S2867 --APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELFCI'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMCel; PLUMBING-MECHANICAL.
S 2867
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SAN'I'LARY NO. APPLICATION SUBMITTAL DATE
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PHONE:. R TO NAM
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RCHITECT/ENGINPERLC NO�
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CON'TACI. - PHONE. ' HUILDINGPERMIT INFO -
�� ❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
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LICENSED CONTRACT ORS DECLARAON QTY ELECTRIC PERMIT FEE
IImeby arfrntbt la licensed I p fChapter9(amn etg _. JOB DESCRIP'PION
DMZ with Seu'on 9001pofD Sof lhe9us rte Yrofesso:Cd day licenses PERMIT ISSUANCE 3 e�� RESIDENTIAL'
F w O. in full farce and effcppZ/• 3 ❑SFDWL ❑KITCHEN REMODEL
XuF Llcerlse �{J�--Lie.#
Q U (p'� ,,.�' '� �' APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F'T Date��__.S. ZANCEF—Contactor
❑MULTI-UNIT ❑SI'RUCTURAI.
ARCIIITF.CT'S DE' A I
PANELS MODIFICATION
Z p w Z I undazrnd my pl�ns.eh:dl he cord as puhlic remnts
OZ=� UP TO 2N)AMPS XIR'I'ERIOR ❑CHIMNEYREPAIR
�4,F w LmrFl,,d Purm,,iond 201-I000AMPS IMPROVEMENT EjSWIMMING POOLS
•'a OWNER BUILDER DECLARATION�'Ma'4 OVER INK)AMPS ❑BATH REMODBUREPAIR ❑DEM01.1'1'ION
Q r 1 hereby aBlnn that I ma exempt from the Comractm5 License Law for We
k a ❑OTHER
O fallowing mum(Section 70315,Business trod Professions Code:Any my or ,coumy SIGNS ELECT
w3wy which requires a Permit t t It p d I,f p ,a erre _
nations i....ov,a1 4 Ih ,li If n. -I to Fla a,i,bod,ouram., SPECIAL CIR TI .C.
ded he is licensedp tIll he p caurs in the Contractor s License Law(71fiapmr9
W{yvg0 (eonnenc ngit h Sceimr9000)ofD viol 3tl the Buxinevs d P af...too,Crde)or TFMP.METER OR POLE IN. COMMERCIAL:
d X c,. Thal he is c.nnpl duccel oro and the basis for the alleged exemption.Any—Aatian of ❑NEW BLDGIADDH'ION ❑DEMOLITION
w-.w Section 7031.5 by any applicant for a permit subfems theapplicam to a civil penallyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
CZQnot more than Evchundred dollar,($500). IMPROVEMENT
❑L as owner of the property,or my employees with wages as their role eongmnsalicn, SWIMMI NO POOL ELECTR IC
p. willd Ih k nd lA t I t t Id ff df -I (S
Business
❑OTHP.R
Wim and Polessions Cade: the C I' I :License Law doesI apply to an owneret OUTLETS-SWITCHES-FIXTURES O 'U
prolan}who firolds or ou,noves Gerecon,and who does suali work himself th amil
his own eniployces,provided that d improvementsam notintended ff red for NEW RESIDENTIAL ELECTR SQ FI'.
sale If.h the building or improvement suddwthno ytr dcvnpinior the SQ.FT FLOOR AREA $ISQ.FP.
owamr-builder will have the burden at moving that he did not build or improve for Pur- -
p,sc nfsale).
1,ax owra,of the property,am exclusrvcly comn¢ting will licensed mntm,or,in
,oromalth p )ca(See.9044 B :I xsandProt....on,C(,d :)The Counneema,Li- - - -
se Law does netapply t rofproperty who builds or-ou'rovesthereon,and QTY PLUMBING PERMIT FEE
who mnbas,,for,u,h premr s with a,embe,ua(s)Feens.it pursuant to the Comnnrrs
License Law. PERMIT ISSUANCE
Fj I ren exempt code(Sac. .B&P C for this reason
Owner Data ALTER-DRAIN isVFNT-WATER(EA) VALUATION
WORKER'S COM PHNSXFION DECLARATION BACK PLOW PROFEC'1'.DEVICE eev
I buch,affin,bad,perealy I I J rymucol he fellow ling duellist -
� I have arld will mairijin a Certificate vfC t to self-insturefor Worker Comper- DRAINS-FLOOR,ROOK.AREA.COND- TORIES TYYECON�TION
earl ......red far by Section 3700 of ce,Label Code,fiernepeffintinmince of the
work for suchin permit oolued. FIXTURES-PI9R'I RAI'
El I have andwill maintain Workers Compensation hiscrancea,incurredb S ton
3900 fIllLabor Coca Faille peI..clause of the work l or is M1mh this ,,I'll is':m.I. GAS EA.SYS TEM-I INC_4 OUTLETS OCC GROUP PEN
My Werkefs Catinsnsmion lssurnncc carrier and al icy samba am'. w�""j
GAS-EA.SYS'I FMOVER4(EA'Cartier'. Policy No.: ...
