S 2246 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUP'RTINO BUILDING-ELECTRICAL. ' Pint]'I'NO
BUILDING DIVISION APPLICATIONIPERMIT PING BINGPROD CT MECHANICAL �J 2246
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BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
o a esu X• 9,!w/ s
%%S N r %,/ / / . PHONE �a� C 'R TO 'S NAMH: f Nf1'. O CONT OLM
ARCHITECT/ENGINEER. / LIC NO: J[•11A AIII>J2 S: ( ,OQ f%
CONTACT:
PHONE: / BUILDING PERMIT INFO
/ / l/_z,l /jj�`�D ,(,/ ❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECHH
Mt
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMIT FEE
I hereby affrm
that 1 am licensed under provisions of Chapter 9(creme ting JOB DESCRIPTION
O Tzz with See a. visiom3anne x ossa aProfeasiomseade,and y1menseis RESIDENTIAL,
WOO in PERMIT ISSUANCE •S—
F full force a -ff n ❑SFDWL ❑KITCHEN REMODEL
aUU License Clax, LD��J Et# pppLIgNCES-RESIDENTIAL ❑AUDITIONEl PLUMBING RE-PIPE
F z W Date - Crammer.,
GP`
ARCHITECT'S DECLARATION ❑MULTI-UNIT El STRUM URAL
p.,pm PANELS MODIFICATION
z O m 7a 1 undersmnd my plans shop be used as public rettnds
Oz"O UP TO 200 AMPS [_1 INTERIOR El CHIMNEY REPAIR
F.�'.F;W Licensed Prafessionrl 201-TIN%LAMPS IMPROVEMENT SWIMMING POOLS
`,�•S'AOWNER-BUILDER DECLARATION OVERIOW AMPS - El BATH REMODEIJREPAIR El DEMOLITION
C 1 hereby affrm that 1 con exempt from rhe Gmtrecmr's Lecenew Law for the
O G O following reawn.(Scctinn 903 L5,Business anA Professinnv Code:Any airy nr county SIGNS ELECTRICAL ❑OFHER
F W C Nwhich requires a permit to construct,alter,improve,demolish,or repair any smactu
Q rc
qq .] prior m its issuance,also requires the applicant for.such permit.file a signed statement SPECIAL CIRCUIT/MISC. S-Sv
y y drat he is licensed puzsuam.the provisions of the Contractor's License Law(Chapter<C (commencing with Section 90001 of Division 3 of the Business and Professions Code)or TEMP.ME'PER OR POLE INST. COMMERCIAL,
Y d c C that he Is exempt therefrom and the basis fame alleged exemption.Any vmlia, of ❑NEW BLDG/ADDITION C]DEMOLITION
Section 90.315 by any applicant for a permit subjects the applicant. V a civil penalty of POWERD1ES ❑TENANT ❑FOOD SERVICE
not mom than five hundred della,,($5IX). IMPROVEMENT
�
EI 1,as owner ofthe property.or my employees with wages as their sole compensation, SWIMMIN ELECTRIC
F will do the work,and the,mucmre is not imendedmoffered forsale(Svv.70aU,Business ❑OTHER
W and Professions Codc'.The Contractor's License Law does not apply to an owner of OUTLETS-SWITC .S FIXTURES
progeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc net intended or offered for NEW RESIDEN'UAL EL SQ FT.
sole.ff.however.the buildi ng or i mm
proveent is sold wait n one year of completion,the SQ.FT.FLOOR AREA 8ISQ.Ff.
er-buBdor will have the burden of proving the,he did nm build or improve for Fur-
,a,.1 soled.
