S 2011 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO TUMBfNC.-MECH NICA glT No. 2011
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT
IDENNICAE
ItI111.DING PROJECT II11i:V9'IF'ICKI'ION
SANI'fANV NO. nPPLICAf10N SUI3MI'I'IAL DATE
BUILDING ADDRESS:
tqog Old �� COty'I'u TO R'S RO p.( ��'� LIC NO:
!lila.''.- NIC CONT Rol.q
ARCIII'TCf/ENGINEER; LIC NO. ADDRE;S!k ❑
CDN'22C'I' PHONE, BUILDING PERMIT INFO
1e ��n ❑ Coladniout Fees Paid by Applicant(Initial) BLDG ELECT I-UM6 SIECH
1'A -ZS3 - (, Z� `1 1:10 ❑
LICENSED CONTRACTOR S DECLARATION Q'rY ELECTRIC PERMIT FEE JOB DESCRIPTION
I li after R but I licensed L provisions- of Chapter 9ler n Outliving
"Z wlhS i Soap lD 1 fore Bea 11 rxsiotscodcand an,license RESIDENTIAL:
tis U O PI;ItMIT ISSUANCE.
N in rail fora and Jiee1. ❑SFUWL ❑KITCHEN REMODEL
aU-U License Claw Lie of I- L
U APPLIANCES-RESIDENT'InL ❑AUDIT'[ON ❑PIAMHING RL-PIPE.
FZtal loam CaircrTSDEler
r'Qp, ❑MUhI'I-UNIT ❑MOLIFICAMO
ARCIII'l1iCT'S DECLARn'l1pN
URAL
F,❑m> PANELS CHI ICA'fION
O ztoy.�.F undersand try plans mall he used as public records UP'10200 AMPS
zog ❑INTERIOR �CHiRIiV kEPA1R
F�,N]W Licensed Pmfessionui 201-10a)AMPS IMPROVEMENT IMMING POOLS
�,-4 OWNER-BUILDEk DECLARATION
yY .J OVER High AMPS 11 BATH RI?MOUEUREI'AIR DEMOLITION
1 hereby affirm that 1 um unapt front the Contmcter'.v License Law for the
U n.U follawing reason.(Section 9031 5,business and Prolc,cei se,Coda:Any city nr county SIGNS ELIiC"CItICAL O�LR
ae Wy which rcyuirex it pranut to rnrtprueL tiler,interned,demolish,or repair any ntactare
.F.N�< prix t t also 4 - ,'be dedicatorl h peridelt file a signedsratement SPECIAL CIRCUI'1'IMISC. -
��yy
that lie is licensedecoolant It,the provisions eftM1 Controller's labeled L (Chapter 9
ThMP ME-I'ER OR POhE INSI'. COMMERCIAL
{ye�� conarrovngwn
Lin Division 3 of the Bus' u'e and f f ` nsCode)or
G y y that he is exempt thercfmnt and the hncis for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
W..0 Sccaon 91131,5 by any applicant furs oenmt subjects the applicant to it civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not marc than live hundred differ,,500). IMPROV HMEN'f
��+d I...owndr of my n,am In ccs with wit nc thvir.nlemon Gen, SWIMMING POOL ELECTRIC r
�9G pmpc Y YemP Y 6ce erne ❑OTHER
W � will do the wnrk,and fe.nachare is ant atemdedoruffemd unsaid(See 9014.Business
and Professions Code:The Contractor's License Law docs not apply to an owner, nd OUTLETS-SWITCHES-FIXTURi3S
3� prupi whit builds or ingprovec thereon,and who docs such work h neat or hrough
his awn employee•Provided that such irepmvementx are not intended or ar d for NEW RESIDENTIAL ELECT R SQ Fr SQ FT FLOOR AREA S/tip.FE.
sale.If,however,the building or impmvemcn isxold wicaut as yetnf cmnplc.ion,'hu
crbulder will have the burden or proving that he did not build or attorney liar sur-
or
.l
p fah pr,,,,',. I- Iy I t g 'thl J t t oto
ort tthpj .(S 9fW3Bs dPl '. Gd )'rhG t's ,
verel Laa,doc,a,,,apply t f property h brojob,or inipalve,thereon, d QTY. PLUMQING PERMIT FEE
wM1 tuts for such l yucwith elaborations)lcesed pnuae"thlC actors
Users,Law. _ PERMIT[SSU CF. / Y
❑ lam yxet under See. .13&1'C nnni'n t
AUGER-DRAIN Nr VENT'-WAT[R(EA)./ - nTION
� D _: (
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby spatial under Penalty..f pe Juryane ofthe ellfollowing dcdn C...
