S 2436 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATIONMERMI'r PLITHRING-MECHANICAL S2436
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: t SANITARY N(]. lON SUNMITTAL DATE
JAIPLICAI
rARCHIT=�GINHIE
/x� �P ON CONTRACOR�S NAME LIC NO:
C N'fR(lLM
LIC NO: ADDRESS: ❑
PHONE: I BUILDING PERMIT INFO
w yobs��b i9 'u CollSultan[FXid by APp ican[(Initial) ELECT MECH
s ENSED CONTRA R'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby amnm mw 1 on,licensed under provisions of chapter 9(u,mreacing JOB DESCRIPTION
OCZ with Section]00BofDivision 3 ofthe Business and Professions Core.and my license ix sNTIAI.:
�O O PERMIT ISSUANCE
W; in full force and elle,. FDWI. ❑KITCHEN REMODEL.
aUF 1.icensc Class Lick �yx�rr�'LUMBING RE-PIPE
I. U APPLIANCES-RESIDENTIAL
El p+'
rFit6i Uute Cnnvucer ❑MULTI-UNIT El STRUCTURAL
[.,7m ARCHITECTS DECLARATION PANELS
wZ I understand my plans shall beusedaspubiic records MODIFICATION
p Z,N.m^ UPT0200AMPS ),INTERIOR El CHIMNEY REPAIR
r-0,11sO,e LicensW l'rofessinmml 2U1-I(XXIAMPS IMPROVEMENT SWIMMING POOLS
90-J OWNHR-BUILDER DECLARATION OVER IIx1UAM1'S ❑BATH REMODEUREPAIR El DEMOLITION
C I hereby uHire,the,I nm encntpt from the Continence',License Law for the
xSx O d U following reason.(Section]1131.5,Business and Professiore Cole:Any city or county SIGNS ELECfRICAI. ❑OTHER
W 3 0 F- which requires a permit m construct,aheq improve,demnli,r of repair any structure
F,�.O prior lairs rummncgalao requires the applicant for such permit to file it signed.statement SPECIALCIRCIII'pMISC.
pppp�]t{t{nnyyy that he is licensed pursuanuo the provisions of the Contr:umrs License Law(Chile,9
1'q� (commencing with Section 7000)of Division Sof the Business and Professions Code)or TEMP.METER OR POLE INST. R
allS y m y that he is exempt therefrom and the basis for us,alleged eaemption.Any violation of NEW BLDG/AUDITION ❑DEMOLI]ION
LLXI W
Section 7031.5 by any applicant for a Nrmitsuhjects the applicant n a civil penalty UlPOWER DEVICES TENANT [I FOOD S17RVICE
F Z} no,more than Eve hundred dollars(55(101. IMPROVEMENT
< [1 1.asownernfthe properly,or my employees with wages as their vole compensation, SWIMMING POOLELECTRIC
G will do the work,and the structure is not intended m idifcred hostile(Sec.]044,Business ❑OTHHk
6'3 and Professions Cole:The Connector's License Law does not apply to an owner of OUTLET -SWITCHES-FIXTURIS
Ila—
Property who builds or improves thereon,and who does such work himself or through
his own cmpmyca,,pmvidad that such improvements are not intended or offered for NEW RESIDENTIAL ELGCTR SQ FI'.
sale.If,however,the building or improvement is sold within one year of I-—,..tion..be SV FT.FLOOR AREA LSQ.Ff.
ler-builder will have the burden of proving that he did not build or improve for put.
post,of sale.).
A1,as owner of the property,am exclusively contracting with licenced contractors to
,mrshow,the project(See.]t W,Business and Professions Cole:)'Ihe CUntantors W-
cense Law does not apply ar on owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEF.
