S 2548 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2548
BUILDING PROJECT IDENTIFICATION
BUIhDINGA�REgS: /1 \ackvmc� p-fZ SANITARY NO. APPLICATION SUBMITTAL DATE
(lNI3 'SNA E" N CON
a � 2, f 3
N-J 4� a ^�
.1 RACT.R NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS' �❑
5'li Cv`C, IS
CONTACT: PHONE:
BUILDING PERMIT'INFO
�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
*1 ❑ ❑ ❑
LICENSED CONrknCTOR'S DECLARATION QTY. ELECTRIC PERMIT FE8
I he,ehy of irn mel I am uCe.wil turner pooiaimta of chapter 9(aonmenens JOB DESCRIPTION
Woe, with Section 9000)of Division 3 of be Business and Professions Coda vndmy I reare is RESIDENTIAL
F-W in full force and aRhe PERMIT'ISSUANCD
4 U U Licensc Class ` + Lic.X J V i `� ElSFDWL El KITCHEN REMODEL
HQ WM Dam Contmnnr AI'F'hIANCFS-RESIDENTIAL [-I ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION 0 MULTI-UNIT 0 STRUCTURAL
y Z N R m MODIFICATION
I understand my plushall he used as public records EA
pp UP TO 200 AMPS
F,iF"1+7 Licensed Professional LD INTERIOR El CHIMNEY REPAIR
gYg OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT El SWIMMING POOLS
I hereby affirm that 1 ore exempt from the Contractor's License Law fur the OVER RNID AMPS 0 BATH REMODEUREPAIR 0 DEMOLITION
i6yl W O Fallnwin,reason.(Sor 9(131 5,Business and Pmfe..no,Code:Any city an county SIGNS ELECTRICAL 0 OTHER
which requiem a permit to conswct,clear,improve,demolish,m repair any suucmre
(;QC) prom itsissmmce,also requires the appli,ap,duarehpermiuo file asignediasumnent SPECIAL CIRCUIT/MISC.
�7 that he is licensed pursuant o the previsions of the Contractor's License Law(Chapter 9
C) (maintaining with Section 7000)of Division 3nl In,Bmia,ss and Prof asciam,led,)ar 'TEMP.MATER OR POLE INST. COMMERCIAL'
6 W o y that he is exempt therefrom and IM1e basis for the alleged exemption.Any violation of 0 NEW BLDG/AUDITION 0 DEMOLITION
i4C1 V•
Section 90315h applicant
tfor a peon subjects mevpplicem m a civil punulty of POWI7R DEVICES
rn hundrddomfma ermil suhj OT ANT El FOOD SERVICE
mol mitre its(owner
five hundred ROVEMENT
C Q ❑ Lo(he work,and
the the
he pcny,or remyemntended with wages estheir(Sec. 044,Rwtinn, SWIMMING POOL ELECTRIC100 THER
2 Fs will do,hework,and theme Co na is tee's ended orolw doesed not
apply to an.owner of
"^m and Pndessiolu Cod..The Ga,lopor's License Law dues nm apply himself owner of OUTLP.I'$-SWI'TCIIHS-
Fy1,3.. FIXTURES
propcny who builds or.den thv thereon,andve a dcont,m a work ednrrrsnngh
his own oweveroca,pmvlded thus such ment is old within thin not intended or offered for NEW RHSIDBNTIAL ELECfR SQ RI'.
owner-hewevea the,,he linden of vemenl is at hedidon build
or improve for the SQ.PF.PLOOR AREA 5/SQ.RI'.
�oiter-builder will hove IM1e M1UNen of proving that he did not huiW nr improve for pur-
ae tufxme.>.
