S 2373 (2) -APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 2373
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDHf 5S. SANITARY NO. A(P/PPLLIICATION SUBMITTAL DAT
17,7
O S.AM PIIONIi:�� COMP ORI6 NA ��L•C�n I `-�
r^4�7• /.e 7 r N/C CONTROL#
ARCH ITECT/ENGINEER: LIC NO'. A ORFSS ❑
95
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ l� ❑ L9�
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
CWZ 1 hereby mffmt that I turn licensed under provisions of Cheerer,9 Qommenciag JOB DESCRIPTION
WO, with Sforce a 0fXo of Divisinn 3 of the Businessand Professions Code.and my licenseis PERMIT ISSUANCE �/1 RESIDENTIAL
El KITCHEN REMODEL
eft
Ru License Qyly- hic.p !
APPLIANCES-xISIUL•N'TIAL ❑ADDITION ❑PLUMBING RF PIPE.
E-Z W Dore #/yl� —Cnntracmr
❑MULTI-UNIT El STRUCTURAL
'Mon ARCHITECTS DECLARATION I PANELS
Z O to 7J. 1 understand my plans shall he used as puhhe records MODIFICATION
OZ-O UPTOIDBAMPS C1 INTERIOR El CHIMNEY REPAIR
W Licensed Pndessinted 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
S,j7-i OWNER-BUILDER DECLARATION OVER 1000AMPS El BATH REMODEfJREPAIR DEMOLITION
LL CL C Q 1 hereby uffimt that I am exempt form the Contractor's License Law for the
0 y V following reason.(Seciiun 7031.5,Business and Professions Cadv:Any city or county SIGNS ELECIRICAL ❑OTHER
which requires a permit m construct,after,improve,dcmalish,or mentors,imacam
� Peprior to its issuance.also acquires the applicant forsuch nnino rile a signed statement SPECIAL CIRCUITIMISC. f #•J {--/ t -x
� that he is licensed pursuant to the provisions of the Gmnactors Licenw Law(Chapter 9
yip (commencing with Section 7")of Division 3 oDhe nosiness nod Professions Code)or TEMP.METI2R OR PULE INSI'. COMMERCIAL
d L c y that he is exempt therefrom maids,basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDD'ION ❑DENIOLITION
4• Scclien7031.5 by anyapplicant forepemtit subjenx Neapplicamo,a6ml peradl d POWER DEVICES El TENANT FOOD SERVICE
h,yy mrinwre than Eve hundred dollars($500f IMPROVEMENT
E9C i]hssuwnerwflte progeny,or my employees with wages as thcirsolecwmpensation. SWIMMING POOL ELECTRIC ❑OTHIiR
will do the work,and the snunun N not intended oronered for sale(Sce.0044,Business
�3an and Professions Code:The Contractor's License Law does not apply to an owner of OUTLET'S-SWITCHES-FIXNRES
progeny who builds or improves thereon,and who does.such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECIR SQ FT.
salo.IL however,the huilding or improvement is sold within one ycroofcnmpletion,the SQ.FT.FLOOR AREA S/SQ.FT.
