S 2241 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE 11 NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 2241
BUILDING PROJECT IDFN'rDICA'I'ION
BUILDING ADDRESS: - $ANI"fANY NO. APPLICATION SUBMITTAL DAT
103 a�o Dv-
OWNEN' NAM13: PHONE CO=R'S NAME: LI N NIC CONTROL#
►'�1 a &Arz e- e- -9 J2«/kms ❑
ARCHIT C-LIENGINEER; LIC NO'. ADDRESS:
N a /Y79 zsr>Z
CONTACT: PHONE: BUILDING PERMIT INP
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLMECH
❑ EJUM ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECfRIC PERMIT IEE JOB DESCRIPTION
1 hereby alum that I am licensed under previsions of Chaplet 9(commencing
DMZ with Section 7000)ofDivi,wo J ofthe Buvinessund Pmfessiuns Code,and my licen,a is RESIDENTIAL,
O PERMIT ISSUANCE
aU0 in full force node '1 rel ❑SFDWL ❑KITCHEN REMODEL
<ZU ("df yN (p Al'PLIANCIiS-RESIDIiM'TAI, []ADDITION El PLUMBING RC-PIPE.
F. W Date Contra
costa ❑MULTI-UNIT ❑STRUCI'URAL
ARCHITECT'S DECLARAPON MODIFICATION
'=o') ARCHITECT'S
lunders..not my plamshall beused as public rec.N, PANELS
Oz�Q UP 70200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
Fcity�LL1 Licensed Pumcsramal 2111-I00IAMI'$ IMPROVEMENT OSWIMMING POOLS
OWNER BUILDER DFC1ARA'I'ION OV-R 1000AMPS C1BATH REMODEIIRF.PAIR ❑DEMOLITION
A),tE st 1 hereby affirm that 1 am exempt from m
Ne Cumcmrs L'.enae Law for the
O L U following,coon.(Section 7031.5,Business and Professions Code:Any city ur county SIGNS ELECTRICAL ❑OTHER on �/f
6]3 W F' which rt coir m amumu 1.al..c improve.dnoark,b,nr repair on umarm L YZ d u
F�Om m its ixsuxnaru6mrcmm,thea Ream Wrsucb no rile a si Inatement SPECIALCIRCUIT/MISC.
yy prior 4 PP Pcrmi Ener
C"'1y6f that he is licensed pursuant lothe puvisionx ofihe Contractor's license Ww(Chnpmr9
(commcncia,,olo Senior OOORydDivisiun3of the Buainexnand l'rv(essiom Cde)ur TUMP.MID'ER OR POLE INS1'. COMMERCIAL:
6 d c C mat b.Is exempt therefrom and the Faris fame alleged exemption.Any violation of 1 O NEW BLDG/ADDITION ❑DEMOLITION
n"y Section 70315 by any applicant for a perrdit subjects the applicudnraovil penalty of POWER DEVICES 0TENANT FOOD SERVICE
pour marc than rive hundred adds,($500). IMPROVEMENT
;5C O Lm owner of the pmpert,or my employees with wages ns their sole eompenswinn, SWIMMING POOL ELECTRIC El OTHER
CP. will do thewok,and me anicmre is not intended or offered for sale(See]fW4.Theinens
23�^ and propositions Caie:The Cardam h License law does not applym an owner of OUTLIOS-SWITCHES-F
property who builds or improves therm,,and who does auch work himself to through
his own employees,provided that such impnwatnems ore n.t intended m idu red for NEW RESIDE?
sa1c.IL however.the building nr improvement is sold within one yea,.(mmpleti.n,the SQ.PI'.FLOOR AR II $/SQ.FT
owner-builder will have the burden of pmving that he did not build or improve fur par-
pna.of sola). .:
O L as owner of the propany,um exclusively contracting with licensed contractors to 1'
on.mmct the pm ice,(Sec.10pt.Business and Prufassinm Calea The Claim, rlak
cense Law dews not apply to an owner of property who huilds or improve ' PI, B PE T FEL?
