S 2949 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEWFINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-NIECIIANICAL
BWLDING PROJECT'IDENIIFICAI'IDY IC
IIUILLIINGADDRES S: ISANITARY . A TL.ICAL'ION SUIMI PA,DATE
11WNli 6Nr\boli: I'1{ONE CONTRACTOR'S Nr\MG: LIC NRY CONTROLSARCIII'1'ICT/ENbWEEK: LIC NU: ADDRI!SS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Counsullanl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CII
❑ ❑ tr ❑
LICENSE:[)CONfRACTOK:S DECLARATION QTY ELECTRIC PERMIT FEF,
I hereby nano mm 1:nn remised under prr+visions„IChnmer 9 monnme,dng JOB DESCRIPTION
PCZ with Sccnrn91XX11of Division?ofthclho,incwund Prot.......Coda,undtny limmels RENIDEN I IAI,:
I+IOQ En _ IPI:KNIT ISSUANCIi
FCWF full torte and e0ac � QZ ❑SI:UWL ❑KI'ICHIiY REh10DE1.
GUU Lwem.m cl-n Licx E AP1'LLWCR-RESIDENT'IAI. ❑ADDITION O.Yf11hiBING RE PIPE
FZW D;vc G.nntmm,,r
rpQp, []MUCH-UNIT' ❑STRUCTURAL
AHCHI I IECI'S DECLIRA'fION
~vz Iundemm�J mY planuhall be used ns puM1lic Tensed. PANELS MODIFICATION
ZOZ1O Up TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W hwrnd I...fe...ionul 2ul-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
re
y OWNER-BUILDER DECLARATION OVER IIXXI AMPS ❑BATH REMODEL,oRF'AIR ❑DEMOLI'T'ION
C C Q I hereby afl.that 1 am exempt remains,Cumncmr's larrise Law for the
x�x G U Iblluwiog mnxon.Ni 9131.5.heir....nal Profession.Code.Any city oa county SIGNS ELECTRICAL ❑(71'HER
W a i- which require,a fetish m cnnstme,alcor,trip nrvc,de list.or repair any arcOurc
I prior ttai 1 y theI such n fl . bed statement SPECIAL CIRCUIT/M
{y} math 'I' Ip : II b P fah Contract L L (Cnapmr> COMMERCIAL:
a� ingwth Seen tltI 700(ool D'v'ion 3(,l'ine BrI n '
and Pofl,, CivE)+r IF 1' I.MrI:R On POLL INS1
O fe smnu n
t1 d c C that he is exempt therefrom and me basis for the alleged exemption.Any violation ofElNEW BLDG/AUDII TION ❑DEMo1.Tf10N
x,ar
,w Section 7031.5 by any applicant for a Permit.ubjecu the applicant to a civil Penally of POWER DEVICES ❑TENANT ❑Fool)SERVICE:
not more than five hundred dollen(F91q). IMPHOVEMENT
SDF1 I.us owneraflhe propenY,nr mycmployees with wages as'but,sale romrynsuuon, SWIMMING POOI.ELECTRIC
License ❑o'I'HIiR
will do the work,and Ibe xmunure is nm imunJcd orrRerel for sale(See.90U.....ineaes UUThETS-SWI'I'CIIT:S-61%TURP.S
C^m
�3� and I'rnfr_sn+unx Code:The Camrudn.'.LicenseLm nw Jaws not apply an owner I
Imopvny who build.or in us thereon,and who it such work hlnucll or through
his own employee%,provided that such improvements art not:mended or offcred for NEW REESIDEN'I IAL ELECT It SQ 1711
sale.It'however,the building or improvement is sold w ithin one year ofcumplution,'he SQ.FE FLOOR AREA VSQ.En
rNone,will hnvc the burden of proving than he did no'build as improve lin pur-
1 pom,,I salty TOTAL: e
❑1,as miser of the propcny,am exclusively contracting with licensed contractors to
comnuO the project(Seo.9044,Bt mess and Poute,sione Code:)lMe Connamors Li-
,caw Luwdocxnol upplyto nnewmrnl properlywomm�ildsnrLnpnrvcs l erim.and fiQrYPj-UMB[NGPLUMBING PERMIT FEE ( L\,\ ff who contractsfor such prjecl.uith a contractions)licensed pursuant to the Cumntur,License l.aw. SUANCEcon cxcmpt under S¢, .EI h P Cliv'hix reason nRA1NhVl?NT-WA'TL'K[EN rs J RON 1Oxne, Damfl�f'1WORK]:R'SCOMPENSA'11ONDECLARATION W PROTECT.DEVICEI herebyIdfirm undo'penalty of Perjury otic of'hc fillowmg dccbtru'iun.: p❑ I hnvc and will nuin'mna Cenifi[ale of Conunnn,all-insure fur Wmker.Cnmpen- ILOOK.ROOF,AREA.COND. U SroRIF'_S 1'Y ECONSTRUCI'[ON
