S 2892 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION S 2892
BUILDINGADDRESS. SANITARY NO APPLICATION SUBMITTAL DATE
AOk L cJ f� ernb%
OWNERS NAME: �� PHONE: CONTRACTOR'S ME: LI NO: ^`Y
N/C CONTROL#
ARCHITECT/ENGINEER: LICO: RES ❑
NA D
2
CONTACT PHONE: - BUILDING PERMIT INFO
- �/S�
El consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMP MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that[;or, act pvision
n,licensed brro ,,of Chapter 9(annmen ins JOB DESCRIPTION
BOOceZ wilM1 Seclian]IO11)nf Division3of the Business and Pmfevsinm Coda and my liwmei, PERMIT ISSUANCE RESIDENTIAL'
F1_ in full forty and effect
h'�F ❑SFDWL ❑KITCHEN REMODEL.
yVU Licence Clnsa Lie.
NQ1 Dula I,obaa APPLIANCES-RESIDENI'IA1. ❑ADDITION IZW.t1tvIBING RF.-PIPE.
ARCHITECT'S DECL A ON PANELS
FDto El MULTI-UNIT El STRUCTURAL
I z O y zr 1 undenumid my pluns,hall be used as public records MODIFICATION
0z4- UP TO DO AMPS
F !.ru�.FLicensed ProfessionalEl INTERIOR El CHIMNEY REPAIR
�`W g,,, OWNER-BUILDER DECLARATION 201-IO00AMPS IMPROVEMENT 0SWIMMING POOLS
xyy z Lzd 1 hereby aRirm that 1 ant exempt front the Contractors Liceme Law for the OVER 1000 AMPS El BATH REMODEUREPAIR Ll DEMOLITION
W 3 d F fallowing notion.(Section 703 L5,Business and Professions Calc:Any city or courtly SIGNS ELECTRICAL ❑OTHER
W�O which requires n permit m construct,alter,improve,demolish,or repair any structure Eq"�y
prior to its ,akin beirimsfh pplirn t lorsuchpe mit to file.%signed statement SPECIAL CIRCUIT/MISC.
"a''ell licensed pursut to the provisions fthe Control License Low(Chapter9
Cyr d��
(commencing with Section 700p of Division t of the B o s dProfessions Code)or TEMP.METER OR POLE INS T COMMERCIAL:
N y M eG Ihot he is exempl chamber,and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ElDEMOLITION
W..y Section 7131.5 by any applici for.,Penn,,salivate the vpplicnnt to a cavi l enmity of POWER DEVICES
yy ma more than five hundred dollars($500). ❑TENANT El FOOD SERVICE
cd ❑ Las owner Offhc property, y employeeswith g. 11 1 pen. t mIMPROVEMENT
CC Q done,
SWIMMING POOL ELECTRIC
will doc work and Detractors, tm I
's ' d [f nal l' I (6 70440 . ces ❑OTHL>IU—��C"-�—�•"
m and Professore Cade Th Counselors Lc L d I apply I of OUTLETS-SWITCHES-FIXTURESr_.
r�I
property who builds orimprovesth d h d h khimself through
his own employees provided that such improvements am not mo
ended or offered NEW RESIDENTIAL ELECTR SQ PT. � ) ]J II U
sale.If,however.the building or inlpmvement is sold within one year ofcomplaion,the ISR.Ff FLOORARB� 199'i 1$44.FT.
fir-builder will have the burden of proving that he did not build or improve for put- APR
- paeafsuleJ.