whoc.ntraets for such Floats will acononeursf licm.ul pursuantt unmmrs,
License law. F.K ,
ISSUAN t
I am erempound"Sec. ,B&PC t ' m
it
-DRAIN 6 VENT-WATER(EA) VALUATION
Owner Dune
WORKERS COMPENSATION DECLARATION BACK 11000 IROfECT.DI?VICIi
1 hereby affirm under penalty of perjury one of the following declaralk
❑Ihave and will n.idam a Campeau,of Consent to self-insure for Workers open- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TY PE CONSTRUCTIO:
t, smion,as provided far by Section 3700 of due lads CWc,lo,the pe,a n,ner of the
walk for which this permit is issued. FIXTURES-PER TRAP
O 1 have and will mainmin Workcr's Compensation Insurance,as required by Section
3700oftbe Lahr Cale Bathe perfnnnanecnfma work for which this permit is islad. GAS-FA.SYSTI!M-I INC.4 OUTLETS OCC.GROUP APN
My WorAels�m'ReryVW1 tarjt_ry�,e comer and Policy n m yB1l�n Q
Cartier: L N 11 1e Policy Ne.: � "L'Y gT�S�`' Gn5-IiA.SVSTIiM OVER 4(EA
iRTIFICATE OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUANDBsTRL INTER BUILDING DIVISION FEES
Old,wetiunneed am bccompietdifthepantit is Immune hundred dolla,($KKU GRF.gSB TNAP
at less) Nk1.ANCHECK FEE
fernifythetinthepntnrmanceol'the work for which this permit ix issueJ,lshall ISRWER-SANITARY-. E RGYFFF
oatemployanypersoninanymanner so as a her a.nabjr,l Rsoho Walker,'Cron,� smiun laws of California.Dam WKI'ERHEATERWNEN' LECTRzOApplicant t DING FEE
N01 ICE APPLICANT:Bottler mauling this Cenificme of Exemption,you should WATER SYSTEM/TREATI G
V1
f"t haom
become the Worker's Gompensmiisimts of the Labor Coke,yaw moat SOILS FEE
I Lg1 � l.rthwitu comply with such pmvisions or this is armpermit shallMdeemed revoked. WATER SIiRVICG
Uz CONSTRUCTION LENDING AGENCY NEW NFSIDEM'IAI.YLMB, SQ.IT. PAID U e Receipt M
U O hereby issennswet30 lending agency rte the perfnrmnnce of
W F-' the work hn which Wis permit is issued(Sec.3ll9'I.Civ.C)
O Under',Name
U 'IYyfAL:
Ixddett Addrrss TOT
1 certify that I have read this application and state that the above infra miud is BUILUIN AAE
Ncenter.l agree it)comply with:dl city and.mmy ordinances and state laws relmingm QTY. MECHANICAL PERMIT FF.F, SEISMI .
U Z building construction,and hereby authorize reprc.wn.tives ofthis city to enter upon the
above-mentioned progeny for inspersion purposes' PERMIT ISSUANCE
(We)agree hs save,indemnify and keep handless the City of Cupeninu almost F.LF.CfR F.li
habilities,judgmema cos,and Upenses widen may lnanywayeecraeugxinntaai.[City ALTER OR ADD TO MICH. PLUMBIN FEE
no come wreeof the gtaminf�ttIND, nit.
APPLICANT UNDERSTA b.S AND WILh COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MHCHA CAI.FEE
SOURCE:RIiQ CATION .
y.— Z� NN HANDLING UNI'TIOVBR Magi CFM) CONSTR C ION TAX
Simon of ApplicntCuntmetra Data EXHAUST HOOD OVMUCTI HOUSING MI'IGATION FEE
HAYARDOUS MATERIALS DISCLOSURE
Will the applicant.,future building oecupamsmre.r handle hmanlous tmnerial HEATING UNIT GO 100j"BTU)
as defined by the Cupeninn Municipal Code.Chapter 9.12,and the Hcahh and Safety
Gale.Section 25532(x)° H17ATING UNIT(OVER 100,000 RTU)
❑Yes 0 N VHN ELATION PAN(SINGLE RESI D) PAID
Data Reccipt#
Will the applicant or fumrc building occupant use equipment or devices which ROLLER-COMP(JHPOR Ifq,ll(H RTU)
emit havmdous air conmainuo,:,defined by the Bay Arcgem
Area Air Quality Ma,aem T L o
Forbid^ BOILER-COMP(OVER 100.000BTU)
Oyes ON.
1 have rtml the hazard......liok requiremedts under Chapter 6,95 of the Cali- AIR CONDITIONER /y ISSUAJ]tCF,I�TF, Q /�
floor.Health 6 Safe,,Code.Section.25505,25573 unJ^5534.1 undc,mnJ that If the NEW RESIUEM'IA1.MECH. SQ.17.
building does not currently have z..nant.that'it is my rcspm.sibillty b,amity the occupant L /
of the triturated.which must In met prior m km anec ora Cenincate of Occupancy. zap
Owner or amhorizcd sBem Dna
TOTAL: ISSUF.DRY: — .7Q �Q
OFFICE