S 2371 (2) APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF
CUPERTINO BUILDING.ELEC'TRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUII,DINC PROJCCT IIIENTIFICATION
BUILDING ADDRESS ='PL I F1'AL DATIiR3(o `�OL `�. d�O NERSNAME: PHONE: CONTRACTOR'S RAMC; LIC NOARCHITECT/ENGINEER LIC NO'. DDRESS:4... L L �
CONIAC : PHONE: BUILDING PERMIT INFO '
❑ Consultant Fees Paid by Applicant(Initial) tlL�DSQ. FLECI'_ PLO_MMB MEE�C�III
GL unlL, -7 L C 7
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm That I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ with Section7000)of Division 3,dlhe Businessand Probations Code,wd my license its RESIDENTIAL:
PERMIT ISSUANCE
C�� in full force and elle S�LI(�/29 _ O ❑$FOWL. ❑KITCNF.N REMODEL
RV)L License P... Lien _! /�'�' APPLIANCES-RHSIDEN'I'IAL ❑ADDITION ❑PLUMBING RE PIPE,
F Z W Dam Commc
rn6a ❑MULTIUNIT ❑STRUCTURAL
F,=oe> RCf1DECT5 DECLARATION PANELS
Z p ti❑ 1 undemm�d my plans shall he used as public matiols MODIFICATION
Oz— - UP TO 200 AMPS [3 INTERIOR El CHIMNEY REPAIR
L•4FW Licensed Podessional 201-1"AMPS ,..IMPROVEMENT SWIMMING POOLS
a E
�-I OWNER-BUILDER DECLARATION OyIiR II1fX1 AMPS HVA H RI:MODI:I./REPAIR El DEMOLITION
a a— 1 herehy afrnn That Iran exempt from the Cemracmr's License Law(nr the
I a U following return.(Section 7031.5,Business and Professions Cask:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 LL F' which requires a permit to construct,aher,improve,demolish,or repair any.suuaum
' �ll�0 prior to its issuance,also requires the applicant lnrsuch permitto Tile a signed statement SPECIAL CIRCUITIMISC.
E r�o" that he is licensed pursuant to the provisions of the Commcmr's License Law(Chapter 9
sew�'co (commencing withSiniion]IMM))ofDivi.cion3oftheBusiness anti Professions Code)(IT TEMP.ME'IF:RORPOLEINST. ME9(f IAL
L d e that he is exempt therdi ma and rhe basis for the alleged ower,imt.Any violation of EW BLDG/AUDITION ❑DEMOLITION
Xm�
Section]031.S by any applicant for a permit subjects the applicant to a civil penxltyof POWER DEVICES []TENANT ❑FOOD SERVICE
ILLF.^w not more than five hundred dollars(S500) IMPROVEMENT
C=Q1]I,as owner office property.or my eniployecu with wages as their sole compensation. SWIMMING POOL ELECTRIC ❑OTHER
XX willdo The work,andtbeud mm isnot intended or offered for side(Sec.]IW,Business ,�
rail and Pmfessiore Code:The Commemrs License law does not apply m an per of OUTLETS-SWITCHES-FIXTURES
L property who builds or improves Thereon,and who does such work himself or through
his own employees,pruvidelThat such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL a
however,the hullding or improvement is sold within one yrofcontpletion,the SQ.Ff.FLOOR AREA $/SQ.1T
owner,burider will have The burden of proving that he did not build or improve for pur-
pose of sale.).
❑I,u,owner of the former,ant asdr,ively cmbon in,with licensed contractors to .T s
construct the project(Sec.70i.Business and Prnfessiore CNe:I The Contractor's Li-
cries,Law does not apply to an owner of property who builds or Improves thereard.=it QTY. PLUMBING PERMIT FEE
who contracts for such pro eco,with a contractors)licensed pursuant the Contractor s
License Law. PERMIT ISSUANCE.