❑I,as owner of the pro"PP,oN,si
exclusivelyconooman with licensed contractors n TOTAL /
ansmum the project(SeaPmtr xl Code:)The Camm�;.rs Li-
ceawLrwdoesnmapplyyh buld,,ninaroveslherion,and QTY PLUMBING PERMIT FEE
who commc ,forsuch pro li en dpar, ant.the Coruscate',
License Law. PERMIT ISSUANCE
❑ I am exemptunder SeC o this r u
ALTER-DRAIN&VENT-WATER(BA) VALUATION
Owner Date
WORKER'S COMPENSA'T'ION DECLARATION BACK FLOW PR(Yf[C'1'.DEVICE
I hereby affirm under penalty of pvrjnry one of the following declarrium , ✓ O
❑I have and will maintain a Cenificate ofCmuvntto self-insure for Workers Compen- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Seciian 3900 of the Labor Cade,for the performance of The
work for which his permit is issued. FIXTURES-PER TRAP
❑ i have and will mountain Worker's Compen.satien Insurance,as required by Section
3900ofine Labor Code.for The rtimancco me work forwhich bM1ispermit'rsissueyJ. GAS-EA.SYSTEM-I INC.40UTLETS OCC.GROUP APN
My W.fthki
Policy nudl(ctvr,�.)���(I() OAS-EA SYSTEM-OVER 4(EA)
Carrie. cy Na:-L/�j'/r
CERTIFICAT OF EXEMPTI N FROM WORKERS' GRIiASFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifbhe permit is for one hundreddollar,$100) GREASE.TRAP
m less) PLANCHECK FEE
I civility met In theperfarmnnceofthe work for whiehthiapemit,is lssned,Idmil SEWER-SANITARY-STORM EA.200 Ff.
not ennploy any person many manner ao us bo became sub1.ject Nn Weaker,'Can,,.- ENERGY PEE
sitLawsaf California.Dam WATER HEATER WNENTIELECI'R
Z Q Applicant GRADING FEE
H f/2 NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYSTEM/fRFA'1'ING SOILS FEE
become subject to the Wodace,Compensation provisions of the Lahr Cade,you must
w � fanhwian comply with such pneamemsrr this permushal be devoted revoked. WA'PER SERVICE,
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENT'IAL PLMB. SQ,I'i'. PAID
z Iherchy alarm the,uhero is uconswdinn lending agency for the performance of 'Dem Receipt#
Wthoworkfar vehlchmis permit is issued(Sec,3099,Civ.C)
U Lender's Name TOTAL:
L>a Lender's Address
1 certify that 1 have read this application and stem the parties,btfafmmion is .DING PEE
F-T N corteeb.I agreed comply with all ctry mW county onlinances ata sem laws relating m up
QTY. MECHANIC .R FEE
V Z building coecoaction,and hereby authorize repo enceives of this city to enter upon the SMIC PEE
annewwanention,d property for inspection purpasec PERMIT ISSUANCE. Pit(We)agree to swc,indemnify and keep harmless the City of Cupertino against BUT FEE
liabililies.judgmenbe,costs and expenses which may in any way accme against said City ALTER OR ADD TOM LUMBING FEE
in consequence of me grunti g of t permh.
APPLICANT UNDERSTA D, A D WILL OMPLY WITH ALL NUN-POIN'p AIR HANDLING UNIT IT MECHANICAL FEE 7 I sO
SO :REGULATIONS
AIR HANDLING UNIT(OVER 10.000CFM) - CONSTRUCTION TAX
re of ApplicanU nlmabo, Dae EXHAUST HOOD(WIDUCI') HOUSING MITIGATION FEE
HA7JARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as de0med by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Gide,Sermon 25532(a)Y HEATING UNIT(OVER 10QOW BTU)
E]Ycs VENTILATION PAN(SINGLE RE5ID) PAID Date Receipt#
•� Will tire.,heart or futurebuilmng nccupam use eqm uipnmor devices which
'01
ILER-GOMP(1HP OR 100,000 BTU)
emit ministers air containment,as defined by the Boy A.Air Quality Management TOTAL:I��I�•'�
District? BOILER-COMP(OVER 10(1,000 BTU)
❑Yes L.
I havercadthe hazallousmaterials regniremces under ChDoli-apter6.95 afma AIR CONDITIONER �tilCi 0 ISSUANCE DATE
fornix Health&Safety Code,Sedianr 25505,25533 mad 25534.1 undersmnd that if the NEW RESIDENTIAL MECH. SQ.FP.
building does not morally have a beard.That it is my responsibility to notify the occupant
nfine requirements which must be tine prior to Issuance alit Certificate of Oscupe, '/y v�
Ownu or authorized ogwb Dote TOTAL''L/9.51;) ISSUED BY:v 0 e /y `��LC�Y'Cr
OFFICE