S 2675 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
RUII,DING DIVISION APPLICATION/PF,RMIT PLUMBING.MECHANICAL �` 2675 o�7 C
BUILDING PRodEcr IDESETIFICNERIN J 5
BUILDING ADDRESS: SANI'IARYNO. APPLICATION SURMITI'AI.DAI
77a q r • e � l' � ci- r '� 3-9'- 99
NF,R'SNAME PHONE: COMPACTOR S NAMIn iWc LI N('' NIC, C'ON'I ROhX
Ledj� S6 ' r 1 S
jj'FARCHITECT/ENGNIi[R: LIC NO: ADDRESS: C_+ ❑
I 1 0 Ab 5,C C
CONI'AC. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicaal(Initial) ISLDO 13LECT I'LUMH MECII
A✓rd i-edW 36 �/6/ o" ❑ ❑ ❑
LICENSED CONI RAC'I'OR'S DF.CLARAI'[ON QTY ELECTRIC PERMIT FEE
CXZ I hareby amrm ma I am Eeeowd coder pmO,im[of Chaptzr 9(commencing
]OB DESCRIPTION
sigh Sectio 9lglp[anivi:inn J onha Mesion,,aml Profcs+iom Cade.and my license,., RESIDENTIAL:
WOO PERMIT'ISSUANCE
al"F` mhJl form vlJcffecl �y
�VV Litems Clas. �`'I'9 1,ics 6 33 �I APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMHBING RE-111PE
NZS Date ma"Al. Vndor
F-DH ARCH] DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAh
Z O y L I undern:uld my plans shall M moil as public records MODIFICATION
O Z�^ UP TO 2W AMPS
❑INTERIOR ❑GIIIh1N13Y REPAIR
F�FW Licensed Pndessimml 201-1000AMPS IMPROVEMENT SWIMMING POOLS
<,;�; OWNER-BUILDER DECLARATION OVER 1000AMPS Ll BATH RF.MODlilllil?PAIR E3 DEMOLITION
C Q I hereby uftirm that 1 am exempt fn+m the Committers License Law for the
3 W U folloxing rt m.Ne,lion 911.31 5,Bmina'.and 11 fc[sin c,Cn 1, Any city n T
county SIGNS ELECRICAL ❑CT HER
y which require,a permit m construct,alter,improve,demolish,ur repair any.mormor
^k,to prior,oits i.enan.C,vhotetuar,theu+,Iieum for acM1 1a+fileasi Jaaemum
11 ll gnc SPECIAL CIRCUIT/MISC.
y,.
WCQthat he is licensed puede unthe pmviuinnsofthe N B.,mtr,, Licemtlaw(Chapter9
p (ammmucing with Rection 91X)01 of DivininnJ of the fiuxmeasunJ Prelevsion[Clde)nr "TEMP.METER UR PO ,'NST. COMMF.RCIAI,:
a a e C that he is cxarm therefrom and the basis for the alleged exemption.Any.edition of NIiW BLDG/AUDITION ❑DEMOLITION
u• Section 91131.5 by anyupplicant 0naperam,subjects meapphcant macivil pcnully of POWER DEVIC°
y + T ❑FOOD SERVICE
urn more Than five thundreddollarsS5pqLyempl L EMENT
=C
1.as owner of the ffic .ormyempmyceswimwages
ced ka,their role704'Ba,ion, SWIAIMIN '001,ELECTRIC
P.
will dalhe%ionsmde [he
Liecrow Law
notaala(Sec.oan,Business 01 HE
3 m and,Try wsions ds re h'he oyes hemr.Licenm law dot.not apply IV an owner of OU'f 1'S-SWI'1'CHF_S-FIXTURES
prCl'�Y who buIIM or imprnvex Ihemon,coil who Jut[such work hincelf nr Ihmugh
his own employees,provided that such improvements am not intended or offered for EW RESIDENTIAL ELECM SQ FT
side.If.howcvca the building(a lmpmvcmeat is sold within one year ofcompletinn,the SQ.FT.PLWRARF,A SRQ.PI
cavncomilder will have the burden of proving tial he Aid nal build m improve for pur-
+u ol'stile.).
❑ I,asw
oner of he pmpeny,am e,cdio.valy contracting with IicnnseJ toramnor.,to TOTAL.
crmwuct the project(See.9(44,Fri and Professions Code:)Me Contmaors Li
claw Law dans notapply manowner of property who builds for improve marcon,and Q'rY. PLUMBING PERMIT FEE
who contracts for such projects with a contmctor(s)licerwall pursuant to the Conlracmt.
Locure Law. PERMITISSUANCE
❑ 1ran ,aum under Sec. ,B Xr P C for this tens..
Owner Data
ALTER-DRAIN A,VIENT-WAI ER(EA) VNAA I'[ON
✓V
WOR KERS naltyof ni AI'ION DECLARATION BACK PLOW PROTECT.Ur:VICIi
t• IM1noby ullinn coder penalty of perjury one of the following Acdurvtiono'.
