S 2510 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELE('PRIC'AL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMIIING-MECHANICAL S 251
BUILDING PROJECT IUENT'IF'ICATH)N
IIUILDINC ADDRESS: SANITARY N(l.
APPLICAI SON SUBMHTAS,DAT1
CT-
.O XU CAM1 &&r+I nt Zr 1'tl0 �3T.s CDf �1 � ba T
NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
rONC'F. PHONE: 6UILDING PERMITINFO
❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
hereby affirm that L am licensed under pmvisinns of chapter 9(commencing JOB DESCRIPTION
WOOaim700(Bnt Division 3 ofthe Business and Professions Cade.and my license is R ID NTIAL:
WOO PERMIT ISSUANCE
CSF
I.fallorte and elect bbl b$7 DSFDWI. [I KITCHEN REMODEL.
aVVCl_ss Lic'N APPLIANCES—RFSIUFNI'SAL - ❑ADDITION PLUMBING RE-PIPE
FZu1 o— Conuactor� #�
had' ARCHITECTS DECLARATION DMU[.T[.UNIT ❑STRUCTURAL
Oop� PANELS MODIFICATION
m 1 uvdemvnd my plans shell he used as Puhiic records
UPS 0200 AMPS [I INTERIOR DCHIMN REPAIR
F•4tt�il Licensed Praftwimed 201-1000AMPS sI-�*I SWI 1 POOLS
�44 OWNIA-BUILDERDECLARATION OVIiRIIIIXIAMI'S BTHRF EFAIRIUJDEh ON
C C Q I hereby affirm that 1 am exempt from the Contnminrs License law for the LLLJJJ
aLL F following reason.(Section 7031.5,Business and Professions Code:Any city nreountY SIGNS F.1.1!CMICAL HER
y which rcyuires a permit to construct,alcor,improve,demolish,or repair any sfmcmr,
prior to its issuance,also requires the applicant for such permit rile a signed statement SPECIALCIRCUIT/MIS
ythat he is licensed pursuant to the provisions of the Contractnls License Law(Chapter 9
gQp (commencing with Section700ap or Divioon 3 of the Business and Professions Code)or 'T EMP.MCTNROR LE INST. I
IL m tY that he is exempt therefrom and the baxix En the alleged exemption.Any vinfroo.of EW BLDG/ADDITION ❑DEM N
"N Secllov]OIL5 byany applicam farapermit subject the applicant macivil penallyrf POWER DEV 'S fypNT DpOOD SE ICIi
not mom than five hundred dollars($500). Hd1�9 A,191:>F;4
F30 ❑I,as nwnenRthe pmpeny,or my employees with wages ustheirudc asmpenaninn, SWIM GPOOLIiLECTRLC
will do the work,and the structure Is not intended orolTered for.sulef Seo.]044,flusiness ❑OTHER
vnd I'rnfessinns Enda The Crnlmnnr's License Law does nal apply to an owner of O .EIS—SWITCHES—PIXTURGS
A'3 property who builds or improves thereon,and who does such work himself or through
his own employee,,provided that such improvements are om intended re offered for FW RESIDENTIAL ELECrCR 1
sale.If, the building or impmvemenl is sold withinone year of completion,the SQ.FT.FLOOR AREA SISQ.14.
ter builder will have the burden of proving that he did not build or impuwc for pur�
Pascal salej}
E)1,as owner of the property,am w
emluvively comnacna, in licensed emantetora Ir 'TOTAL:
mxwcl the project(tier.7004.Businesx and Profession,Cale:)The Cantmcuir's Li
-
amelawdoesnotapplytoanowner of property who builds or improve%thereon,and QTY. PLUMBING PERMIT FEE
whm contras mr such projects with a rnnuacions)licensed pursuantSo use Cenlmenir's
License Law. PERMIT ISSUANCE
D l um exempt under Sec. ,B&P C for this mason
ALTER—DRAIN&VENT—WATIiR(EA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROfECI'.DEVICE IhereM1y affirm coder Penalty of penury one of the fallowing declarations: (fir {O
Colas and wills for
neC3700 of the Labor
Codensurefer Worker'sce of the
DRAINS—FLOOR,ROOF,AREA,COED. S'T'ORIES TY .TRULTIOI
smirk, r provided for by sissued.
