S 2594 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 2594
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
0NP.I' NAME: PHONE: CON ACI R'SNA yIC�O:
! OCA �Pch/S [�(6f N/C CO TRGL#
ARCMTECTIENGINEIR: LIC NO: ADDRESS' ❑
3�'old v>S3, �✓/e a Q,�f',Z
CONTACT: PHONE, BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG E[,Eel PLUMB MP.CH
olio 1p�; Tv7 Q?t�-ozi ❑ V ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby ammo foul 1 stn licensed Under provisions ob Cbap or 9(em rrencl m JOB DESCRIPTION
'a2, with Section 7000).fDivision 3 ortheBwinerxandPrfir,xinn.Cwe,midow license in RESIDENTIAL,
ulOp In PIiRMI'I'ISSIIANCE
H lull tome and alt��yp r
�UU License Clans [%�� Lic.# �O ❑SPDWI. [I KITCHEN REMODEL
U T.�lN� APVLIANCF;-RESIDENTIAL ❑ADDIT]ON ❑PLUMBING RE-PIPE
N til Dole CnnDECL
m 4i �CTS DECLA A'I'ION PANEL ❑MULTI-UNIT ❑5'BUC'1'UkAL
F7m UP 10
Z p l undecaantl my plan,skull be used as public record. ,y'-y �-r 2 ^ MODIFICATION
OZ-Q Ya UPl'026n AMPS G�[� V ❑IN'I'PRIOR El CHIMNEY REPAIR
b ut Liwreel Pmfessinnal 2111-I W6AMP5 IMPROVEMENT El SWIMMING POOLS
?C •�] OWNER-BUILDER DECLARATION OVER IIlIX1AMP5 ❑BATA REMODP.IIRIiPA1R 11 DEMOLITION
C W G 1 hewh offurn that I am exempt Ir n the Corrosion,License Law fm'the
OdU followingoaam,Isom on7031,5,Bunincis and ProfcAimn Codec.Any citynr county SIGNS ELECTRICAL ❑OTHER
mwhich requires a permit to construct,alter,imp ruvc,demolish,nr ,,at,any xtmclurc
d prior o ire is,uancs,also requires theapplicaut forsuch peredit o fileasigned stamunde SPECIAL CIRCUIT/MISC.
DO he is liansadpunuanun the provisions of the Comectors License Law(Chapaerit
(comundrawgwith Section 900oni'Division 3ofthu Pmincraand PwfiAJonsCaddor TEMP.ME'[EIR OR POLE INS I'. COMMERCIAL;
d ry�o a 'he,ho is exmnpt thercfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
>C li Section 96315 by any apdirana for o permit subjects theapplicnnt to a civil Doolly of POWER DEVICES
n mom than live hundred dollars D500f ❑"fl3NANT ❑FOOD SERVICE
� E]1,as owner of the property,or my employees with wages as their sole comp.nsnti.n, SWIMMING POOL ELECT RIC IMPROVEMENT
H will do the work,and tiro smtcutm is not intended or o0'ered for sale(See.9644,Business - DOTTER
and Prd.ssums Code:The Contractor',License Low does not apply In an owner ob OUTLETS-SWITCHES-FIXTURES
properly who fatigue improves thereon,and who docs such work himself nr through
his own employees,provided that such improvemerlm arc not intended or offered for NEW RESIDENTIAL ELECTR SQ
sale,If.however the building or improvement is sold within one year efcomplefoo,the SQ.FE FLOOR AREA losgEl
ser-huildcr will have the harden of proving(bathe did net build or Improve for per-
goof,alc.).
❑ L senwrer of the property,are exclusively Concocting with licensed contractors o L:
rust....the Tracer(Sec.9(94,Business mm Due...om Cwic:)'I'he Coalmnor'n Li-crude -
Law does notapply In an owner ob propany who build,or innproves thereon,and QTY. PLUMBING PERMIT FEE
who contraele for such projectswith a contmcmr(s)licensed pumm nl lobe Commcnns
License Law. PERMIT ISSUANCE
❑ Ism exempa under Sec. ,B&P C farlhiarensm,
Owner Date ALTER-DRAIN&VENT-WATER U.A) VALUATION
WORKERS COMPENSATION DECLARATION SACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury ons of the following declarations'.
