S 2289 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EITC'DUCAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
S 2289
BUILDING PROJECT IDENTIFICATION
❑UILOGAI)I]ItESS: %�� /N�� SAN(('ARV NO. APPLICATION SUBMITTAL DATE
O RS33A33E: / / PHOS .a ,,' 71` ACI'�It'S NAMIi:,_
{//• / // ( plFl /Vr)WY7�+ LLI 3r RIC CONTROL#
A CHI'ITCTIF,NGINHER: LIC NO: ADDRESS:�'O ce r 4 ❑ /
CONTACT; _ PHONE: BUILDING PERMIT INFO
IO/fO A ,/� -/7)jk ❑ Consultant Foos Paid By Applicant(Initial) BLDG ELECT PLUMB _ ME❑cx
LICENSED CONTRACTOR'S DECLARATION lJ QTY ELECTRIC PERMIT FEE - �/
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ with Section](g1)of Division 3 of Ne Businessand Professimn.'Cod and ylicense in RESIDENTIAL:
W O p PERMIT ISSUANCE
F�..
at later and ❑SFUWL El KITCHEN REMODhf.
U F License tse Lic.#
U AI'PLIANCIis—RESIDGNTIAI. ❑AUDITION -1 PLUMBING RE-PIPE:
tiIt1 Owe Conw<tnr
>0.p. ARCHITECTS DECLARATION ❑MULTI-UNIT' [-1 STRUCTURAL'
Z O'r' l underemmd soy plant all be nsal as public records IANELS MODIFICATION
O Zr" UPI'D 200 AMPS 1 ❑INTERIOR Ll CHIMNEY REPAIR
F+.o1, Liccnvcd Prafensional 201-10DOAMPS IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I(NXIAMP5 ❑HATH RFMODFL/REPAIR ❑DEMOLITION
C I hereby affirm thin I nm exempt from the Contncmd License Law for the
x 3�hU+ following reason,(Section 7031.5,Business and Professions Gude:Any city nr county SIGNS ELECTRICAL ❑OfIIER
y which requires a permit to consimal,alter,improve,demolish,or repair any structure ' 4
0� prior to its issuance,also requires the applicant for such permit to file a signed statistical SPFCI At,Cl RCUIT/M ISC.
fly that he is licensed pursuant In the provisions of the Contractor's License Law(Chapter')
�IypO (rommencing with Seninn](x1l of Division of the Business and Professions Caro m TEMP.MM)IR OR POLE INST. COMMERCIAL:
St.a e z that he is exempt Ihctcfrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES n ❑TENANT ❑FOODSERVICE of more than five hundred dollars(5501).
F Z i IMPROVEMIiNT
W ❑Lo¢hwnerk. ad pmpcny,or is..imoyalfrimhwired aslhei(See compensation, SWIMMING POOL ELECTRIC QOTHFR
_ will dotbewons and the he Conn tic of s Licensa Law does not
apply
an Business
63 and professions who
ho b Code:Theoves theca license Law apply himself owner
of OUTLITS—SWITCHES—FIXTURES
.. property whooyees or improves thereon,and who improvements
such work himself f through
his own employees provided that such mentis old w am not intended or offered for NEW RISIDIiNT1Al,F:LEC!R SQ FT.
sale.If,however,the building orimpmveooem is sold within one year of completion,the SQ.FT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put.
pose of sale.).
❑ L as owner of the propeny,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sea 7044,Business and Professions Cade:)The Contractors U.