❑ 1,as owner of the Sea property.,B exclusively contracting....a,wire licensed Can,... , TOTAL:
,nalnel me pmjem(sans 21ua,Btuxmexx and Prereaainnx ere:)TM1e cenlmelmr'x u- _
use Law does not apply to an ownerofprepeny who builds Cr hnpmvec thonam,and QTY. PLUMBING PERMIT FEE
who contends for such projects with it coma civabd licensed pursuant In the Coraacla"
License law. PERMIT ISSUANCE
0 1 am exempt ander Sec ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLAIIAT'ION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following declthatioos:
I have and will nommumo a Cenificamof Consult In,,&insure!Workers Compal- DRAINS-FLOOR,RO ISTORIP.S TYPE CONS'FkUCI'ION
smion,as provided for by Section 3700 of the LOMav
,Code,for the ps rfor re,of the
work Tor which Ibis pemlil is issued. FIXTURES-PCR TRA
0 I have and will maintain Worker's Com,emention Insurance,as required by Section
37000'the Labor Cedc,for me perf romineof the week fur which this Penni,is toned. GAS-EA.SYSTF.M-11 . OUTLETS
OCC.GROUP APN
My Worker's Cnmpencminn Insumnec certier end Policy numlxr are:
Carrier: Policy Na: GAS-EA.SYSTEM-0 (EMIR
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRI. TF.INI'F.HCEPTOR
(This section need not be completed iDhepem,it is faronehundred dollars($I W) BUILDING DMSION FETES
mrlcas.) GRGASHTRAP
PLANCHECK FEE
I cenifytha,in lhuperfvrrearce oftlework frrwhich,hlsperinit ix issued,],hall SEWER-SANITARY-. rd08FT:-
notemployanypersoninanymannersoastobeema subject m the Workers Coupon- ��� ENERGY FBI.
z salmon La a f Ca64nllfa OMC
C) Applicar �x C WATER IiCATtik WNENT/ELECTR GRADING FF.F,
rt .N.
NOTICE O APPLICANT:iF,after ten ng Isis enifica a of Exemption,you should WATER SYSTF.MCEREATING
Iss ume subject to the Worker's Contpunsomon provisions of the].shot Cade,you muss SOILS FEE
mithwimcomply with such provison—,Ibis permit shall be deemed revoked. WATER SERVICE
WW
Uz CONSTe is eco NLUNDINGAGENCY NEW RESIDENTIAL PhMH. 50.FF. PAID pate Receipt#
Q I hereby oBhm,saber i isaumnmc,ipu lending agency for performance of
LIa
the work for which this Fvnnn is issued(Su'w.3f199,Civ,CJ
Q U
Leaders Name TOTAL Ixudeds AdJrcvs IOTA.:
G1 Benny that I have read this application and state that the above information is BUILDIN P.P.
Z? correct.)agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FE
f-t SEISMIC
C.J � building cnmwction.and herehy amhoria rcprcsenm,ivos Cfthis eitymenmr upon the
above-naurmad propcny far inxpeaion purposes.
(We)agree m save,indenmily and keep M„mless the City of Cr,cdia.agnlnsl PERMIT ISSUANCE ELf?C IC
limalums,judgmentx,costs and expenses which may irony way Scene ogainst said City ALTER OR ADD TO MEOH. PLUMBIN ISE O
in consequence of the granting of this permit.
APPLICANT UNDER,IANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO f000CFM)
SOURCF% � T(OVER III,
W ATIONS. MF.CHAN CAI.FEE
`` AIR HANDLING UNION)CPM) ION TAX
CONSTRU
M
Signature of Applimmt/Contras r Dam EXHAUST HOOD(W/DUCT) HOUSING TIGATION FEE
HAZARDOUS MAI ERIALS DISCLOSURE
Will the applicant or future building ormupnntcmfe nr handle hamular,matin is] HEATING UNIT(TO 100.OLO BT U)
as demand by the Cupertino Municipal Code,Chapter 9.12,and the Heallh end Safety
Code,Section 25532(a)1 IIEAdINC UNIT(OVER 100,00 RTU)
❑Yes
VENTILATION PAN(SINGLE RES]D) PAID
Will the applicant or future building occupant use equipmenl ter device,which Date Receipt#
emithaeeNous sir eomaminama as tlefineJ by the Bay Area Air Quality Management BOILER-COME(3HPOR I(NI,(NII)BTU)
TA
Uimrictl
❑Yes C;1gola BOILER-COME(OVER laity IDHU)T'
I has,read the harnmlous mme,iak requirements i der Chopnr h.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
form,Health&Safety Code,Sections 25505,25533 and 255311 understand hard the NEW RISIDCNIIAL MECH. SQ.UL
"I 'and
snml cunenly hove atenan[,that itis my rea,vourbilay m notify IM1e occupant
of m're Ir ,emwhichmust emelp' miaaaanxc tura Cenificmo aCOceupvncy.
Owner m authori rd a,mat Date TOTAL: ISSUED BY:
OFFICE