S 2361 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT ND,
BUILDING DIVISION APPLICATION/PERMIT i'LIIMNINGSIItC11ANICAL S 2361
BUILDING PROJECI HIT. N'ICATION
BUILDINGAI)1> S: ems- T SANITARY N(I. APPLICATION SUBINITTAL DATE
OWNI" N33AMIi: PION'.: CO RA OR'S ci I LIC NO'. ,
NIC CONTROL II
0/1
�tAIiC ITECT/FNGINEHIt LIC NU: ADDRESS: �� �� /J/�p�/a ❑
CONI'ALT, PHONE: C dU11,DINC PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) RI.DC, ELECT/PLUMB MEC+
� d7^ Q9� ���� ❑ Lam' ❑ ❑
LICFNSFDCONTRACIOR'SDI[CLARATION QTY ELECTRIC PERMIT FEE
1 nemby Int m mm 1 a�n heen,ed a..oar pmvian,n,of Chapter 9(emumeacmg - J013 DESCRIPTION
Qa'Z willlswdon Ponln of Divixnm3nOnc nuninaxwoe roe@xaioI,coal,ardoo,hoer.cin RESIDENTIAL
W 00 PP.RMI'I'ISSUANCE
a lu llfnrce anti eIfe O O ❑SFDWL ❑KITCHEN REMODEL
V Liccnu Class Lic.x
I- V APPLIANCES-RESIDF.NTIAI. ❑ADDITION ❑PLUMIfING R61'll'C
h d L Dme Com)Hc'or
A (. ITECT'S DIiCL lAl'ON ❑MUhI'I-UNIT ❑STRUCTURAL
~y m I understand my plans sNdl rte u,ced us public rccnrdc PANIiLS q MO+IIlCAT10N
ZOZ4O UPT0200AMPS T+0 [I INTERIOR ❑CHIMNEY REPAIR
F-�t:W Liconsed Pmfivoinnal 201-1000AMP$ IMPROVEMENT SWIMMING POOLS
9.�f,-.•.)1 OWNIiR-BUILDER DECLARATION OVIiIt I111111AMPS ❑BAIT{kEMODIiVkEI'AIR El DEMOLITION
C w a I hereby al'lirnt thus I ren exempt I in de ContoreaCs Licence Low ka the
k 3 6 F following reason.(Section]031.5,Business and Professions Cade:Any oily or coumy SIGNS ELECTRICAL ROTI{ITR
ul u.y which requires a perms to construct,nitre,improve,demolish.or repair any amemre
LLQ
prat t 'o....ac.odkao cautiousIh i'do If M1p lI ie b J:omnent SPECIAL CIRCUIT/MISE.
'N flood ems I II I II p 1 fof (' I' t 1 L (CI pter9
E.-.00t0O1 K dall hSection91and e 3 hthe e
JI 1 :CmlOor TLMI'.METEROR I'DLH INS F. COMMERCIAL:
E.a e C that he is exentpl Iherefrnm and the basis for the ellcged nsempt,n Anyviolation of El NEW BLDG/ADDITION ❑DFd101.ITI0N
�y Section 9031.5 by any applicant for a permit subjects the applicant n a civil Penalty of POWER DIiVICIiS El TENANT ❑FOOD SERVICE
S)., not mom thud live hundred dollan($50B). IMPROVEMENT
d I,m�wner nl thd n,nrm em lu ccs with con•es as lhuir sole core tion, SWIMMING POOLELECTRIC
Q ❑ pmpc y Y P Y b pen of
p., will prthe won,and the she C is urot,Liccrdaroak,doesed act
.111,1. a(-alofnts, ❑GTI{LR
a 3 m and Iknfessinns Code:The Cnmrdnnr's Lirenu Law does nal apply Io an owner of Odl'LCTS-$WITCIIl3-IyXI'1/BELS
praluny who huilds or improves thereon,and who does such work himself or through Q
his own employees.provided that tach nnPl'nvenmntr am nal Intended on ofr a l for NEW RESIDEN'GAI.F:LEC!'It SQ Irl'.
sale.If,however,the building or inipnrvermnt is cold within onoyearofenmpledim.the SQ FL FLOOR AREA 41SQ.I'I'.
wocnbuilder will have the burden of proving that he did not build or improve for par-
,so of salad.