❑ 1 have and will maintain a Cenificae of Current toulf-inure for Worker's Cori DRAINS-FLOOR.ROOF.AREA,COND. STORIES IYI'13 CONSI'HOC II(
Lotion,a.pnwided for by Sec n 3900 of d+u Luber Cede,for the part armee of the
work fur which dsk permit is issued. fix'rURES-PER TRAP �•
❑ I have and will maintain Workers Cmnpensatlen Insurance,mix required by Section
3700.1`I1oC laNu C'Idc.Entire perfommnceofine work for which this pcmtit is issued GAS-EA.SYSTEM-]INC.4 OUr ,'$
My rker�? Mtnn Y 'V}arne lnythOCC GROUP ..
APN
Coeaky No.:
GAS-h:A.SYSTEM OVER Aj
CERTIFICA'1 li OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE C.REASPJINIIIJSTRI. STCINI'ERCEMOR
('Ihiswationmic
nd not hecon+plemdmeppnolt is bronehundreddollarkPi0bI BUILDING DIVISION FETES _
nr lcx.l GRI3ASIi THAI' PLANCHFCK FEE
Icenily perhatso, a priianyaranan<e of the markforwhichelhi horns i...CJ.lshall SEWER .ANITARY-STORM nA.21X)FI'.
I employ any peman in any muntxrp+ns hr y�mte—supigcl�Ihe Workers'Compen- ENERGY 19,.E
�nn3alion laws of Ca�^i Dac �__T T
zQ rlpplicanl " ,//,-��,.��'�,1�J(J\ WAIVER IIISAIIiR W/VIN"T/BLEC'IR GRADING IEE
h
NOTICE ED At ,'CANT 10tfier ansfUng this Certificate of Exemption,you should WN1 BE SYS'1'EM1IRP,A'I'ING
? Mcmme subject to the Worker's Compeamdnn previsions of the Lather Coal.you mu.t
W forthwith comply with such this pencil shml be deenmd invoked. WR'I'ER SERVICE
6. 0
Uz CONS
l.. here i,a a[ON mi.in[NCAGENCY NEW RESIDF,NTIALPLM1IB. $Q.ET'. PAI
V Q work
or which nthm.it is eco San.30 len Jing agency fill the pcAnrmance of Dam ciplX
me work Gn which This IXnnil Ix is[ueU San.JEW],Cos.CJ
U Lender',Name gFA I Q
AL:
O {U Lenders Address TOTAL: tan x
a 1 ttnify mal 1 nava read this npplicatinn and rune mm the above infnrm;viun i. BUILDING FEE
Zi correct.l agree to comply with all city and county ordinunr%and%late laws reuing e+ QTY. MECHANICAL PERMIT FEE
U Z building conswetion,vnd berebyamhori a reprawmalives al his city roamer upon the SEISMIC FEE s s
above-mentioned propeny for inspection purposes,
(We)agree it,save,molcu mfy and keep harmless the City of Cupertino against PERMIT ISSUANCE T=FRIC FEE
Iiabllities.judgmems,costs and expenses which may in any way accrue against said City ALT'ER OR ADD TO MSCI I.
in s,,or,ttm m the grunting of this peril. PLUMBING EEE
APPLICANT UNDERSTANDS AND WILL COMPLY WE Of ALL NON-POINT AIR HANDLING UNIT 110 I0.000CFM)
4
0UR1 H REGULATIONS. MECHANICAL IEE
lAIR HANDLING UNIT ER 10,010 O'MI CONSTRUCTION TAX
Signature of ApplicartY,mmncr Data H HAUS'I'H(H) W/DUCT) IfOUSIKG MITIGATION FEEIIALARWUg MATERIALS DISCLOSURE Will the npplicunt or Future buildingort, r arm or handle hamnlousmnitrial HEA'I'IN' NI'P(T(I I(IQp10IITll)
as defined by the Coleman Municipal Crde,Chapter 9.12,and the Health and Safety
Cute,Section 25532(x)1. TNG UNIT To
1(x10110 BTU)
❑Yes It3No
I ill VENTILAI ION FAN(SINGLE RESID) PAID-L"
Will the applicant or from building oumpvnt use cquipmcm Cr devices Much Date Htary,X
1buildiii,
mit Incautious air cumaminents as defneJ by the Bay Area Air Quality Management BOILER-COMP LIVE OR 100,000 BTU) 7�Y �O
'TOME:❑Ye o BOILER-COME(OVER 100.(1,BTU)
I have maul rot M1armJnu. aedaB rcyuirumcnn under Chap¢rfi95 of the Odl- AIR C(NDITIUNERISSUANCE DATE
nrnih Ilmldt&Rafdy Ctde.Scetions 255115.8594 and 25534.1 undemend that ifthe NEW'RESIDENTIAL MEED. SQmaw�nol,.�mlynnLl mit is my mspnnsibilirymnutiy mctmcup:mt
the tt el m IV ixsuatneofaCtnilCalcof( mpunry. 7C Dac TOTAL:
ISSUED BY:
OFFICE