eaneidsailo.)r will have the burden of proving that he did not build or improve for put- f P2
El 1,as owner of the property,ant exclusively comnning with licensed contractors to T d
construct the project(Sec.01144,Bu.einesx and Professions Care:)no Contractor's Li-
cause Law does notspinymrean awrof pmpeny who boildler improves thereon and QTY PLUMBING PERMIT FEE
who contracts for such projects witha lintowea(s)licensed pursuant to the Contractors
License Law. PER MIT ISSUANCE 6661, 0 N(lf
Tum exempt under Sec. ,n rw
R P C far lhixson
An
ALTER-DRAIN Fr VENT-WATER(EA) VALUATION
Owner Dore
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
I hereby affirm order penally of perjury,one of the fallowing decla hien s:
Ibaveandwillnummum.Cetlif core of Cnmcnuu self-insure for Workers Compem DRAINS-FLOOR.ROOK AREA,COND. ST 'fYPIi CONSTRUCTIOI
cation,as provided for by Section 37M of Ire L a1 wr Code.for the performance of the
k fur which this Permit is lased, FIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance.as required by Seciion
.100of the lahe,Code.fordo,Petri ante of the work for which this permit is issued. GAS-EA.SYSTEM-I INC 40UTLEN:S OCC.GROUP APN
Ca e, rx mpc u m a redP.IiyN.vityEMtary'flf J4 GAS-EA,SYSTEM-OVER 4 EIA)
Cartier' s Policy No Ti• T
CERTI]CAT E OF EXItMPHON FROM WORKERS' GREASIIINDUSI'RLWASTEINTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION LESS
Obis section need nm be completed if the pi is for one hundred dollars(1000)orlcss.l GREASE'IHAP PfANCHECK FIiE
I certify that in are pertoneranceofthe work for which this permit is issued,Ishull SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'ComPer- ENERGY FEE
z,Z xsit..Lows of California.Dore WATER HEATER WNENT/ELECTR
Applicant ` GRADING FEE
NOTICE TO APPLICAN'C IL enter making this Ccnirica¢of T:xemptinm You sM1ould WATER SYSTENVI REArING
become subjwr la the Workers Compensation Pmvisinnx of the Lnbwr Coyos SOILS FEEde, u mu
fnnhwilh comply with such provisions or this permit shall be decmwlrevoketl. WATER SERVICE
0.
CONSTRUCTIONLENDINGNEW RESIDENTIAL PCMB. SQ,1'r. PAID
L)Q Ihemhy affirm thatthere is construction lendingng agency
fnrthe performance of Uate Rweiptx
'he work fur which this Permit is issued(Sec.3(191,Civ.C.)
u•' Lenders Name TOTAL:
WLender's Address TOTAL. BUILDING FET.
I certify that 1 have read this application and state that the above information is
F h cornet.L agree to comply with all city and county ordinances and stale laws Mining to QTY. MECHANICAL PERMIT FEE
r) Z buildingenngmdion.and herebyamhmare representatives of mistily lnemer upon the f^••� SEISMIC FEE
above-mentioned property for inspeeian porpoises. PERMIT ISSUANCE 'V
(we)agree ret save.indemnify and keep harmless the City.1 C.111m.sgainst I IiLECDUC PEE
Imbilitiespdgment,,osis al expenses which may in.ny wnyaccrue agrimaiaid City ALTER OR ADDTO MECII. PLIIMBIN PEE
in c ..eastern of the porous,of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY W117H ALL NON-POINT AIR HANDLING UNII'(TO 100010CPM)
SOURCE.RJ%I �. ONS. MECHANICAL FEI
( �e, AIR HANDLING UNIT(OVER IDgO CFM) CONSTRUCTION X
Signature mf Applicam/Contacuo , Dat EXHAUST HOOD(WMUCD ROUSING MITIGA O k E
HAZARDOUS MATERIALS DISCLOSUBE s n Q
Will theapplicanl or mum building occupant store m handlehewrdI I
ous material , HEANG UNIT(TO 100,000 BTU, G
redefined by the Cupenino Municipal Code,Chapter 9.12,and the Heahh and Safety
Code,Section 25512hr? HEATING UNIT(OVI;R 100,0011 BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID -
Dam Receipt#
. Will the applicant or future Wilding occupant use equipment or devices whir], BOILER-COMP(1HP OR 100,000 BTU)emit ha madous air conlaminanls as defined by the Bay Area Air Quality Management L:
District? BOILER-COMP(OVER 100,00)BTU)
EI yes ❑No �#
I has c read the hazardous materials tequiremems under Chapter 6,95 of the Cali- AIR CONDITIONER .31Q�'\ ISSUANCIie DATJ: A
lornia IIwIN&Safey Cdu,Seniors 25505,25533 unJ 255]4.I unoOrsmnJ That If the NEW RESIDENHAL MECII. SQ.PT. O 4 /yI
Wilding does not carmn amnanft tMt' is my rtspowibility m bulify meorcupint
of the requi nn .h mu. Mntet psi ea fn CenificialOsa cy
(� !�
Ovme irel as - I T ISSUED BY:
OFFICE