CEKFIPICATE OF EXEMPTION FROM WOR KF,RS' - f -
COMPENSAION INSURANCE GREASFJINDIISTRL WASTE INTER£1'TOR
TBUILDINGDIVISION FEES
(Th is section need no(be cauliveled if the Pennies I or hundred dogre,l$100) GREASETRAPR f1( E
..nn A R ,QM PL IF.CK PEE
or less.)
I 'fyltrt' Ih p t(....... fIh kf F M1Ih p I .':: I Ishull SEWER—SANITARY S'IORM EAt.21)0111
b u th k pen- ENBN PEE
Z e31t Lws al Call y ,Pa -` WATER HEA'IEM. 4—
R WIVENT/ELECTR
7Q7O Appl GRGRADIN,FEE
a 2 NOTICE f0 APPLICP�N�If,after making IM1 s Can f ca v f E unpin t Y u should BEAT]NO I '�•,1
H !� becomefi t t theW k .C pe : p signs of the 1 abor Code,you must _ `�4FAID
forthwith wmPly w\h such provision. rtM1.p a shall he deemed revoked CONSTRUCTION rcImlNG AGENCY v1B. $Q.FT.LcrobY aBLm tbnuhere isactawetin lending agency fnrthe per(urmmc¢of Rereipt#UiM1c k 'EchThi p I Issued(S '.909] C' C) TOTAL
Lend N OLcd Add :: Z2I rift tht Ih Ithi:'ppI ( dsc tht11 b 'dormaroo is QTY. AL PERMIT FEE
C) Lx' buildingem.wetion,and hereby authorize representatives oflhis city to enmrupon the abevomenttoned property far Inspectionpurposes. PERMIT ISSUANCE J(We)agmcmeavc,mdemnify and keepbuirum ss theC.iyofCupertino agninsa
Iiahilitics,rydgmeno.costs and expenses which may many way accrue againsrsutd City AI.TERORADDTOMECII. PLUMBIN,PER
In uequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'F(T(1111,WOCPM) MECHANILFEE 41t)
SOUR( E A' _S ]]]���...
AIR HANDLING.UNIT(OVHR 10,000CEM) CONSTRUGTIO TAX
Signaiu of ApplennJContmnnr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will theappGcminr future building occupant stole or handle Initia ua mmcad H EATING UNIT(TO 100,gO B'FU)
as def,n.d by the Gtpentno Municipal Calc,Ch,,ner 9.12,and re Health and Safe,
Code,Section 25532(x)? HEAT ING ON]I(OVER I W,000 BTU)
[3 Yes El No TILUPAID
VENAON PAN(SINGLE KESID) Date Receipt#
Wol the mplicam or filmor b itl g p sempnicut or d ' - Inch BOB ER—COME FIHPOR lIA),rn)B'I'U)
'
t M1' d is air ea I ,na ns as do tied by re Bay Area Air Quality Manag rent l T TA
Di I et! BOILER—COME(OVER IIN,WO RTU)
Yes ❑Nn
11 I the h J 't tialmultimillion, d Chapter 6,95 f d C Ii- AIR CONDI'IlONER ISSUANCIJ VAT
bariaHealth&Safety Code,S f .25505 25533 d 25534 1 d u J,lan d he NEW RESIDENTIAL NIECE SQ-RE _ 44
building Iclarih 't 'nhd t t Yresponsibilitytotally lh occupant
A h me /p/�I tb `t t aanwtfa Len lcatcs up
Ow
Fe Iagenl ��c TA - ISSUFD BY'.
OFFICE
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