❑ L as ownm of he properly,ant axehlxively denuding with lis-ansed con mouse to
construct the pruicid ISec.9144,Bodrovx and Pufe,tom,Cm1cp'111e Contractor,Li- Oy
cense Law does not apply at an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contacts hnsuch pmjects withaeomranor(s)licensed pummand tothe Counselor's
hkcnne Law. PERMITISSUANCE
❑ I and exempt under Sec. ,B&PCErthisreasan
AIDER-DRAIN&VENT-N'dI'ER(EAI VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROIT rI',DE IC17
I hereby al'tion under Penalty of 'Juryone of IIIc following aculamtlnns:
❑I have and will maintain aCertficateof Conunin.self-invane for Woraces Coot DRAINS-FLOOR,ROOF,AREA,CONDSTO '1''i CONSTRUCTION
option, w provided for by Section 3)00 of the OOIW,Code,for the perfarm ace of the
wort.for which this permit i.issued. FIXTIJ It HIS-PER TRA I' L,
1 have and will maintain Workers Contponeatinn not rune,its required by Section
3900ot the Labor Calie,r..ale somarmfferof the work far ehich,his permit iv issued. GAS-IiA.SYSTEM-I INC.4 DU'rLETS 419 G > APN
My Worker's Compelnainn Insuancc carer and Policy number art: �QV
Corrin: Policy No.: GAS-IiA.SYSTEM OVER 41EA)
CERTIFICAI'17 OF EX17MITION FROM WORK17RSI GREASIaNDUSO RL WASTE IN I'ERCE111. R
COMVENSA'1'ION INSURANCE 111111. DI
+ GVISION FEES
se
(Thisnian need not be completed ifthe hu
e permit is feature ndreddolur,5100) GREASETRAP - -- -
or Ices) PLANCI '
IceNfyoun intheperfmntaneeolduwarkfarwhichlhispenniit,liwucd.I shall SBWI!It-SANITARY-STORM EA.200 FI'.
note..gtlny any'anon in onynenne nuxmhpp�� yyy�lpd o(hu Walken Curolo- -- ENF:kOY FBF
Z satin..Laws of Culilnmia.1) 1Cl JL4..-�f WATER I IBATER W/VENTELECTR
ZApplicant I I GRADING FEE
y NOTICE TO APPLICANT.IL otter mukin6 Nle CdniOctne df Excmptinn,you should WA'I'ERSYSTEM/I'REATING SOILS lopI7
a [' bccmuc eobject m the Workm",Com ca,inioll ptovi,ldns of thv Lal o,Cada You nma
Uj ry forthwith comply with such provisions or this permit shall M council revoked. WATER SERVICE
4' in
CONSTRUCTION LFNDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT [PAID
UQI herchyairm th.Ohcrc iv acon,luaa nlmulillgngancy lhr the parhtnn:mm of the—al,for which tis Forntit Ix Issued(Sec.309],Civ.C.)0Leader',Name 'I OTALL) Lender,Address TOTAL: 11.DINC1 cdnify om have reaA Isis applicutinn and.qumthm the above information is
correct l agree td comply with all city audenunty ordinance,uad aam lawn rciatingm Q'I'YMECHANICALPERMIT FEbZbuilding construction,and hereby aathinue representatives of this city m enter upon the SMICFEE
aMrve.mcntioned pntperty for inspection purposes. PERMIT'ISSUANCE(We)agree lusect,indenmify and kdcphemdess the CityofCuponinn againstF.C'IRICFP.Iiahlllties,jud9mans,anlsunJuxpenscswhichmayinnny way actions ams,said City ALTRk ORAUUTO MECH.in mequencaol'the gantingof Isis pdnnh. UMI{INO Fl1E
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIN HANDLING I/NI'ILTO 111.1100CFM)
SO RF.Gl1LAT10N5� " Z _ j���� MECHANICFION i
��(r«JJJJ r�� AIR HANDLING Lot I(OVER 10,1X10 CFM1 CONS'rHUC'PION'I'AX
Signe for of Applicanl/Cun nor Date EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will dw.,,lemlorfilter,baildingaecOamt,lore'or handle hamrdons muarlal HEAT INC,UNIT(TO 100,000111'U)
as detinet by the Cupertino Mon eipal Code,Chapter 9,12,and the Health and Safety
Code,Section 25532(x)7 HF.A'I'INC,UNIT(OVER I OO.IRNI RTU)
❑Yes n No
VIiN'1'ILATION FAN(SINCI.Ii NASI+) PAID
Umc Receipt It
Will the appl'een no I e buiding occupant ase ulaipnmnI it,eeviccs which
tmoordous air contaminants as defined by the Bay Area Air Quality Monagentem flOILf?k-COMP(11{1'02 100.000 BTU) OTAL:
�Disnot
❑Tics No BOILER-COMP(OVER I WJXA)BTU)
1 have read too hnus ata¢rials myuiremenu ander Chapter 6 9 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma health&Safety Code.Scotian,25505.25533 anti 2!FUP.1 un leo and that Bthe NEW RESIDENTIAL.MECH. SQ.FT
building Jces not currently have a tenant that it is my responsibility to notify the occupant ( V I
of our requiremcnls which mune bract prior In i—emer uta Corneum of Ocntpancy,
Owncnrz uuthrnizeA agent Dore TONAL' ISSUED IIT:
OFFICE