cionso Law does ant apply to an owner of properly who builds or improves thereon,and QTY PLUMBING PERMIT FEE
whocontracts liar such projects with a contractors)Iicemed pursuant to the Conmtcmr'x
License Law. PERMIT ISSUANCE -�
l atm cxantpt under Scu. ,R&P C for thlsrcnvnt
AI:1'Eli—DRAIN&VENT—WATER(FLA) VALUATION
Owner Data
WORKERSNSADECLARATION
HACK FLOW PROTECT.DEVICE ,y
unonunte,lnch,of o,moof the molmwa : /
❑ ve and%illmaintainCenihcamof Cnsenseomi-WoTke,Compcn- URAINS—PL( Ik.ROOF,AREA,COND. S
TOSRIEoS O U TVYP
ECONSTRUCTION
xmim.as pmvidal for by Section 371mf the Labor Cade,for
the perfnrmmce of the
work for which this profit is issued. Ta FIXTURES—PER TRAP �� (�
❑I have unit will mainmin Workers Compensation Insurance,.sea
Z
quired by Senion
37Mofthe Labour Cafe.manic performance oftbe work for which this permit is issued. GAS—EA,SYS]EM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number arc:
artier. Policy Nm.: GAS—EA.SYSTEM OVER 4 EA)
CER HIICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GHGSFIINDUSTRL WAST[INTERCEPTOR
BUILDING DIVISION FEES
(Thissection need oat be completed fine permit is formic hundred dollars($100) GREASETRAP
our less.l I'LANCHECK PEC
I ecrifytial intheperformancenfrhe weak fa-whiehlhis permit is issued,l shall SEWER—SANITARY—STORM EA.200 FIR
not employ any pe r i y or rma;Fyas ro befpme suyj#CLrptie Workeri Cnmpcn- ENERGY FEF.
swim Laws f mm. he L —"!D I WATER HEATER WI ENT/ELECTR
Applicant A GRADINGFEE
rzn y NOTICE TO APPLICAN'E IL ufer making this Certificate of Exemption,you should WATER SYSTEM/TREATING
h become,object m the Worker's Com nsmiom f the Labor Code,you must SOILS FEE
ai d pe provisions hall
{J: forthwith comply with such provisionsmthis permit shall he deemed revoke.). WATER SERVICE
fY Q
UO CONSTROCIlONLENDING AGENCY NEW RESIDIiNT1A1,PLM(. l ) Date Receipt#
I hereby which
this
is n ad(Secd30lending agency for the pufnnnunw of
tti Ne work for which this permit is issued(Sec J(W],Civ.CJ '
IL f"t Lenders Name U U
TOTAL:
V Lender's Address '1 T
?s a / QJILDING PEC
p{.s rertee that 1 hove rand this application and sloe that @,,lava infrnla inn ix
U4 buildin l,greememnply hwait erchyl cityantcoumyntaiives ofmdcratedu ntrfinar m QTY. MECHANIC LPERMIT FF:F.C.J '& hulldiug amnructlnn,and herchy aullomrim rcpresmmtives oRhis citymenter upon the MIC PI313
ahave-ntentinnedproperty for in.'peniun pulosoa. plikMl1'ISSUANCE(We)agree m save,indemnify and keep harmle.'s the City of Cupmino against Cl'RIC FEF.
liabilities,judgments,costs and expenses which may in any way acme against said City AL[HR OR ADD TO MECH.
in meequence of the gmmingoflbis .it.
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIB HANDLING UNIT(T010,000CF14)
SOURCI?j{1GULAHONS. MECHANICAL 2G
_ AIR HANDLING UNIT(OVER I0.00)CFM) CONSTRUCTION TAX
graatt//tuuremf Applicant/Contranor Data EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantorfutare Wilding occupmtslopeor handle himrdous mmerial BEATING ON[T(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety ""7�������//
Crile,Section 800 532D1^ BEAT ING ONI'I-(OVER 100.0BTU) PAID /USrO -
Yes � VEND LATION FAN(SINGLE RES IU)
Date Receipt Of
Will the applicant our future(wilding by the B Mauritania, TOTAL: `use equipment of devices which I{OILER=COMP(3HP(1k((1,(10 RTU)
ha
emit eunlma
s air mtaminnms as def by defined the Buy Area Air Qualify Munagc /
Distrie[I
C]Yes N......//////n BOI I.ER—COMP(OVER 100,000 BTU)
AIR C'ONDI'TIONER
I have rend the huz:mloux materials requirements under Chapter 6.95 of the Car. ISSUANCE DATE
fnmiu Health&Salary Code.Scalars 25505,25533 and 25534.1 undersand had if ma NEW RESIDENT(All MECH, SQ.PT.
building dis:s mol cta featly have a mount,thal it is my resf inw,hlllly m nnllfy the ocatp,nt
nhbapgµitemamiswl hmusyfjpE•t pdnrtn isea ofaCa) i"Jouly
Owner our authorized agent (/I/ Data TOTAL: ISSUED[Dzrclle- �~7`�~L
OFFICE