S 2296 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECFRICAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 2296
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NU. APPLICATION SUBMIT-1'AL DATE
WZ KIRF, IL•
OWI(faR' Ah ,�_ErHONE: CO.TRACfOR'S NAME: LIC NO:
111.A' �ull NIC COM'HOLp
ARCH IEC'1'/ENGIN T.
R: LIC NO: ADDRES. ' D ❑
� r
CONTACT: PHONE: BUILDING PERMIT INFO
SConsultant Fees Paid by Applicant(Initial) BEL13 PLUMBMGCY YJn0{ 2-- ❑ OID
IICcRATION
I Qty ELECTRICPEI2MIT FEE
Z License Cl.. e1Te G Bus g—al a of Chapter v mo;nmense is - JOB DESCRIPTION
Q I Lamby Abounded 1 unl licensed under prnv
wfin Senian7malafomisinrt3mnne Basinecxand Prof asi J� license is RESIDENTIAL'
p / PERMITISSUANCE
UW h- Y ❑SFDWL [I KITCHEN REMODIiI.
.y V APPLIANCE$-RISIUENTIAL / []ADDITION [3 PLUMBING RE-PIPE
y6 Dam ContractorDF7T
,^7y AR,hallh CTS DECdhic re PANELS MODIF11 MULTI-UNIT ❑STRUCTURAL
TION
Z O I understand my Plan.c shall he used as puhlic records CHIMNEY
REPAIR
0 _ UPT02B)AMPS [I INTERIOR ❑CHIMNEY RF,PAIR
I, ul Licensed Prol'esxional 201-100JAMPS IMPROVEMENT SWIMMING POOLS
�y OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATHRCMOOG REPAIR DEMOLITION
W Q I herchy aif, that 1 am exempt from the Comrterm's License Law for the
XO h V following rc;mm.(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
4477 O which requires u permit m construct,alter,improve,demolish,or repair any suuchum
primu,its i.csuanee.also requires the applicant forsnch Permit to fileasigned swtamenl SPECIAL CIRCUI'IYMISC.
that he i.c hiscused pursuant to the provisions of the Comracmrs License Low(Chapter 9
� a (commenting with SmtionRxl(p of Division 3 ofthe loomeas and Professions Code)or 'TEMP.METER OR POLE INS COMMERCIAL'
a p that he is e®nlpt Therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
Section 7031.3 by any applicant for u permit subjects the applicant to a civil penalty of POWER DHVICCS []TENANT ❑FOODSERVICE
} nal more than five hundred dollam($5W). IMPROVEMENT
60 ❑ I,asmvnerof the propcny,army employees with wages as Neirsole roon,am on, SWIMMING POOLELE TRIC
p� will do the work,mud the structure is not intended oroBared for sale(Sec.7(W4...... ess ❑OTHER
and Professimrs Gale:The Contractors License I.aw does not apply man owner of OUTLETS-SWI'PCHES FIX'I'US S
property who builds or improves thereon,and who does sack work himself or through
his own employees,provided that such improvements an,not intended or offered for NEW RESIDEN'1'IAI.F.LECfR SQ
sale.IL however.the building or improvement issold withinone yamofcompletion.the SQ.FF.FLOOR AREA S/SQ.EP.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.). -
❑ 1,as owner of the property,ma axd iSaMly contracting with licensed contractors,to TOTAL:
mstmct the Project(Sec.9041,Bushes vad Profession,Cmde:)'Me Cmmmcmr's Li-
cause Law does not apply to an owner(if
i-seLawJiexnotapplymanowner(if property%no builds or improves themm.and Q'I'Y. PLUMBING PERMIT. FEE
who contracts for such pmjects with a contracmr(s)licensed pursuant n the Comraaors _
License law. PERMIT ISSUANCE
❑Ian,exnnl.under Sec. ,B&PC for this rem..
ALTER-DRAIN&VENT'-WAJ HE IEA) VALUATION
Owner Data O
WORKERS COMPENSATION UIECLARATION BACK FLOW PROTECT.DEVICE _-2,200
n 0 J
1 herchy affirm under,Paoalty tcperjury one of the following defaces Co: .C.
Ihave and will main mina firm Sate of flue Labor Code
forperfam Comp the DRAINS-FLOOR,ROOF.ARIiA,CONU. STORIES 'fYl'ECONSTRUCfION
work,r provided for by Ss issued.
