S 2522 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD f;-FTECOUCAI, PHRMITN0.
Bu1LD1N ,DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL S 2522
BUILDING PRO11:CT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
S Zr� 1 -01
WNER'S AM': �_YIIONE: CONTRACTOR'S NAME LIC NO:
2y 17/ _ NIC CONTROL#
.IA fl' TIENGINEE /'fed LIC O: ADDIO S: a ❑
"0 e pYoto
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant FecS Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
TJ ❑ ❑ ® ❑
LI"'hia,D CON'1'RACI'OR'S )IiCLAHATION QTY, ELECTRIC PERM IT FEE
1 hereby affirm that I am licensed under provisions of Chaprer 9(commencing JOB DESCRIPTION
"Z with Section night of Division 3 ofthe Business and Professions Cale,and my license is
W O O PERMIT ISSUANCE RESIDENIIAL
H W fall t'nrcc am
I cIfc FDWL ❑KITCHEN REMODEL
aUV License Cl ss Lic.p APPLIANCES-RPSIDLN'iIAL ADDITION E]PLUMBING HIi-PIPE
I-Z W Date Cootmcmr
m-ay ^/Id� ❑MULTI-UNIT ❑STRUCTURAL
ARCIIIDECTS DF.CI t ON
l).7 m PANELS MODIFICATION
Z -Z I understand my plans shall be used as public recoNs
OZ—m UP TO 21NlAMPS I El INTERIOR [I CHIMNEY REPAIR
f~41— Licensed professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
Oed I ma exempt
DECLARATION OVER I(NOAMPS ❑BATH R MODEURI?PAIR DEMOLITION
W 6 I hereby.Seel tam I am exempt from the Certain,....minasCook:
License Law 6d.the ❑fTTHC
O y U following remote.(Section]0315,Business�ed improve.
de laminas Code:Any can x1county SIGNS ELECTRICAL u�
3 W vP'i pooch sissuance.
ssnein.u permit re uir sthe at�+,i t for ch
demolish,or repair nor arucmre CoA C'2 Z PN' I PA 11/'
g bionoi¢iensed Pan requires tthe pacculicao for he Contrarmiuuicensfile ae Law ned
SPF.CIAh CIRCUIT/MISC.
Cy ehmhcsociall oh Sectihurl(epmvi,kior3tdlthe Contractors License Law(Chap¢r9
��� (conheisting pt hereirom and The basis far the aleged texemton,Any vi Cndc)or 'I'IiMP.METER(3R POLE INST. COMMERCIAL;
II.Q. Thal he is exempt therefrom end the ba+is far Ihe alleged excmpinn.Any vinlmirn of ❑NEW BRAG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the uppiacant los civil penally of POWER DEVICES
p= imam...a mon live hundred dalla,($5001. ❑TENANT ❑FOODSERVICE Q D I,us owner of the pmpenY•mnn em In ees wi0t wa their sola,mr tion, SWIMMING POOL F;LECI'HIC ❑OTH OTHER 6A6A'' Y P ) gasses pens.
E. will do the work.and thesuumum is not Intended or offered forsde(Sec.J044,Business
W�m and 1'ndemions Cafe:Ihe Gmtmcmr's License Law does ern apply to an ,,net our OUTLETS-SWITCHES-FIXT RPS
property whit builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ
sale,If,however the building or improvement is sold within one year ofcnamcdon,the SQ.Ff.FLOOR AREA FT.
fISQ.
ownervhuilder will have the burden of proving that he did not build our improve for par.
pose of sale.).
