S 2172 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT P,EN ONLY
CITY OF CUPERTINO - BUILDING.-ELECTRICAL PEtG NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL ` 2172� ��
BUILDING PROJECT IDENTIFICATION V
BUILDING ADDRESS: ^� ^ / SANITARY NO, APPLICATION/SUBMITTAL EAU
OW 'S NAME: /`I{/• ' // PHO F:: gC� CONT 70R'S NA LIC
O SG_ 7✓8'/� E,� N/C CONTROL#
IARCHITECT/F, GIN ER: LIC NO. q � � �` � ❑
CONTACT: �1 PHONE: fY BUILDING PERMIT INFO
/ n ("`
Consultant Fees Paid by Applicant(Initial) BLDG EL T LUMB MECH
6 U (O J ❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�Wcc with Section 9W0)afDivision3s the Business and Paul'raslons Code,and atlicense is
Fy',Q in full force and effect. y PERMIT ISSUANCE RESIDENTIAL'
QZV License Class REMODEL
Dam Contractor APPLIANCES—RESIDENTIAL OADDTION ❑PLUMBING RE
y4L
ARCHITECTSTS DECLARATION DECLARATION PANELS OMULTI-UNIT []STRUCTURAL
OF 4- I understand my pl...hall be aced as public records MODIFICATION
Z 1` UI"f02W AMPS
�'y�,'I"6�l Licensed Professional "O INTERIOR ❑SWCHIMNEY MING POOL
QK GK� PAIR
; 201-IIkM1AMP5 IMPROVEMENT -
OWNER-BUILDER DECLARATION O SWIMMING POOLS
yy 6 1 hereby affirm tM1a I am exempt front the Contractors License Law for the OVER I WU AMPS El BATH REMODEVREPAIR El DEMOLITION
y(�6 U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
LSNl a W y which requites a permit m concoct,alter,improve,demolish,or repair any structure L
prior to its issuance,also requires the applicant for rash permitmfile asigned statement EMEIEROR
T/M TSC -rIOiT
�y y that he is limned Pursuant provisions of the Conwemr'a License Low(Chaptm9
m FJ00 (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TIME POLE INS'I'. COMMERCIAL'ai Thal he is exempt therefrom and the basis for the alleged exemption.Any violation o[Scction]f13156y any npplicainforu pumit subjects the npPlmant to ecivil penalty of ❑NBW BLDG/ADDITION ❑DEMOLITION
F2. not mare than five hundred dollars($51x). ❑TENANT' ❑FOODSERVICE
Sa ❑1,as owner refthe property,or my employees with wages ax their sole connpenxntion. ELECTRIC IMPROVEMENT
will Bothe work,and the swcture is notimendeJoroffeteA Octale(See,9044.Business ❑OTHER
mend Professions Code:the Conforms F License Law dues rat apply to nn ownr of CHES—FIXTURES
C prnpcny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvemenls am not intended m oit al for NEW RESIDENTIAL ELECTR SQ Flt
sale lf,howeveq the building orlmprovementis sold within one yearofcompletion,the SQ.FP.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build m improve for par-
p sof sole.). '
P I,as owner of the property,am exclusively contracting with licensed contradocs m 'AL:
I street the project(Sec.WALL Business and Professions Cado:)The Controcmr's Li
return Law does not apply to an owner of posperry who builds or improves therecon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a entnracmr(s)licensed pursuant to the Counci s
License Law. 7,0
1 am even plunder See. PERMIT ISSUANCE
❑ ,B&P C f Thi, iso
ALTER—DRAIN&VENT'—WATER(EA)
O rData VALUATION
WO E S COMPENSATION CLARATION BACK FLOW PROTECT.DEVICE
-CI and will
mai under penalty lsperjury one of the]allowing Workers;Co
❑a have and for by a tion 37W of theConvertLah to sof insure Por Worker's Compete IJNAINS—FLOON,ROOF,AREA,GOND,
smirk,as provide)far toy Section 3]W of the Labor Cada fur the performance of the STORIES TYPE CONSTRUCTION
work for which chic marailis issued. FIXTURES-Ph:R TRAP
❑1 have and will main artard lain Workers Compensation Insurance,ash respired t i Section
My ooke Labor Cadefor nthe
surancem ora of the work nrwbich this permit is issued. GAS-EA.SYS'T'EM-1 INC.40UT1,E'TS ANN
My Worker's Compensation Insurance cafiieroli Policy number oto:
Carrier: Policy No.: GAS-P.A.SYSTEMOVER 4(EA)
CERTIFICATEEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINWSq'14 WASTE INTERCEPTOR
This section need net bewmplemdiflM1epemll is Gerona hundred dollars($I(10) BUILD] ISION PP.ES
or las.) GREASE TRAP � C
11 lull
Icenify that in the performance nflhe work for which this permit is issueJ,lshall SEWER-SANITARY-STORM EA.2001T.
oat employ any person in any name,m as to become subject to the Workers'Compen- ENERGY PEE
z ,� emion laws of Califomia.Dale
O Applicant WA'T ER HEATER WNENT/F,LEC'TR GRADING FEE
to NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMTREATING
M1ecume subject to the Worker's Compensation provisions of the LobnrCode,you must SOILS PEE
W forthwith enmply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0. Q
CONSTRUCTION LENDING AGENCY Z NEW RESIDENTIAL PLMR. SQ.PT. PAID
V Q hereby issued(So.,30 lending agency for the performance of Dam ReceiptN
W the wad forwbich this pemnir is issued(Seo.309],Co,C.)
T.1 Lenders Name
Lender's Address 'TOTAL: TOTAL:
dI certify that I have read this application and state that the above information is BUILDING FEE
v] correct.l some to comply with all city and county ordinances and state laws totaling to QTY, MECHANICAL PERMIT -FEE
V Z building cnmarroiml hereby authorize representatives of this oily mender uponthe SEISMIC FEF,
abava-mentlone l property for inspection purposes.
(We)a PERMIT ISSUANCE
fishi
( gree to cast,indemnify and keep hay in an the City is against against ELECTRIC NEE
in conlnotaion,ofhecostsesmf and iafacnses if may in any way social against said City ALTER OR ADD'1'O MECH.
sequence Nthe graining S this permit. PLUMBING PEE
SOURCE APPLICANT
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT pIR HANDLING UNIT('to I0.W0 CFM)
' SOURCE REGULA'T'IONS. ML'CHANICAI.FEB
AIR HANDLING UNIT(OVER I0,000 CPM) CONSTRUCTION TAX
Si lure of App NCtinmemr Dole EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF,
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant store or handle hazardous material HEA'T'ING UNIT(10 I OPOW BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532(op HEATING UNIT(OVER 100,000 BTU)
OYea E3 No
e VENTILATION FAN(SINGLE RES ID) PAID
m or
Will the a,fcafuture building occupant use equipment or devices which Date Rome,
mit hazmdtus air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(3HPOR 100,000 BTU)
Dutnet4
❑Yes ❑No BOILER—COMP(OVER 100,000 BTU)
I have read the hwallous materials requirements under Chapter 6.95 of the Call- AIR CONDITIONER ISSUANCE DATE
bonnie Health no Safety Gavle,have
Sections 25505.25533 and 25534.I understand tha if art ,NEW RESIDENTIAL MECH. SQ.FL � ' ^�
of
fihe req ceementss not which hast amnanLlhmo icua responsibility aCllitymteof'Ofy heuamppnt --7'
Y
ablM1e requirements which moat be met prim m issuance of a Cznifctteof Oueupancy.
Owneroramhorizedagein hale TOTAL: ISSUEDB
OFFICE