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S 2501 (2)APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELELTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICALS PHALDING PROJECT DIEN"FIF'ICATION' PERMIT NO, 2501 BUILDING ADDRESS© ,� SANITARY NO. APPLICATION SUBMITTAL DATE 3 -y O'.AMI?: y PI I(N 3: NIC CON'IROLx ARCIHI'ECUENGINEER: LIC NO. ADDRESS: CONTACT: PHONE: , � ? Me'I Q Z y/� ❑ Consultant Fees Paid by Applicant (Initial) BUILDING PERMIT INFO BLDG ELECT PLUMB NilED/ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that 1 am licensed under provisions or chapter v kommenemg with Section 7000) of Do.,inn 3 of the Businessland Professions C(de, and my licence is In full farce anA clfcc Licentt5'lav hoop '���� are_3j,..�- Convacmr � ARCHI'1'ECIol DECLARATION 1 underse nd my plans,lull be used as public records Licensed l'nticsvinnvl [ OWNER -BUILDER UF.CLARA'I'ION 1 hereby uE"mn that I am exempt rrom the Caflua,b ', License Luw for the following reason. (Section 70315. Business and Padcaions Gale Any city mentally wh'mh requires a pttmit to eonsnua, Aber, improve, demol'vsh, lir repair any varsame prior to its issuance, alvo requires the applicant for such Permit o rile a signed.tawrical IbatIn,I v,etund pursu.nuo lhoprovi:iunstil the Conuanor's License Law (Chapter 9 (commencing with Section700nof Division 3oflhe Basinesxand Professions Calc) or thm In, is exempt IucreGont and the bulls far the.[laced exemption. Any violation of Section 7031.5 by any applicant for a Writ subjects the applicant tit a civil penalty of nolmorc lhmt Eve hmu[red dollar, ($500l • ❑Lar owner nOhe pnrpeny, or my employees with sages as their sole annpenmtion. will An the work,andthu vlrucwmisnol imm�dW nndiercJ for sulclScc. ]IW,Businave i and Professions Code Me Contractor's License Law does not apply to an owner of property who huilde o improves themon, anti who does such stickhinwnlf or through his own employees, provided that such improvements am not intended or okimd for Vdv.fl: neve.cr.din hni[dn",, ingtemantenl is sold within one year of completion, the owner tholder will have the burden of proving that he did not build lir improve for pur- pose of sale.). usoa[y contracting with Iicrycontractors E]1, as owner or the progeny, am exdnW m continuer the prujac, IScc. 7144, Malone,, slid Poll bion, COJcp'Dtc Convaewr's Li- meLawdoesnotappymanownerorPearsnywhobuilJsorlmpmveslhereon,and who countiesfn m,I. pniftas wuhit,ont cert(.') licensed'Aman, e, the Contracts", License Inw. ❑ I ma cwntpt under tine. . B & PC for Thin meson QTY. ELECTRIC PI?RMIT FEE JOB DESCRIPTION RESIDENTIAL: ❑SFOWL ❑ KITCHEN REMODEL []ADDITION [I PLUMBING RF_PIPE ❑STRUCI'URAI. MODIFICATION D INI'IROVE ❑S IMMING POOL, IMPROVEMENT SWIMMING POOLS ❑BATH kl?MOUF.UREPAIR DEMOLITION PERMIT ISSUANCE APPLIANCES - RES] DENI IAL PANELS❑MUI.TI-UNIT UP TO 200AMPS 201-1000 AMPS OVER IOIX) M11'N SIGNS ELECTRICAL[IOTHLEE SPECIAL CIRCUI I'/M INC. TE MP MET 12R OR POLI"INST. COMMERCIAL: ❑ NEW BLDG/ADDITION E)DEMOLITION TENA'"1' El FOOD SERVICI7 .1P VI3MF,NT ❑ POWER DEVICES SWIMMING POOL. ELECTRIC OUTLITS- SWITCHES - FIXTURES NEW RESIDENTIAL ULECIR SQ ET. SQ_IT, FLOOR AREA 9SQ.Pp. TOTAL QTY PLUMBING PERMIT FEE PERMIT' ISSUANCE ALTER -DRAIN & VENT -WATER CA) Owner Unm VALUATION WORKER'S COMPENSATION DECLARATION I hereby atfina a oder vothyof,crj Arynuc of the fol lowing douleanions: ❑ I have and will maintain a Certificate of Comm mule insure for Worker's Cohen- ,anon as pmvidcd fill by Scchnu 3700 of the Lubar Code for the le,f mmnen oflhc work for which )his peril is koned. 