S 2374 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO mHLDING.ELECTBICAh veHMn'NO.
BUILDING DTVI' N APPLICATIONMERMIT PLunnnNG-NIECHANIC], S 2374
IIUILDINO I'ItOjiiC1'IDI:N'i'IF'I"I ION
BUILDING ADORES - SANITARY Nf I. APPIJCAIIONSIIBMITTALDATE
� 4, 4 ��sa�s 30 5'
OWN NA .: PHOMI: CO C�D N.MF C LIC Na: NIC COM'ROLN
2<9
t ❑
IARCH['I'ILCI'/i?NGINHP.It: LIC NO: UI il?S5
CONI'ACI': PHONE: 6U ILDING PERMIT INFO
❑ Consultant Fean Paid by Applicant(Initial) BLDG qxg PLUMB MUCH
1:1 ❑ El
CONTRACTORS UECLARA'HON Q•py •ELECTRIC PERMIT FE o
1 hereby alHrm that 1 am licensed under prnvieinm of CR m
Chapter 9(comencing JOB DESCRIPTION
1, wife ScentsagM)7 of Di.ixion3nfine easiness and Profe.xions G.le,and my license i. -- �'
RESIDENTIAL
YIQD �+ I'EHAfIT ISSUANCE C]
FBF to full force anile o. w a ❑SFDWL (I KITCHEN REMODEL.
qq U License 'It Ll�Lic.q
6- U API-LIANCES-R[.SIDIiN'HAI. [,]ADDITION ❑PLUMBING REPIPH
FF..L Dem TSCiteDFzCL
tn6a - ❑MULTI-UNIT' ❑S'1'RUCfURAI.
ARCHITECT'S❑ECLAIt Acords -
g,pm I'ANIil.S MODIFICATION
Z p T Z 1 undeestand my plans shall leaned as public records
o y�,O - UP T02(XIAMYS O ❑INTERIOR 11 CHIMNEY REPAIR
F�t:W I-wensN Professional 2014000AMPS - IMPROVEMENT 0SWIMMING POOLS
gtie 5-i OWNER-BUILDER DECLARATION OVENIN AMPS ❑BATH REMODIiI REPAIR ❑DHh1DLITIGN
Iy� I herchy affirm thin].,in exempt Crum the Pomaceous Liccnxe Law for the
iWWiyy t7 W U following tmsun.(Section]031..5,Ilusineas a¢I Isrotesdons Ce d:Any city or uwtnY SIGNS HI.FCTRICAI. ❑01 HER
which requires a permit to construct,inter,inmrove.demolish,or repair any structure I'w
J prior to its issuance,also requires tie applicant for.such permit In life.signed statement SPECIAL CIRCUIT/MISC. ^
f } that he is Inowef nmm
pursuant the provisions of the Cocmis License Law(Clulmern
W^p0 (comm�encingwith Section]1X10)nf Division Ldthe BusinesanJ Professions Code)it TEM P.MER OR POLE INST. COMMERCIAL:
6 4x p�' Ihut he is exempt therefrom and the basis fit the tmeged exem a i.Any suds inn of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^wnSeen ot more teat lac hundred Jnllurc(SS1MH 'n objects the appl'manuoa civil petudty of POWER DEVICES ❑'DWANT ❑FOOD SI?RVICIi
y any opplinw fill a Pcrm
L-Z6 1.as owner of the ro rt.orm loco with woes as their sole cons tion, SWIMMING POOL ELECT RIC IMPROVF:h11iN'f
��o ❑ P Pe Y Y e'nP Y g penva
will do the worA,and the structure is not in¢ndnl or nf(ereJ for sale IScc.]I/N.Business O 1ER
W m and Pmresaimvs Cade:The Ci mracmr'x License Law does not apply to an owner of OUTLETS-SWITCIIIS-FI%'I'URES
progeny who funds or improves thereon,and who does such work himself or through
his own entpluyccx,prnvidcA Ilett smelt itnprn.enuenlx am nor IlnmWed or offered for NEW RESIDENT AL 1:1Fi-I R SQ PT.
sale.If.however,the buddintor lmpm
rovcedkited within no yeaOd completion,the SQ.lel'.FLOOR AREA S/SQ.lel'.
ser-huilder will have the burden of proving that he did nm(wild or improve for put- '
Iwae of sets.). -
p 1,as owner of the tragedy am exclusively contracting with licensed con mctom to T Al
construct the project[Sea 7044,Business and 1'mfessions Cale:)The Contractor's Li.
remso law dors molopp.yto un ownerror property who huihh or mpruves thencn,snit QTY. PLUMBINGPE'RMIT FEE
who contracts Ibrxueh pmien'ts'with m omacncle0t)licensed puna un (,,,he Core..t,'s
License law. - PERMIT ISSUANCI?
