S 2205 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PESH NO C
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MROUANICAL Z Z O5
IlGI1.IXING 1'RfIJECI'IDF.N'I'IF'ICATION
OUII.DIN .ADIIRF;SS: SANITARYNO APPhI'ATIGN SUIiMITI'AL DAIIi
3 U i -3
UW T NAMIi' 'HONIi: C NT Cf R'SN F:: ^_�` �� 0
/l./Vl U R('7�] RIC CONTROL#
•pHCHI'ELT?NGINE iR: LI ✓VSv:V (/f� �11x-x r J LJW ❑
CON ACT: PHONE: v BUILDING PERMIT INFO
/ �., I I /q�� n _/ ❑ Consultant Fees Paid by Applicant(Initial) RLDG E E PLUMB MEC]]
dv
LICENSED l`C/ONTRACCTOR'S DECLARATION1({^T QTY ELECTRIC PERMIT pEE ❑ ❑ 17�V`/I
1 hefeby afros mat I am Fcar.wol under provisions of Chapter 9(commencing JOB DESCRIPTION
DaZ with Section 700(1).Miodlion 3.ftha Business add Pfole,luns Code,and my llconxe is RESIDENTIAL
:
a�� in full fnreaundcR 0 /"'# po� ( `',gal` PERAi11155UANCli ❑SFDWL ❑KITCHEN REMODEL
Q,UU Licelts�G1,; Lien lA , LLMC) alk J �111 nPPLIANCE.C-RFSIDENI'IAL ❑ADDITION EJ PLUMBING RF..PIPE
tFZW Dared'OLI-"t"k Commcho �....`.�_I ..
ARC]HE DFCLARATION ❑MULTI-UNIT ❑STRUCTURAL.
L..'>N PANELS
Z O�Z 1 endesumad my plans shall Saused as public rat lx MODIFICATION
oz-0 UPT0200AMPS ❑INTRIOR ❑CHIMNI?Y REPAIR
UJ
Licensed l'ndessimal 201-1000AMPS IMPROVfih1ENT []SWIMMINGPOOIS
OWNIiR-BUII.DFR DECLARATION
CC �` OVER 1000AMPS ATI]REMODFURI:PAIR DI?MOLITION
a Q I hereby afrnn That 1 atn exempt from the Cnnlraonds Licwtse Law for the
W 3 a U following reason.(Section 7031.5.Business mtd Professions Coda Any city orcounry SIGNS HLECI'RACAL fif 11
LL 1- which require,a permd m rons,ocL.her,improve,dena.li,h,m repair any slntamc Vr ativ
0 prion.in issuance,alznrc9uims11ieupplicam for,uch proud,,tilea,lgneds,a¢memSI'F.CIAI.CIRCUR/A515C. Er
} that he islicenzedpurzuamtotheprovisinnsofthe Conoactor'sl.icenx Lrw(Chapror4
CLd� (annmcausing with Seclion 70otonf Division3ofwe looinecrond Professions Code)or TEMP.METER OR POLE INST. COMMEROAL,
d a o Oy that he is exempt therefrom and the basis for the alleged exemption.Any vinlutioe of ❑NEW BLDG/AUDITION ❑DEMOLITION
LMN Section 711.,1.'by
any
"Ph".m fon.lwnnit xahwcla we applicant 1,a civil, altyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars(5500).
F Z Y IMPROVEMENT
❑ I,acowner of the pmpeny,nrmYelnpLYttswith wage.ax theirsolecnmpeR , SWIMMING I'OOhIil.liC1"kIC
OTIC'#
will do the work.and the structure is not intended or offered for sale(Sec.7044.Ilusincsx ❑
aim and prefessi.ns Cale:'FW Commaors License law dos not apply ,,an owner of OUTLU I:S-SWITCHES-FIXTURES
pn.peny who milds of ilnpmvcs thereon,and who does tech work himself or through
his own employees,provided re that such improventems anot intended or offend far NIiIV RILSIDHNTIAI.T:LF.CrR SQ IT.
sale.If,howevu,the building or lmpmvcmem is sold within one year of completion.had SQ.FI'.FLOOR ARIA E/SQ.F..
owner-builder will have the burden of proving that he did not build or improve for our-
pnc of'.1a.),
❑ 1,as owner of the property,am exclusively contracting with IiiamuJ enactments to TOTAL:
construct the project(Sec.7600,Business and Profession.Code:)The Contractors ldi
canoe Law does out apply to an owner or prapeny who had lots or i reproves thereon,and Q'FY. PLUMBING PERMIT FEE
who contracts for such projects with n ammucmrfs)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. .B k P C for this reason
ACFER-DRAIN A,VIiNT-WATHR(HA) VALUATION
owner
DIO
Wm under SL'OM d perjury on Df Ce olio ON RACK FLOW IROTECf DEVICI?