E]Ihave told willmaintain.Ccrtificatenf Connell lurch i...u,for Worker(,Gm.peo- DRAINS-FLOOR,ROOF,,AREA.COND. STORIES 'CYPG CONSTRUCTION
nation,u,provided far by Section 3700 of the Labor Cade,for the per urn amed of the
work Ibr which this permit is issued. TEXTURES-PER TRAP
❑ I have and will maintain Worker's Compensation Insarmce,as required by Section
39Wof the Labor Code,for the performance of Ilio work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP =APN
My Worker's Cmnpensalion Insurance carriu and Policy number arc:
Carrier Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE IN TERCEFTOR
('1'his,ectienevednm he completed ifthe permit is borons hundred dollanis100) ---"�'- BUILDING DIVISI(�NPHHS
or less) G F ETRAP PLANCHECK FEE
Icerliby that in lhepsrfonnanecnfle,work lorwhichthi,permitls issued,l shot l SI SA 9KRTV ORM 4.200
had OuPloy any pershn in any eo h yt�e su m the Ww1vd,i Compen- ENERGY PP.E
Z
satiou Law,of hfoy' Da m�--r°S�j°�'�1}"c to^�7 W I lE 't o /V r T JLr
Pon-
0
Applicant ; l--t GRADING FEL
NOTICE TO APPLICANT'.If,alter making this Certi(m.ae of Exemption,you should W rR SY 'f: RIA'I'ING
Weaker become cmrect to the Woer'.n Compensation provisions ofthe Tube,Code,you roust SOILS FEE
W forthwirh,on lywith ouch provisions tudi,pennihmll be deernedrev.sch, W TER SERVICE
CONSTRUCT ION LENDING AGENCY N dd❑❑ UAl. PAID
���'�7777LLLLI misty affirm that co
here is a r,rrucdoB
n lending agency n the pcfommnec.0 Daly Receipt#
V.F the work fur which this permit is issued(See.3007,Civ.CJ
O U LendeL,Num. TOTAL:
W Lender',Addw,,, TOTAL
Ty(hat)have wad the application d,tons that the above-onfundriumn is BUILDI EF
�a y 'mrser,.1.'are In amply with all city andly I' , I send I wlafng o QTy, MECHANICAL PERMIT FEE
U ] hrildig 'I fun,and hewhy phorize P - toti `oflh city to t open line SEISMI EC
above-mentioned popchy for inspection purposes' PERMIT ISSUANCE
(We)agree o save,indemnify and keep harmless the City of Cupertino against ELECTRIC -EE 7
Iinbilities,judgments,costs and expense,which may in anyway acame against said City, ATTER OR ADD TO MECH,
in onsdgrided oft he gfunding of dins penult PhUMBI 'PGB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(M I0,04M CPM)
SOURCE.RF.GULAI ONES MECHANIC FEE
J9
AIR HANDLING UNIT UVERFLOW CPM) CONS I RUC I]ON TAX
gnamre ofAp,lmam/Cwrrad.r /s Date EXHAUST HOOD(W/DUCT] HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theappliesM orftnure building occupant sdmorhown,,hmardnus residual HEATING UNIT(TO 100,00 RTU)
a,defined by the Culmtline Municipal Code,Chapter 9.12,and the health and Safely
Code,Series 25532mC HEATING UNIT(OVER 100,000 RTU)
0Yes ✓ENm VENTILAT ION PAN(SI NOTE RES III) PAID
Dom Receipt p
W,11 the applicant or futrn, obuilding occupant use equipment lin ily Mara which BOILER-COMP(3HP OR 100,000 BTU)
-:mit District'
nus sir mnwminmrts as defined by the Bay Arco Air Quality Management 'POTAI
Disnim?
❑Yes RK BOILER-COST(OVER I1111,110I HTl)
1 have read the hazardous inammils rcquiremenm under Chapter6.95 of the Cal i- AIR CONDITIONER ISSUANCE DA'E
Cornu Health&Safety Code,Scrims 25585,25533 and 25534.1 understand that iltbe NEW RESIDENTIAL MECH. SQ.RE - 2
b 'Id' gdoe,nm entre by hnvm mnonq thvt it i,my rasponsibdaymnntifytlm oecup.nl L� T
oflhyRe aIyse yinet whion met prix missuancs nfa0. y.
Owner n�yr usulh'7�ffddaal� am TOTAL' ISSUED BY:
OFFICE