`71,as owner of the property,ran exclusively contracting with licensed contmaora to O L'
construct the project(Sec.](144.human,send Profession.Code)]It,Cminemr's Li-
cause Law does not apply tocon owner ofpmpctywho builds orimproves thamnn,and QTY. PLUMBING PERMIT E
who contracts for such projects with a duromfori licensed pursuant o the Contractor's
License Law. "It RMI'(ISSUANCE
E)I am exemp under Sec. .B&P C ronhN reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROI-ECT.DEVICE
�� I bereby affirm under pc.all,.f perjury cant the following declarations:
❑rave and willmnthtale a Cenaficaeof Consent o self-ince four Worker's Compem- DRAINS-FLOOR,ROLE AREA,COND. STORIES TY['IT CONST RUCTION
smion,as provided for by Section 37W of the Loper Calc,for the performance of the
work for which this perms is issued. FIXTURES-PER TRAP
r'I have ami will muintam Workers Contpenunlon Insurance,as required by Section
3700of the Labor Gde.for lM1e performance ofthe work forwhich this permit .issued GAS-HA.SYS'I'Elm-I INC.4OUTLETS OCC.GROUT' MIN
My N'urkd II�� ti Ansuruq�ro mrrieroli Policy onto 7�-�..-s,/���
Currier: -�Jjy7P stn Policy No.: )- �y1L1( S�� GAS-IiA.SYSTEM-OVER 4 pin)
CERTIFICATE OF EXEMPTION FROM WORKEiHS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(T unwition need not ltecomplmed tons permit is for enc hundreddollars($III) GREASIi TRAP
our less) PL 11 ECK PB
Icenify Nm in the performance nftbc work(our which this permit is issued.lshell SEWER-SANITARY-ST ORM I.A.20014.
not employ any person in any manner so to bee �stb,Wt mine Werkeri Compen- tm�
satin.Laws l'�Cy�fomiu.Dalrl .� � � WATER HEATER WN1iNT/ELIiCI'R
O O Applicmt �r t `}, •��Ir
h NOTICE T( ,C :I(after;,.Mn,Nis Ccntficare of Exempuon,yuu should WATER SYSTr. BEATING
(~ become subject m the Workers Computsntion provisions of the Labor Cade,you must
forthwith comply witbsuch irmsim.mar this(Iemul hall Ise deemed revoked. WATER SERVICIi zCONS'i'HUCTION LF,NDINC ACCNCY NF,W HF.SIDF.NI'IAI.PLMe. SQ.FT. Receipis
U O 1 hereby affirm there is a construction lending agency for the performance of
W. f' Ihe work for which this permit is issued(Sec.3091,Civ.CJ
O U ' TOTAL:
Lcm1crs Name
Landers Address TOTAL:
{. G 1 certify that 1 have mad this application send ata a Ihim cm aNice information is BUILDING FEE
6.V1 correct.I agree to comply with all city'and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives of this city m enter.upon the SEISMIC PEI?
mace-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree at nava indemnify and keep hunmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way ucconagainst said Cary ALTER OR ADO TO MECH,
PLUMBING Il?E
inconsequence of the granting this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.100 CFM) MECHANICAL FEF:
SOURCE HIZCULA'fIONS.
\. /,��� ' ltQ,/�� AIR HANDLING UNIT ROVER IO,(NM)CIM) CONSI'RULTION TAX
Si pbcaml/Co 1,Wgf Dnro EXHAUST HOOD(W/DUCI) HOUSING MITIGATION FEE
HA'LARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupard mom nalmadle hazardous material HEATING UNIT(TO 100.0M)BTU)
m defined by the Cupenanu Mnniclpnl Cale,Chapter 9.12,and the Hcahh and Safety
Code,Section 255321a)? HEXI'INC,UNI T(OVER offoon it
❑Yes PJ Na VENTILATION FAN(SINGLE RESIDE PAID
—Date Receiptp
Will the applicant or future building cecupont use equipment or devices which BOILER-COMP(3HPOR UIDO X)BTU)
emit haaallous air contaminants as JefinW by Ihe Bay Area Air Quality Management T '
District? BOILER-COMP(OVER 100.1%X1 BTU)
❑Ye. 7 N T
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDI'T'IONER ISSUANCE DATE
fomia Health&Safely Code,Sections 25505.25.533 and 25534.1 endernmd Thal if tha NEW RESIDENTIAL MECH, SQ.17. T
bail gJoesnot currently h�veumna 1,that it is my responsibility to tify the occupant -7-`C
on n ememrw hj�ymhemet,5Orm.amanreofm Cenlacuy�f«p�ey.
V �7st LtLt 1 / {✓/ l
Ow tt mhoriz<J em
s' 'rnar� TOTAL: ISSUED tlY:
OFFICE