1 hereby affirm under penahy.f perjurynncofweinsum or dvalardtWorkers Ca
❑lbws and will for byneCion 37m of Ce Labor Cash.for The
Worker's Camped. IlRA1N5-FLOOR.ROOEAHEA,COND, STORIES TYPHCONS'fRUCT10N
scion.ns hick this
pe mi Section 370NI of the labor Calc,for the per0nmanco of the
work for which this rcould is issued. PI%TURIS-PIiH TRAP
y�{�(�I have and will mainmin Workers Compensation work
hi h requited by Section
(i1lXl of the LuMrt Cwk.limM1e performance al the work lar which this psarmit is issued. GAS-EA.SYS'1'GM-I INC.4OUT LF:T5 OCC.GROUP AI'N
My Work a n4gxumnce remained Policy n r�' -
m
Cnmert�_L_Pnhey O ORRAS A,DUSISYS I R WAS 14 IN1
C. TIFIC O OF SAT] MINS FROM WO KIiRS' GHP.ASIJINDUS"I'RL WAS 1B IN'f1iHCH140H
COMPENSATION anRAsfor BUILDING DIVISION I'IiI+S
(This section nocd not M completed if the permit is for one hundred Dollars(5100) OHI?ASIi TRAP
or IesyJ PhANCIIFCK Igili
I sanity that in the perfivinance ofthe work forwhichthis permit is iswed,l shall SI?WF.R-SAN[TARY-STORM EA.200 FL
not employ any Person in any manner ms as as become subject to the Workers'Cooper- ENERGY FM
� Z cation Lawx of California Late WATER HEATER WN17NT/1![.FGFR
Z O Applicant GRADING HE
NOTICE TO APPLICANT]':Better making this Cenifirtm of Exemption,you should WATER SYSBI?M9RHATING
a ? become subject to The Workers Compensation provisions of the Labor Code,you must SOILS FEL:
w forthwith comply with such provisionsonhi.s permit shall he cast revoke]. WATER SERVICE
1. Q
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PCMB. SQ.11'. PAID Dot.
I hereby allirm thnl There is a wns,mainn lending agrncy ILr the action lnunroot
'pt#
the work for which this permit is issued(Sec.3097.Civ.C.)
w I-" Lender,Name 'I'O'fAL:
� U Lendcr.Addmss TOTAL:
T w 1 rectify that 1 have read this application and stem that the have infommtinn is BUILDING FF,E
Lnmneet.I agree ,,comply with all city and county ord'mance,and sane luwsfelating In QTY. MECHANICAL PERMIT PEE
U Z building construction.and hereby amhorire representatives of this city to enter upon the SEISMIC HE
.hove-iormioned property for inspection manses. PERMIq'ISSUANCE ✓-
(lVe)egret m save,indemnify and keep hamdesa the City of Cupertino.gains, ELECTRIC FEE
liabilitics,judgmems,snots and expenses which may in any way forme against.srid City plat(ik OIt AUD'fO MIiCH.
in asequence of permit.the granting of this permit. PLUMBING Mr.
APPLICANT UNDERSTANDS AND WILT,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,6X1 CFM)
zz
SOURCE RTGULATIONS. ^ M[CIIANICAL fTL f
�( // AIR HANDLING UNIT(OVER 11.1X10 CFM) CONS1 RUCTIONTAX
Signature.f Applicant/Conm or 1 — Date EXHAUST HOOD(W'IDUM) HOUSING MITIGATION ME
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant crown,holding occupant s,orcorhandle hazardous material HFATING UNIT(TO Band")HTU)
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safe,,
Cain Section 25532001 HhATING UNI'],(OVER I WENT)B'fU)
El Ye., FI No VI:N MLATION FA N INGLII RESI DI PAID
Data Receipt#
00711 the applicant infuture building occupant y A en Air
or devices which
emit haaalloos ter contaminants as darned by The Bay Arca Air Quality Management BOILER-COMP(JHI'Ok I00,000 NTD) TOTAL: o
Di.arict?
Dyes E]No BOH.Fk-COM 11(OVER 100.00 IFFU)
AIR CONDII'IONFR
I have it Safely
h ode,Set,
x moda,a...s 25505yui 533 an 2.dei Chaptcl 6,95 df the Cali DAN^CE DATE�
inmin gHeallht..,&Safety Goda,e a tams 25505,25533 aoA 25534. understand Nm If the NEW RESIDF.NI'IAI.MIiCH. SQ.FT. (�[/Y•�
huildingdm nomurrently haveamwt4 pmt it is my rczpnnzibility aucotify the ce<upant
ofthn requite s b'Bc nluzl�';t,e rin' ...a nfn Cart. f0
V� _xo /T�W�)
Ownormuurizcd agent �' Uma TOTAL: ISSUE: NY: v
OFFICE