Ihuve and will
edfor by eGnipdme of the Labor
scales rcfiturcualle II'd DRAINS-PLOOIt,RUDE.AREA,GOND. STORIES T 'CONS'I'NIIC'T[ON
,at 'p 'IJf by i 19W fah 1'b 'Cd d lifep f folie r
0 1 have
ti this R t'. J I IX TURES PCR'IIiAP �
II I will t Workers Cooperation required byS ton
39lfarl the hnhnr Gde.lnnhe eerfurnauudthe work t' heli olio'serol Y.-..ted. GAS CA SYS'1'P.M-I INC 4OUTLIiTS OCC.GROUP APN
My Woo ker's Compensation Insurance wrier and Policy number are
Canoe PolIll No: GAS-EA.SYSTU -OVER4HiA1 /
CERTIFICATE OFEXEMPf[ON FROM WORKERSGREASUINOUS"TRLWAS'1I7IN'FCRCEP'i'OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(I'hixemtion revert...becontrolled if the penvit i.fur one hundred dollac(5100) :ASE"TRAP
or le"')(*lot IIiE
I cunify that In the petlobbanct,of the work far which this permr is issued,[shelf SEWER-SANITARY-S'IORM EA.20OFT,
I employ any lw. nnya ncr sa as,,free ore.ub3eeuuthe Workers'C^mpen- ENERGY I'13E
t nn in tun '
Z setinn linea nl'Culifornin.Date WAFER HEATHR W/VENT/ElAhmR
z O Applicant ' GRADING FEE
NOIICH"EO APPLICANT:If,afar balking this Certificate of Exemption,you should Wt'I'L'It SVSTEMI]REATINC
V] p SOILS IPI7
a �
hereon,subject to the workers Cuoupoessionpmvisinn.ofthe Labor Code youna,q
a a,y donhwula conoely..'It such prel"or ou nr IM1is permh shall nc ddcmeJ rcvnkcd. WA HK SERVICE
Q
CONSTRUCTION LENDING AGI7NCY NEWiRESIDEN'UAL PhM13. SQ.IT. PAID Owe k ci t#
1 I'd",'Oh.hxnherei'aupmanamn lending agency for.he perfarrnancyod D
U
0 the work for which thea Ixrbait'e'nwetl(Syn 309],Cit,C.)
TOTAL
OLenders brand I
U Lc J Ado TOTAL:
Hd I udythat Ih adth'. 'epi . daft O'ithe ab i f ' s BUILDING FEE
Z "arre, 10 . ny II ''lyand ry d' I:.. I EE boo QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V Z Funding construction,and
on.an lhre by confluarrid rquesentativescl O:citytowncr upon tbu
vnuvu^mntionW pmpeny fill inspection propose'. FERMI"C ISSUAN . ELECTRIC FEE
(We)agile to all,endcmnify and keep hannle's the City uI Cupcdimr agvins r
fabilhic,piqumnts.cosh and cxporcv,which Tay en any wary no,
uguinxI Cny Y' ALTER OR ADD' 1CH. PLUMBING FEE
in nxancnee ad he ganGrg of Oi,Peru,,. 0.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING "EO lgoal CFM MECHANICAL FEE
SOURCE REGULATIONS
AIR HANDLING I (OV. NIF � 8 CONSTRUCrION'I'A
Signuwrc of Applicant/Contractor Date EXHAFFsrbodoi HOUSING MITIGATION IPE
HAZARDOUS MATERIALS DISCLOSURE s
Will the applicant or future building accurate store or handle involdaven.urial HEn'I'ING UNIT( IEd)III U)
n,dcHbcd ny the Cupertino Municipal Coda,Chapter 9.12,and the Hcul.h and Safety
Code,Section 2,5512(v)? IIHATING UNIT(OMI',atN) )
D Ycc 0N VEN'1'ILATIONPAN(SINGLER851D) PAID
vAir
oat karts.#
W.l,.,air be
rrumenurd h shoed by did Has
Arco
AirQmor Mairsocwhlch B)ILER-COMPL3HPOR L1f1.a)o H'IU)
tit haevnloux air atnamimtmx as refined by.hr,Bay Arut Au Quality Mnnvgancnt
District BOILER-COMPLOVER IW,NIO H'GO)
i]Ycx ❑No
l have rend the bvmrdouc maleeah fih under Chof vt• fi.95 the Cali- AI R CONId1'UONL'R ISSUANCE DATE.
dram 11r.J.b no Srfety Edo,Scannas ,than l e en3 and 25514.I undcsaund tM1nl 11 the NEW RESIDIiN'1'IAL MI3CII, SQ.PI'.
dradfingdoas ammo prior
it isayce Lot a ldntywnorfy.hcoco, ( Qr
often rruniren,at.which ma,a�mdt sealant i�enertrd of a cenrewm erokepandy.
0,acrorind cold agent IJam 'I'DEAL: ISSUE])BY:
OFFICE