1 have and will mnintain Worker's Compcnsmion In,no nee, us required by Section 37M eflhe Labor Calls. In, he pe,brnaance at he work tort which this permit is issued. My Worker's Cmnpcaonion laavunec sure, and Pulley Another um: Carrier: Policy Ns.: CERTIl1C oNIP17NSNI ION) S FROM WORKERS' C(Ih1P1iNSA'I'ION INSURANCE IThoo".o be completed if pemtil i, Gnonc hundred dnlluns($II0) or law) keno mind �n wnrkfu,whieu lI,, Penni[ is isvucd,l,hall it cnquo'un (n nvre c been m '1 to the We"ars'Compen- .onion Ltws 'f Applicant BACK IB.OW PROTECT. DEVICE DRAINS- FLOOR. ROOF. AREA. COND' SI(lR1EN ')'VPI" CONS Him iob FIXTURES - PER TRAP GAS - EA. SYSTEM -I INC S OUTLETS OCC. GROUP ams ,C APN GAS - P.A.SYSTE IOVER 4(EA ) GNti1St%INDUST STE I H BUILDING DIv1910N PI?IIS GREASI"TRAP _ A SEWER- trlu SANII'A NTO MDA._ 4. YLANCHECK ILL ENERGY FEF. WATER IIHAI'ER IiN'f/IiLECB GRADING FET" NOTICE T ) APPLICANT: If, al cooking this Cam of Exemption, you'it, q become subject name Workers Cnmpenvaion Provisions of the Labor Code, you must Rmbwitbatmply wllb... h pnevnionvmthi ,comil shall be dccnmdm,akcd, CONSTRUCTION LENDING AGENCY I hereby affirm lunfl reisau.moseems lending agency forms, performance of the work for which this Permit is issued (Sec. 3107, Civ, C.) Lender's Name WATER SYS'I'EWE UBVNG I SOILS Fill'. WATER SERVICI? PATO NI"W RESIDENTIAL PI,MB, SQ. FI', Uma act x TOTAL: Landed Address I certify men 1 have read misapplication and stale that the above information is correct.[ agrecut comply wire all ctoy andntumyordinanccvnnd s,am knov e[oling to building atmaaction. and hereby authorise representatives of this city in enter upon the aMn'c-meminne ny for impenion purposes mum'e.n. mainly and ep humbles, Ino City of Cupenino against liabi res judgmc rovvandcx ch mayin any way accomagaina mid City 0 gr.Imin,o not, AI'PLII AL U .RSTAN? . As L COMPLY WITH ALI. NON -POINT SOUR EC 'I' NS 3 'TOTAL: BUILDING FliE QTY. MECHANICAL PERMIT FEE SEISMIC ITE p FERMI IISSUANCE J e ELECTRIC FEE ALTER ORADUTO MUCH. PLUMBING FEE AIRFANDLINGUNI'FTO 1 bp0dCpVU MECHANICAL IEE y7 %V AIR HANDLING UNIT (OVER 10.00) CFM) CONSTRUCTION TAX Sig azure ofApplieanVComrac r Data HAZARDOUS MATERIALS DISCLOSURE Will the applicant lir future buildingoccuptml sore... handle ho,ardeus nora,bud as defined by the C,upenino Municipal Cale, Output, 9.12 and the Health tad Safety Ede. Section 25532rat]'1 �Ycs _ Nn Will the appllevnt ur r,a building occupant use .Air Qu or dMana which min baraNuus airnems as defined by IM1e Bay Arca Air Quality Munngmmat DiaricR`/v s -yy No Ih a I ham, s bm al •quitcmems under, Ch.pwr 495 of,he Cali- Sonia II f Cntic.: Iioi .505. 255?3 and 25533. I underxmnU Ihall] lM1e o ES t nyh -at Limit iFuace of a Cion In noliry fM1crKasy. nnn� � tut It -ab� tet prime) Issuance oraeenir �,m 'o� ser. EST IAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HEATING UNI 'T(f0100.INO B1 U) �Z• 20 HEATING UNIT (OVER I04).BIN013TU) OO PAI I) VF,N'TILA'I'ION PAN (9ING1.1?RES] D7 BOILER-CUh1P pHP OR 19B,Ikp 11TU1 Date Receipt# 'r(ylAh: BOILER - COMP (OVER I00,I0(I BTU) AIR CONDITIONER ISSUANCE DATE® I ISSUIiD BV: e.JCC. NEW RESIDENTIAL. MECH. SQ. PI'. uuthorizeJ Age ,Date 'TOTAL: Q 1 w � OFFICE