whocommons Cor such projects with a contactor(,)Ilccnscd purruunrto the Contactors
License Law. PERMIT ISSUANCE
lamm eneL code Sec. ,B&P C for his reassmn
Dae ALTER-DRAIN&VF.M'-WATER(EA) (\�\s LUAJ
O WORKER'S ON)P446ATION DECLARATION BACK FLOW PROTECT.DEVICE YJ
I hereby air,,.under penalty of perjury one of t]at fallowing dedan,tion,
❑ [have and will maintain a Certificate of Comentto sell-insure for Worker's Compel. DRAINS-FLOOR ROOM AREA,COND. IO IES ONSTRUCTION
'�
urian,m prvideJ for by Section 3700 of the IaMr Code,for the performance of the 19
work for which this permit is issued. FIXTURES-PER TRAP (]
❑I have sad will mainwin Workers Compensation Inmrnnet,as m,aired by Section d
370(1 Labor Cole,for the performance ofthe work far which this permit isissued. GAS-FA.SYSTEM-I INC.4 OUTLETS I . ,ROUP N
My Workers Compensation Insurance carrier and Policy number on:
Cartier: Policy No.: GAS-HA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASI%INUUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE G DIVISION FEES
(This section need nm he completed ifthe permit is forcing hundred dollars pilar GREASE TRAP
orlessJ P1. FEE
Coy any that in the anyPerformance
urnmenadthe becomork e
%objectch to the Workm'Colslall SEWER-SANITARY-STORM EA.200 FI'.
not employ any person in any mennerso as to become.whjecnothe Wnrkers'Compen- ENERGY FEE
z station Lows of Cold..air.Dam WATERHEATERW/VENT .LECI'R s�
Z0 Applicant s GRADING FEF.
..t ti NOTICE TO APPLICANT:If,after making this Ccru ficme of Exemption,you should WATER SYSTEMOTREATING
a become t,hjeet nt theWmkcrs CI en,atic.pmvElons of rhe Labor Code,you most SOILS PEG
7
forthwith comply withsuch provisions or this permitshall he deemed revoked WATER SERVICE.
—�p' CONSTRUCTION].ENDING AGENCY NEW HESIDF.NTIAL PI.MIL SQ.FT. PAID Receipt#
U 0 1 hereby aflln r that there is a conswction lending agency far the vartonarmcc of
11. the work for which this permit is issued(Sce.3197.Civ.C.)
CF.1 Lenders No. lY1TAL:
D.l lender's Address
G I certify that 1 have read this application and state that the above information is BUILDING
h correct.I agree to comply with all city and county ordinances mi laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE Q
L) building conswction,and hereby authorize representatives ofthis city to enter upon the
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC E O
(We)agree to save,indemnify and keep harmless the City of Cupeninn against
Ii aM1ilitic,,jtal,ra s.co,ts and e,gm,,which may in any way accrue againd said Chy ALTER OR ADD'1'0 MBC IL PLUMBING FE
in cou s,tome,of the granting of this pcfmit.
APPLIC 'TUN STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IL00DCFM) MECHANICALPEE
SOUR C s R Gy AT )NS.
AIR HANDLING UNIT COVER 10,000CFM) CONSTHUCTION'fAX
Or plicantiConvactor Dae EXHAUSTHWD(W/DUCT) HOUSING MITIGATION PER
I IAZARDOUS MATERIALS DISCLOSURE
Will theapplicamor future building oecupmtmore or handle hon lour mawfim HEATING UNIT'(TO 100.000 BTU)
as define)by the Cupertino Mu ode.Chapter 9.12,and the Health cad Safety
Code,Scerion 25532(a)1 HEATING UNIT(OVER 1(X1,000 BTU)
El Y" VENTILATION FAN(SINGLE RESID) PAID Da¢ Receipt#
Will the applicant or future building occupant ase equipment or devices which BOILER-COM I'(3HP OR I00jXX)BTU)
contaminants hazardous air cnaminants as defined by the Bay Area Air Quality Management 9'OTA
Diu iei? �// BOILER-COMI'(OVER 100,"BTU)
Ely- an /
I base read the haallous materials requircmems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health Safety Calc,Sections 2 05,2.S533 and 255]4.1..&,.it thin Vthe NEW RESIDENTIAL MECH. SQ.FT.
building dr ,no enrtently oc n ,t st ileo,respmsibility in notify the occupant 2-
-
of the mq m is who st p nr m issuance of a Certiticum of Occupancy. z
nr u cd I Date TOTAL: ISSUE,)BY: r
OFFICE