El I am exempt under Sec. ,B&P C for Nis mason
ALTER-DRAIN&VENT-WATI7R IEA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 72
J �)
1 hereby affirm under penalty of perjury me of the Bdlowing declarations: /
C]I have and will maintain a Certificate of Conserv in self-insure for Workers Cmufaci DRAINS- O A EA,CONU. STORIES TYPECONSTRUCTION
sauna,as provided for by Section 3]00 of the IaMtr CMe,for the perfoJby
of
rr for which this permit is issued. TURFS- E 'TRA
w I hove and will maintain Worker's Compensation Insurance,as requirn ' ^
3]00 of Ne WhnrGde,for The performance of the work fmohich this pe - A.SYSTEM-II LETS /J OCC.GROUP APN
My Wor es ComyLWulion Insurance cyumr and PIT icyit berur-
Cartier.(,/4LI1'1A.11CMA1/INPolicy No.: G S Y H 1
CERTIFICATE OP E%IMI?ION FROM WORKERS' ILASFIINDUST'ItL WAS' .IN'IiRCEI'I(IR
COMPENSATION INSURANCE BUILDING DIVISION FEES_
(This senior need notMntmplemJifThe permit is intone hundredGREASCTRAP
or lass.) PLANCHECK A v
I Tandy Thai in the perfmnarna of the work for whiahlilk,rmit isI _STORM IA.2011 IT.not employ any person in any mannerso asobe toe The WmFNBKGY FEZ nation lifnmin Date- GG suWATER FEATER W/VENI'IELECI'R
zApplicant GKAIII
NOTICE TO APPLICANT:IL after making Nm C ilicare of Exemption,you should WATER SYSTEM/TREATING
H ; become subject m The WorkerpCM
s Comcemmion rovisions of the I.-hal I,you must SOILS
forhwlth comply with such pmvisimuor This pamon,hal he deemed revoked WATER SERVICE
Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ. PAID Date Receipts
7 '7" I hereby uffimt that them is T."Irrnion lending agency for the performance of
{U 2 Nork l wfor which Nd
is permit is issue (Sec.3097.Civ.C.) L. •�
p U Lenders Name c�
III Leudcr'.s Address TGT ! O
fy I certify That 1 have read This application and state that The above information is BUILDING FEE / Lf p a 0
eFs to cortin.l agree 1.comply with all city and county ordinances and sore laws relating to QTY. MECHANICAL PERMIT FEE ' e 8 UI
U Z buildingconstmmlmt.and hereby authorize representatives ofthiscity metuerupon the SEISMIC PCE
above-mentioned popery for inspection purposes. PERMIT ISSUANCE
(We)agree to.rove,indemnify and keep harmless the City of Cupertino against - F.LECfRIC PCE
Iiabilities,judgmenu,costs and expenses which may in any waynceme againa,mil City ALTER OR ADD TO MECH. PLUMBING FEE 3
in consequence of the Roaming'If Nrs permit.
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT A IR HANDLING UNIT(TO l 0,IXM)CFM) MF.CHANICALFEE 31 , 2
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I0,000 CI:M) CONSTRUCTION TAX
Signature rf A,pllcaMContrunor Date EXHAUST H=RESID)
T O HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thauppliamorfuture building orcupantmoremhandlehawrdous material HEATING UNIT00 BTU)
as defred by the Cuprino Municipal CMe,Chapter 9.12,and the Health and Salety
CMe,Section 25532mG HEATING U0,00(1 BTU)
❑Yes VIiNT11.A'IISINGLE RIi51D) PAID Ilene Receipt#
Will the applicant or future building«cupa d we equipment or devices which BOLLEN-CITiB,IXit) M)emir hzardous air contaminants as defined by the Ray Area Air Quality ManaSemmatT( VDittrich BOILER-C100.010 tlTl1)
C]Yes pKit
I have rad Ne hazardous materials mquiremems ander Ch.N116.95 of the Calc
AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Critic.Secumos 25505,M533 end 25530.1 uadersmM That if the NEW RESIDENTIAL MECH. SQ.FT.
building docs not curtently have atenam,Nat it i.snty resp,rnsibility,to tinily the recupanl / o
oft 'ma which mu he met prior to issuwce III aCenITeate-o1(Macy.
Owner rr authorized agent late I L: ISSUED BY'.
OFFICE