❑I,as owner of the properly,am exclusively contracting with licensed contractors to 'TOTAL:
m
ebus the pro en,(Sea 9044,Business and Pn l'evoom Coal The Commemr's Li-
cense Law does not apply it)an owner of properly who build%or improve,Thereon,and QTY PLUMBING PERMIT FEE Q
who contracts forsuehp projects with econlmefm(s)licensed pursuant lothe G,mmcmr's y
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C ferric woom
ALTER-DRAIN&VENT-WATER LA) VALUATION
. Owner Data
Wm KER underSCOMPE SNI perjoiION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of perjury one of fi9kming declarations:
(have anJ will mainmin aCenlEcmenfCnneem la self-ivsurol6r Worker's C.... ra- DRAINS-FLOOR.ROOF.AREA,GOND. STORIES TYPE CONSTRUCTION
sulfur,as provided for by Section 3700 of the Labor Coda tot(be performance of the
work for which lhis permit is issued. FIXTURES-PER TRAP Q Q
❑ 1 have and will maintain Worker,Compensation Insurance,as required by Scroll
3700 of the Labor Coda for the of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
OCC CROUP APN
My Workers Compenaatinn In.wmnce carzier and Policy number are:
Carrier: Policy Ne: GAS-P.A.SY6'1'HM-OVP.R 4(BA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRI,WASTE INTERCEPTOR BUILDING DIVISION FEELS
(This section need bol ba cnmplaled it(be audit is future hundred dollars S 100) GREASETRAP
in lie".)
PLANCHECK FEE
1 certify that in the performance of the work for wrist Ibis permit is issued,l shall
not cular,an 6EWBR-6ANITARY-STORM EA.2fN1 FT.
y y person In any manner s r us m hccnme,ub`ea m the Workers'Gnnpen- ENERGY FEE
`�. son Luw�sppf C.liI a';,.Da"90—,41r,
e
y�yO Applread t r-i WATER HEATER W/VP,NT/Ef.L'CfR GRADING TBE
NOTICE Ib APPLICA :IL u fir, g this Cmd tate of Exemption,you should WATER SYSTEMITREATING
abecome subject to the Worker'.,,Compensation previsions of the Labor Code,you mum SOILS FEE
fonnwhh comply with such provisions or this perninshall he deemed revoked. WATER SERVICE
Q
CONS
tthc,c RUC I ION LENDING AGENCY NEW RIiSIUENI'IAL PLMI{. $Q.FT. PAID Date
UO ]here by amthi mmmere isaced(Sec 13097,Cins agency rot the terenmunca of pe if
f+. The work for wrier thi,,Permit is ia,nee(ice.309].cies c.)
O Lender's Andre TOTAL:
V Lender's AJdress A
a1 ecrify fhm 1 bate real this ntplinnion nnA,cafe that the shove infnnnminn is I BUILDING FEE
Ir y warts.l agree m comply with all city unJ warty ordinances Imd state laws relating m QTY. MECHANICAL PERMIT FEE
V Z building conswaion,and hereby amhmim represematwes offbi,,it,mmw,i,dm the - SEISMIC FEE
above-memmard property for io,a c oro purpn,es.
(We)lil Ia save,indemnify and keep harmles,the City oI Collection.,%,a,, PERMIT ISSUANCE ELECTRIC FEE
Iitualines,judgments,costs and expenses which may in any way against said City ALTER OR ADD TO MECII. PLUMBING PNAI
to mequerce of the granting at hill permh.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('IT)14001(1 CFM)
SOURCH REGULAI'1 S. MECHANICAL FEE
A ^ �� AIR HANDLING UNIT(OVER IO,INIO CPM) CONSTRUCTION TAX
SitSettle x Applmimalcmtmemr •T/ Dak EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theaptliant or forme building occ......tore fir handle haoinku,barrel HEAT]NO UNIT(TO'I 00,000 BTU)
as defined by the Criterion Municipal Coda Chapter Alt,and the Hahvn
h d Safety
Coda Section 25532(.,)1 HEATING UNIT(OVER 100,000 BTU)
❑Ven
VENTILATION PAN(SINGLE RESIU) PAID
Dom Rmaipl#
Wiliam app,rumnacam fumm building by
Bayse Ands pmentlity Mmconeb BOLLFR-COMP(3HPOR OQWOBTU7
emir haeardnus u]t ennwmintmts ns defined ny IM1c Bay Area Air Qualify Munvgemem (YI'Ala
District!
El Lal EDILEE-COME(OVER I00,000 BTU)
I have bud the hazmdons materials mquiremend under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomib Health&Safety Gde,Sdvions 25!505,25533 and 25534.1 understand that nine NEW RESIDENTIAL MECH. SQ.FT ��
building does bat currently have..earl,That it is my responsibility to notify the aooupant i
I there u t um be met prior to Issuance lira Certificate of Ove ancy.
ora ri.J tc TOTAL:
ISSUED BY: I
' OFFICE