter 9(commencing
th Section Divisinn3ofthe Rosiness and Professions GNP,and my license is R ID NTIAL:
Poo xr PERMIT ISSUANCE
kky--w F m full force and et ❑SFDW L ❑KITCHEN REMODEL
QUU Liceme I.ic.a APPLIANCES-RESIDENTIAL []ADDITION C1 PLUMBING RF.-PIPE,
F z W Date Cnntmdnr
m6S ❑MULTI-UNIT ❑STRUCTURAL.
F=y ARCHITECTS DEChARATION PANELS
z O n Z 1 unddatand my plans shall be used us public records MODIFICATION
_ UP TO 200 AMPS L)INTERIOR ❑CHIMNEY REPAIR
oz— UP
Licensed Prnfessianal 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
C Y2; OWNER-BUILDER DECLARATION OVER IgRAMPS ❑BATH RHMODELIREPALR [I DEMOLITION
tY C< 1 hereby infirm that 1 am exempt from the Contracmr's License Law for the OTHER
�0�(:S U following rensrn.t$ecirso]031 5,Business and Professions Cii Any city or county SIGNS ELEM HICAL
u13 W F which requites v permit to ernstrur6 titer,Improve,demolish,ar repair any drachad
priano its issuance,uEn requires therpplicam mrsuch peonlun filcaaigmWataterri SPECIAL CIRCUI'1'IMISC.
That he Is licensed Tuitional m me pmvixions of the Contm<tnrs License Lew(Chaplain
WR000 (mmmencingwith Section]000)of Division3 ofthe Business and Professions Code)or TEMP.ME TER OR POLE INST.
,L b c W that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION, ❑DEMOLITION
H Section 7031.5 by any applicant far a permit subjects the applicant as a civil Penally of =VICFSZ6EVICES ❑TENANT ❑FOOD SERVICE
t more than five hundred dollars($51X)). IMPROVEMENT
FSS=O ❑1,m�wner of the property.rr myempinyecs with wages as theirsole crmpenmtian, NG POOL.ELECTRIC
will do the work,and the swewre is not Intended or offered forsau(Ser.]I14q BronesxOTHER
mand Professions Cade The Contractor's License Law does not apply to an owner ofS-SWITCI{ES-FIXTUIZ1iS
p' property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements an not intended or offered larSIDENTIALELECfR SQ FT
sale.If.however the building or improvement is sold walincone year of ciardaiion,'be SQ.Ell FLOORAREA L$Q.IT.
neobuilder will base the burden of proving that he did not build or improve for pup
peo,of sale.). TOTAL:
❑ Las owner of the Sec.70y,am exclusivelysad Protracting with T Tie
Contractor's
ors m
nrve La the project(Sat.]f 144, scaButr olcvmd Professions Coda,)t d,t sod.,Li- -sat Law dumnmapply loon oilhscoipmpeny wno remidiAsorinqnovo Connn,mw PI,UMRING PERMIT FE8whocammls forsuch proxts with acnnnucmr(s)IicenseApuunm Inthe CnntrucmtaLicense Law. ISSUANCE S.I am exempt under Sec. ,13&P C in'this uwonOwner Dato DRAIN&VENT-WATER IPA) VALUATIONWORKERS COMPENSATION DECLARATION LOW PauTELT.DEVICE •o . 0 0
T herein,ullimn undo penall,of perjury one ofthe following deelmadons:I have and will indmain a CertiMate of Consent to sel6lnsure lir Workcra Compel. -FLOOR,ROOF,ARBA,COND. STORIES TYPECONS'I'RUCI'ION
r uon,vs rrvitied for by Section 3]1X1.1 the Labor Code,far the performance of the _
whichlhis pcmut is issued, FIXTURES-PER'TRAP
ten have and will maintain Workers Compennmion Insurance,as required by Section
37W ofthe Labn Cprcde.for
rformerice ofthe work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.—GROUP APN
My Wo C mnccita dPnlicy
Curna' sat n cPolicy N., GAS-EA.SYSTEM-OVER 4(EA)
C17RTII-ICATEOFEXE PI'IONFROMWORKF.RS' ORF.ASI/INDIISTRL WASTE INI'ITOCF,PTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
Ludssmionnecdcul he,completed ifthe permit is int ono hundred dollars($I W) GREASETRAI'
or Pus) PLANCI{IiCK PBC -
Ianify that in the perfmarmoccofthe work far which this pemtit is issued.l shall SEWER-SANITARY-STORM EA.200 FIT.
riot employ any Nom in any manner so as to become subjectn the Workers Compcn- ENERGY IEEE
O
z saint laws of Cblifamia.Dau WATER HEATER WNtNT/ELECIR rQ GRADING IEE O Api lieam
rt, NOTICE TO APPLICANT.If,after making this Cartlficum of Exemption,you should WATER SYSTENUTREATING SOILS FEE
abecome subject to the Workers Compensation provisions of the Luhor Cade,you must
LkJ forthwith comply with such pmmurasor this permit shall he directed revnkod. WATER SERVICE
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID are Receipt M
LJ wank
which
thin there isaco (Sce.construction vgenry fonhe performance of
the work for wM1ieh this permit is issued(Sec.iW],Civ.CJ
OLenders Name '/ TOTAL.
{U2a Levers Addreav TOTAL: -f S
f�..nm t1 1 Cerify that I have read(hi.s:mpheri rt,and at
Ihm the above infunnmion is BU
i•m h cored,l agree to comply with all City and Camay ordinunces,nl sane laws relating to QTY. MECHANICAL PERMIT q➢i , r
V Z building eonsimcran,and hereby authnriu represcntntives of chic citymementpm the
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree,. indemnify and kap harmless the City of Constrict,against V
liabilities,judgments,Posts it expenses which may in any way acme against said City ALgERORADDTOMECIL R M N 1'f:
inconsequence UNDERSTANDS
of this permit.
APPLICAN UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT OO III,IXXICPMI MF,CHANICALFEE
50 -GULATIONS.
l,�e�3 AIR HANDLING UNIT(OVER ItIpfNI CPM) By ONS'I'RUCTION TAX
ria re o1A mao✓Conttuma / Date EXHAUST HOOD(WIDUCT) HOUSES 3MI'I IG
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sore or handle hmrdooe material HEATING UNIT TTO I Off"BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cafe,Section 25532fn1? HEATING UNIT(OVER 100,000 BTU) P-5�p� �
❑Yes ❑No VENI'FLAIIONFAN(SINGLERF?SID) PAID-2�i=L {--
Dmc Recdptk
Will the applicant or Land building occupant use equipment or devices which BOILER-COMP(311P OR 100,000 BTU)
emit havNous air contaminants as defined by the Bay Area Air Quality Management TOTAL.
District? BOILER-COME(OVER 100,001 BTU)
❑Yes ❑Nu
I have rend the limitations materials requirements under Chapter 6.95 of the Cali- AIR CONUII'IONF.R ISSUANCE DATE
forma Health&Sandy Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH.
building does not currently have a lemaaa that it is my responsibility to notifythe occa,i of the nomiremenls which must he met prior to issuance of a Cen iticatc of Occupancy. �t�/,—
\\\J Owner or amhoriud agentUme
TOTAL: ISSUED BY:s-/'S e-
OFFICE-