Section 3)1X)of the Lahnr Gde,for the performance rl the 1 t
ark far which this permit is issued. FIXTURES—PIiR'IRAP Y
❑ 1 have and will maintain Worker'sounce o the w rkfor hi h rearyireJ by Section
7]m0 of the Labor Code,for the pertormunce of the work for which this pemiil in issued. GAS—fiA.SYS"TEM-I INC.40IfT1.ETS (KC.GROUP AI'N
My Worker's Compensation Insurance carrier and Policy number are: 22/
Currier. Policy No.: GAS—HA.SYsCEM-OVER 41EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This,ecoon need rot bu,nmplc¢d ifthe peimitis for,.hundred dollars lSIIX) GREASETRAP
or less.) PLANCHF.CK Fl>E
I ttnily th 'n a lwrfournameofthework far which this permit is issued,[,hall SEWER—SANITARY—S'FORM EA.200 IT.
not employ nn in any,mm� sa as m been"�''Oun ks the Workers'Comps m ENERGY FEE
z cation Law. f li �mia.Date L--/ WATER HEATER WNENT/ELEMR
z 0 Applicata GRADING FEE
i�—t 7 NOTICE.T APPLICANT If,after making this Certilicme of Exemption,you should WATER SYSTEM TITRATING
ti SOILS FEE
a 7 M1caimc s Kct to the Worker's Compensation provisions of the Lubar Code,you must
forthwith comply wulsocar pookion,orchis permit shall tie deem ed revoked. WATER SERVICE.
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM9. SQ.F-C PAID
L) Ihereby affirm than there is a construction lending agency for Ne perfonnancenf D #
ate Receipt
O. 2 the work for whist this permit is issued(Seo.3097,Ci,C.) TOTAL: '
O U Lender's Name
TOTALLender's Address
at the above information is IIUILDING FEE
wI certify that l have read this application and state th
it cA roamer.l shommcnnily in.11 city and mumyordlmmes and sum laws relming to QTY. MECHANICAL PERMIT FEE SEISMIC 1LIi
U Z building construction,and hereby authorize representatives of Ibis city to enter upon the
above-memioned or fm inspatton puryrus. PERMIT ISSUANCE ELECTRIC FEE
(We)ogrce an indemnify and keep IS Ne City of Cupertino against
liahil'nicx.jo terns, ms and expenses which may in anyway attmc against snit City ALTER OR ADS)TO MF.CH, PLUMBING FEE
it cons en lift gmntingofthis permit.
API' 'A ' UN LIR STANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING 2! (11 I(I,gp CFM7 MECHANICAL FEE
S( .RCP EGl'.ATIONS.
AIR HANDLING UNL'L'( NEI l4(;;CF CONSTRUCTION TAX
score of pplicanUContmOcif Date EXHAUST HOOD(WIDUC) HOUSING MIT IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wll the applicant or future Wilding oecupant store or handle ha<ardous material HEATING UNIT fI'D Ig1,01XIU' )
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)? HTiATING UNIT(OVERT ,fed BTU) Q
El Yes Cl No VENTILATION PANT CLE RF:SID) PAID
Firm Reccipl#
Will the applanat or future building occupant use e9nipmenl or devices which flO1LER—EOMI' HI'OR IIq,IXNt BTU)
emit mandous air contaminants as defined by the Bay Arca Air Quality Management TOD%L .�
District? B
OILER (OVER 100,000 BT U)
El Yes LI No
1 have read the hazardous materials requirement under Chapter 6.95 of the Cali- F.R ISSUANCE-DATE -
E,mia Ilealih&Safety Cole.Suctions 255(15,25573 am125534J understand that if the MECH. SQ.P-n
building does not currently have a mount,that II is my responsibility to notify the oocupam
of the recarmaents which mux[Be met ptim vi issuance of u Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE