S 2904 APPLICANTTO.FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONITERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANHARY NO. APPLICATIONSUBM(TTA.DATE
OWNERNAME: O ZONE: /�/ CONTRACTOR'S NAME, LIC
6 O/BY� �I/)/ N/C ONTROL#
'A CHITEC /ENGINF,F.R: LIC NO: AD IBES ^ // -_ ❑
M&OZ4Z2
CONTACT': PHONE: /L/�xnu JX.�7?J-�J BUILDING PERMIT INTO
❑ Consultant Peen Paid'by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED I am ON'TRACTOR5 DECLARATION QTY. ELECTRIC PERMIT FEE
1hereby afnmtthat1nmfthe Be owerpePsidt,oll Chapter 9 o,heve,ny JOB DESCRIPTION
X00 rh3ecJctudde7ofDivisinn3aforeBusin xandProfesslmcsGnl ana myliecnseis IDENT
F ntlull tome and eficet. PP.RMI'T ISSUANCE
'u, [.led or. SFIIWI. El KITCHEN REMODEL
HQL ()at, Commcmr APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
[-Dm ARCHITECT':S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZOn,ZU- Innderstandmydanv shall he used public records MODIFICATION
as puOZ-- UP TO 200 AMPS
Ucensed Pmlos,mnal ❑INTF.RIOR ❑CHIMNEYREPAIR
�,4
OWNERBUILDERDECLARATION 301-1000AMPS [I SWIMMING POOLS
6 .1 IMPROVEMENT
t4 X Q 1 hereby offrm deal I am exemia roam the Contractor',License Law oar the OVER 1000 AMPS ❑BATH REM EURBPAIR [I DE OLI N
yG.O a U following reason.(Section 7031.5,Nuaineas and Pmfrsrinnn Code:Any nhy or county OTHER 6
1- SIGNS ELECTRICAL
F�O,, which q pe mitt I r her p I lisp deputed,Turned, — TLC
p rA N.a4 prior to itsalso y luespiduratf h permit To file a signedstatement SPECIAL CIRCUIT/M LSC.
that le lice endp rse II hoplao,t,ums'Ift C a lu,"Liccnw,Lu (Chapter
Cw�gO g ThScel 7Uaq [D' sit 3 Tal Bu:nese and Prn(usions Code)In TEMP.METER OR POL9INS'1'. COMMERCIAL'
d y a a that he is exempt merchant add the basis for the vlleged exanpaina Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Seaion 70313 by any applicam fora pemtil Aubjer,the applicant to a civil penvlty of POWER DEVICES
color c hr five funded dollars($500) ❑TENANT ❑FOOD SERVICE
SSC ❑I,vs owner of aIle prapcny,nnny employees wish wages ns theirsnle cnmpet6vainn, SWIMMING POOL ELECTRIC IMPROVEMENT
will do tnework ana the zwcwa k no,intended aralfwed moronic(See 7044,Boston,A ❑OTHER
and Professions Cotte:The(Connector,License Law docs nal apply Io ort owner of OUTLETS SWITCHES-FIXTURES
property who builds or improve,thereon,and who docs such work Howl ...through
Ills awn employees,ponadrA nuttier improvements are or intradell or offered for NEW RESIDENTIAL ELECTR SQ FL
sole.If,however rhebuildingar inmom,loenr is sold x'i0in ane year of eontplelion,The SQ.FT,FLOOR AREA $/SQ.PC
wGec hailderwillhavetheandenofproving0aIhedidnetbuildorimproveforPar-
paaeatTole.).
A;Ill
1,m owner of the pmpcny,on exclusively contracting with licensed vrd mmnn In TOTAL:
ordloO the project(Sea 7044,Business and Pm[cssion,Coact)The Contractor's Li-
verse Law doe,not:tpply in at owner of pmpcny who hit Ids no i mpmvea thereon,and QTY PLUMBING PERMIT FE
who amvacts fersuch projects with a conoacmr(s)licensed purmana union Conrmewrs
License Law.