anion,as provided for by Section 39(10 of the Labor Cosi forthe perfonmvnec of thewort:fur which'hlx Penni'is Issued. -PER TRAP O❑1 have and will maintain Worker's Comryn.nion Inwmncc,as re,moud by Suction3700of'he Lahm Cod,fo the pefnmunce,,fine x ark for tohieh this permit is mind, SYSTEM-I INC.40UTLH1'S ICC.GROUP APN
My Wnrkc' Cninpcmglnlnxurvncc cancrunJ1Zul! Ix 'n nCur ,yI'alicyN `' Z .SVSTHNUVF.124(EA)
CERTIFICATE OF EXEMPT ION FROM ORKf GREASMNDUSTRI,WASTE:INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES _
(I his.CClion need no'M+conplemd l lhepermills loroncho dmlJollao(SI00) GREASE r RAP
PLANCI IECK I:LE
nr
less)
Icenifythat int in any
of the work h,,cmwhicluI,,Permit is bt,Cougen-hall SIiN'EH-SANITARY-STORM F.A.21X1 FT
nal unnPl,,y any Person in any manner m m m M1rc9me mhjecl w the Waders'Comm- ENERGY Ylili
Z cation Lues of Cahlonia.Door WAI Itz HEATER WIVIS'1'1131,1IC'1'R GRADING ITIS
Z Q Applicant
NOTICE TU API LLCAN'1':If,after making this Cenificate of Hnentpnun,you should WATER SYSTEMI TREATING
fire unbjea m'tic Wurkrd CantPcn.mlou Pn of the LnN"Code,you mux' SOILS FEE
ones mitiho
� ? fnnM1wilh comply with such pros:,inns oa this permit anal'the Jcenmd rcvnkvJ. EwArERVICiiPAIDCONSTRUCT ION LENDING AGENCY ENTIAL PLMB, SQ.ET. Rate Receipt#
UzI hereby alBrinthddem iso constructin lending agency brnhePcrfonamoed
F 'hc Mod for which this penmit is issued(Sn.3099,Cis.C.) 'I OTAL:
C) ULendds Name 2®I,adcrl%AdJar.a T 1' 1.: rr G 1 certiy that I have read this application and state four the aMrve Efifier tin 0 is B111i,UING II:V) emrea.I agree',,comply with all city and county ordinance.and nate laws mlmin6 I ECHANICAh PERMTT PEE SEISMIC FEE
UZ builAing connnnnnionane hereby authorize represcular softhi.%city mercer upon rhevbnvcmcntioni properly frI ,union purposes. UANCE EIFCI'RIC I:EIi
(We)agree to,ave,indemnify and keep harmless the City of Cupertino against
Iiabilifics,judgnncnm,costs and expanses which may in any way accom against Mid City ALTERORADDTGh1ECH. PLUMBING FEE
in[onseyu Ice of the graining of this permit.
APPLICANT UNDELRS'L'ANDS AND WILL COMPLY WITH ALJ.NON-POINT AIR HANDLING UNIT(Ill Ip0011CFM) MECHANICAL IT
SOURCE REGUL\T ONS.
� ? AIR HANDLING IINIT(OVI:R 10,000 CFM) CON'STRUCT'ION TAX
xSia�mre oD\A+phcaMCummcmr a -1 Dam EXHAUST HOOD tW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WiF the upPrcant or litum building neeupu+n"ave or handl,hwerinu, imeriul HEATING UNIT CTO lB).(XX)BTU)
as Jcfined by the Cape, Municipal Cede,Chapter 9.12,and the Health and Sslmy DEALING UNIT OVER 100.003 BTU)
Cedo,Section 25532(x)'! \
Dyes [3PN VENT LXT ION INN I5)NG 1.E RES l 111 PAID Use R...ais
Will the applicant nT future building aecapant um cquipnxnl or novice,xhich BOILER-COMP 13HP OR 100.000BTU)
,mit huzardnus air containment 1dcfined by the Ra)'Area Air Quality Marugemvnt TOTAL:
IJ'wn''n'R IB ILER-COMP(OVER I00.IXX)IfI'U)
❑Ye ❑ l
I have read the harardnu.nmterions requirement,muter Ch:mtcr h91 the Cali. AIR CONDITIONER /// ISSUANCE//E D/AT{E: '
forma Health h Safcry C'Nc.Sccllnnn 255115,25513 unJ 255?4.i nndct. hoturf if the NI?W RESIDEN'I'IAI.h1ECll. SQ.YIP. -,[/�p�.j
building Jee.muco tlyhuvcatenand'haliti.amym,fxmsihilallam'ily the arupum IT / ./3`lf1�C
oa lee Ryujre1 'til tie ax1 tnel p'ina m-uaner m a eenif,[tar n�I�
ownc�ranwnnuaagpnr (/ SOIAL: Issueu nY:c�e.
OFFICE