❑1 ant exempt under Sec. .R&1'C far this reason
ALTHR-DRAIN&VENIT-WATER(1?A) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I h rchy nlRrm Or,Pcnahy of petjnry is of the rnhowittg dcclumanns:
I have unit will maintain a Certificate of Con.mnun self-insure for Worker's Contpen- DRAINS-FLOOR.ROOF,AREA,COND, SIORIILS T'YPECONSTRUCTION
tion,as Provided for by Section 3700of the IaMtr Code,for the performance of the
work for which this permit is issued. FIXTURES-PER MAP
❑1 have trod will maintain Worker's q.mpcn.smlon Insurance,as required by Sectio
3700o1'the Labor Code,for the performance of the work for�whyiych this Perm�riNt iv issued, GAS-F.A.SYSTHM�I INC.4 OUTIJIIS OCC GROUP APN
My Wo C, npensminn�w Policy
Ne dg-A� �1za9 GAS-EA.SYSTEM-OVER 4(EA)
nim yyy 71
��m.d,ry k �M r is Pnliey No�lu
CERTIFICATE OF 17XEMMION FROM WORKERS' GREASIUINDUSTRLWASTE HHERCITI'OR
COMPENSATION INSURANCE. BUILDING DIVISION MES
(Thiseectimn needrm tteatmplemelifthcpcon,isfor nnchundrtddollatsOHXq GNI?ASE TItAI'
or Ins'.) PLANCHECK FEB.
Iamilythal in due,mhmnnnccnrthc work on-which this Permit is issued,.soft SEWER-SANITARY-STORM FA.21X11-1
not employ any Person man
n in oily ner so ns to twee im.cubject m the Workers'Confer- 1?NHRGY FBH
O z .mion laws of Cvlifnmim.Dme WATI7R HEATER WNEN'DELECI'R GRADING FEL?
z 0 Applicant
y NOIICE'ITt APPLICANT:IL a0cr making this Cei ificam of Exemption,you should WATER SYSTEWTRENHNG
F becmnr xt,hjecl In the Worker.Cnmpe...iin(......ions of the labor Code.you must SOILS FEE
.�j for o,kh uontpfy with such prov.sions or this I'cnnit shell be decnred revoked. WATER SERVICE
YY Q
Flt CONSTRUCTION LENDING AGENCY NEW RESIDENT Ai.PLh10. SQ.FI'. PAID
UO IM1erthy affirm thenhcrc i.aconxtrvainn lending agency l'nnrt
he pe.fanunre of Date aciptN
wFthe work for whichthispcmtil is is wed'(Sec.3097,Civ.C.)
I mach Nome TOTAL:
LULeader's Address TOTAL:
y I cenlly'lent 1 Buse real this epplicntio i unit some tout the ahove mfomtminn I-s BUILDING IPH
0 corset.l agree m comply with all city and county ordinances unit state laws relating to QTY MECHANICAL PERMIT" FT-R
V z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection pugw.cs' 141: MITI ISSUANCI?
(We)eg.c to save,indemnify and keep harmless are City of Culenino against 1.1.13M RIC FEE
liabilities,jndgmenis.coslsnndexpen.es which may in anyway uceme against send City ACTHRORADU'I'OMI?CH.
in saPtem'e of the granting of this pmntit. I'LI1h1BING.Eli
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 IH(XXICFM)
SOURCE H[C ' TIONS. MBCIIANICAL I'lili
AIR HANDLING UNIT(OVER 10,000 CPM)
e G CONSTRUCTION TAX
SiCnmureol' plicanV�r�s Date 1?%HAUS'f HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or home building occupant store m ournle hazmilouseraterisl HEAL ING UNIT.TO 100,000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12.and the Health and Safety
Code,Stenon 25532(.)! III?A'I'ING UNIT(OVER 100,1103 HTIJ)
Yes ON.
_ VI?MI'l1.ATION PAN(SINGLE RESID) PAID
Witt the air tomonl nr loam Briding tampons use co Am- a or devices which
'COME
Date Rnccipoa
emu hvuulnus air commnmants as defined by the BaY Amt Am-Qunllty Managunteno 11011.1iR-COMI'(9111'OR IIXI,IXXI II'1'll)
District?
❑Yes ❑No 110111iH-COMPIOVL'H 100,0000TUI
AIR CONDITIONER
I have Suet hamrdouifirm,dxtcquimments under CMtpterd95nfthe if Pu ISSUANCE DATE:
fomla Ilrrtl0t&Surc'y CuJc,Stations 255315,4$$99 noel 25534.1 undcnwnJ that if Ilio NHW ItESIDEN'f1Al.MliCll. SQ.Cr. '
building do t)t 'c' hove tacos ,town Lannyce or a ibilitymnn'ify t not ���
of the ret 1E ttFts wh' 11 moat tw t prior ti's my msofn Cenilicad of ecu nt yq� r�
Owner art auth0riz +I Dae !` , TOTAL: ISSUEDBY:
OFFICE