1 am exempt under Sec. ,B&P C For this reason all PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EA)
Owner Date VALUATION
W.order
COMPENSATION DF,CLARATIONlowing BACK PLOW PROTECT DEVICE
1 hereby affirm under putnhy M perjury one o(We following declarations:
❑ I have and will maintain a Cenllcate of Consrm m self-insure for Worker's Compro- DRAINS-FLOOR.ROOF,AREA,COND.
sarion,as provided for by Section 300 of the Lanar Cada,for the performance(if the STORIES TYPE CONSTRUCTION
ork for which alis permit is issued FIXTURES-PER TRAP
have and will maintain Worker,Compensation Insurance,as required by Section
3 (p ufrhe LaMvCode,for Noryxfmmancoof thewmkforwhirhnispermir isi,sued. GAS-EA.SYSTEM-]INC.4OU'FLETS OCC.CROUP APE
My Workc' 1 r and Policy O �/
Carrion[ T n Policy No.: J/(F fB/��Q� GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRI,WASTE INTERCEPTOR
(This section nerd not he completed if thepermit i.sformic hundred dodurs($100) BUILDING DIVISION FEES
or lc,,.) GREASE TRAP
PLANCHECK FEE
Imniny perhatson in
pedaearoa o the as 1.
whichthis
permit the W.kcs'Comian SEWER-SANI'T'ARY-STORM EA.200 FT.
net employ of penan in any moaner st as ar beconte object m the Wnrkert Cmnpeu- ENERGY PEE
O ,� Amino anws of California.Dare WATER HEATER WAIN DELECTB
Z Applicant GRADING FFM
FN-t NOTICE TO APPLICANT:IL after making chis Certified,of Exemption,you should WATER SYSTEM/TREATING
become subject to the Workers Compensation pmvhshore of the Laborn to,you must SOILS FEE
LCI forthwith comply with such provisions or @iec
s permil shall be dreed revoked. WAGER SERVICE
0. Q
CONSTRUCTION LENDINGlead AGENCY
� Z Ihcrcby uffmvhanhcrcisnamamcainn leading agency[urlbc NEW RESIDEN'I'IALPLMB. SQ.FT. PAID
gency perfnrmm�cc n[ in Receipt#
H+. � the work for which this permit is issued(Sea 3097,Civ.CJ
Lcndce,Name TOTAL:
V Lender's Addrev, TOTAL:
F a 1 certify that I have read too application and,tate(hat rhe shove Infamdion I, s BUILDING)'/
Ir 0 correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V building construction,and hereby authorize representatives ofins city m enter upon the SEISM( irEv _
chive-mentioned pmpcny for in,peu a r purpams. PERMIT ISSUANCE O
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELEA
FEE
iabiliales,judgments.costs and expenses which may o ally way aecrueagainst said City ALTER OR ADII'1'O MECH.
APPLaegnencT ofdhe granting of this permit. G FGE tl
ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIB HANDLING UNI'C(TO II1,W0 CFM)
SOURC IT., IONS. MECH FFA?
zM� AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION
gnaturenf AiTpm:InU)fmlrachn m EXHAUST HOODCV/IIUCT) HOUSING MITIGATION FF.F.
HAZARDOUS MATERIALS DISCLOSURE BOB
Will rhevpplieant or future bondinga"Unconaom or handle lemNdocollerial HEATING UNIT TO 100,000 B'I'C)
as dclined by he Cupertino Mumchel Coda Chapter 9.12,Iad the Health and Safety
Cade,Seaion 25532hiC HEATING UNIT(OVER 100,000 BTU(
❑Yt, Em
VENT[LAI[ON FAN ISI NO LE RES ID) PAID
r Dote Reeeipaor
Will the applicant intimae building by the occupant use ea Air Qu or Management
which
mitict? xvir contaminants Jefned by the Bay Area Air Quality Mnnugemum BOIL(?R-COMP(3HP OR 100,000 BTU) ^
Dlaviap 'TO CJ
❑Yes BOILER-COMP(OVER I00,0IX1 BTU)
1 have read Wo creation,mnteund,ruluimmenta under Chapter 5.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Ibmia Health&Safety Code,Sections 255-0�5,255�33 and 25534.I understand that If the NEW RESIDENTIAL MECH. SQ,FT. 4 Q q
buildmi,ol amu comeraly nh lhaV ny roaprmsmiliay m notify,the cecupalo (/1 ( /
of the requirements which mumh et ITri to ,mceofa Cenlfcamaf(keupancy. ../�
Owner or aahorued agent Date TOTAL: / Q
SSUEU BY:
OFFICE