J]W of Ne Labor Cide for the performance of the
01far which thispermitis issued. PIXTURFS-YIiR TRAP
❑ I hate and will mainmin Worker's Compensation Insurance,as required by Section N
I
9700mf the Labor Co oho e ';rmm�co of thaw hist isaurd. GAS-EA.SYS'1'IEM-I INC.40UfLP.TS OCC.GIt01J1' APN
My Worke i,_'fM1t en^ 1 vu i e comer and R
v Carriec� tiPolicy .:
GAS-CA.SYS'I'EM-OVER4(HN
n II C{RTIFlCATE OF iXEMPFION FROM WO KERS'
COMPENSATION INSURANCE GRGSF/INUfISTRL WASTE INfIiRCEPIC)R
VISION FEES
(Thisseetie.need notlommlPleted ifthe permit is forme,hundred dollars(SIM) GREASF.TRAP
mr less.) HECKF li
Icanlfylhalin Neperhrznurnco nfthe work forwhiuh Nispennit ix insucJ,lshull SHWER-SANI'I' Y-STORM IIA.200 FT.
not employ any person in any roamer sec as to become subject to the Workers'Cord,ii EENERGY FlEE
O ,Z satin.Laws of California.Data WATER Bf R WNENT/ELECI'R OC
Z 0 Applicant iR TNG
y NOTICE to APPLICANT:If,alter making this Certificate of Exemption,yru should WATER STEMORFATING SOIL$TLE
abecome subject In the Worker's Con,onsation provisions of the LaMo Code.you must
L11 forthwith comply with such provisions or this permit shall be deemed revoke. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIUIEMI'IA1.PLMB. SQ.FT.
`� IM1erchy affirm Nm w
there is lending agency for PcrNrmanreM
Date ReceiplM
C.) the work for which this Permit is issued(Sec.3097.Civ.C.)
F" Lenders Name TOTAL:
PV
Laid er's Address TOTAL:
r�+ BUILDING FEE
[.,. 1 certify that 1 have read This application and sonic Nat the iMwc iw rellating is
r. N correct.)agree In comply with all city and county ordinances and.ants lows relating to QTY. MECfIANICAL PERMIT FEE
V Z building const dherehyour shim representatives of this city m enter upon One SEISMIC FEE
above-mentioned p,.,n far inspection purpiscs. PERMIT ISSUANCE
(We)ngreemsave,'ndernnify and keep hamilesslM City of Cupertino against TS—.5-0 IiL[CFkIC FEE
liabilities,judgment.costs nd expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in enn.c nee dlhegrun ng of this permit. PLUMBING FIFE
'III ALT.NON-POINT AIR HANDLING UNIT(TO 100010 CFM) M17CIIANICAL FIDE X1.30
$ODIC I\01
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION'1'AX .
•Signaw o A licant/G
nor Umc txUAUSTHWU(W/DUCp HOUSING MITIGATION FEE
HOLTS MATERIALS DISCLOSURE [.
ill lh mre building occupanLdorc.r handle hanarJousmamdal HHAIANG UNIT IT'Oq(xLWO BTU)us def nal by II Capeunicipul C de.Chapmr9.12,and the HcaIN and Safely
Code,Section 255J2(aHEA'DNG UNIT'(OVER IDO,(x)n 11'ITD Or
❑Yes
C]No VENTILATION PAN(SINGLE RES IU) PAID �V 4�DateReceilnM
Will Ne applicant or future building occupant use equipment of devices which - (�
earn haruchm,uir nems as defined by the Ba Area Air Quality Management BOILER-COMPDHPOR 1p)."B'I'U) -/
Y g TOTAL:
Dixtriefl BOILER-COMP(OVER I(N1,(111(1 BTU)
❑Ycx Na
AIR CONDITIONER
I hav the s matt 255 5,2553 encs under Chaptchartu l that Calm /�-� ISSUANCE,DATED
fay S sn,23505,2533)and S53<.I to
that Had, NEW RESIDENTIAL MECH. SQ.FT. (-]_
wilding aim n rte yresrymsibilitylo nmify the arupanl r/f
m(lne require ch xl ret pnonoixsoance nfa Cenifianc of(Xcupancy. 'l T
Ownersr ma aril ag nt - Dam TOTAL: 6�f,3o ISS UED BYE e-
ld
�� U
OFFICE