S 2271 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PEg flf NO 22 7i/�
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. J L 1
IiiJILUING 1'ROJECI'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO.]APPLICATION
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PHON
OWNS�S µl�. ^ , 1 Gb S3F^439 COM$tGACfOcrN .. f/ L�4sG.
IV•,/N J(C/Y_�aUM'^+_ l/L/ /('!/G
NIC CONTROL is
.�IA Cfil'1'CCf/[NOINfilik: LIC NO'. AGDZDpR S.Q�• S ` �( n• ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
CaA.'l� ��^�`/f' ❑ Consultant Fees Paid by Applicant(initial) BLD ELECT PLUMB _ MO)
LICENSED CONTRACTOR'S IIECLAIIADON G QTY. LLEC'1'RIC PERMIT FEE ®/
I hereby affirm mat 1 am licemed under pnwfuom of chapter 91commeneing JOB DESCRIPTION
Ooz with SccJnn]Ixlp)nf UivlsinnJ of the Bu%inas unJ l'rol'essinnsCodc.and my license is RESIDENTIAL:
WOO PERMIT ISSUANCE
F+W in full force end cRen. ❑SFDWL KITCHEN REMODEL
<—U License Class - Lic.p APPIANCE,S-RESIDENTIAL [I ADDITION LUMBINGRE-PIPE
NabDam Contractor
I-Dm ARCHITECTS DECLARATION PANELS [I MULTI-UNIT ❑STRUCPURAL
z O y z I understood my plans shall W used as public records MODIFICATION
Oz�O UPT0200AMNS C3 INTERIOR [I CHIMNEY REPAIR
[-4F'W Licensed Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
�yf,,...Il OWNER-BUILDER DF.CLARA'1'ION OVER Will)AMPS [I BATH REMODF.IIREPAIR ❑DEMOLITION
C 5 Q I hereby ofhmt that I am exempt from the Commetor's License Law for the
3 W F following reumo.Section]03 L5.Business and 1'nffessinns Coda Any city or county SIGNS ELECTRICAL ❑OTHER Y
yQ which n reason
permit n 03 LS,B cher.improve,Jssion%C de rcpoir any r county _ y
�,yOJ prior et it,issuance,at,.mri he applicant forsecb pemolm fileasignedsraremew SPECIAL.CIRCULUMISC.
that he is leensal pursuant to the provisions of the Contractor's license Law(Chapter 9
QO iroacncing with Section]000)MDivislmt 3oftire Biromea
sa ndip rofmsion,iCode)or 'TP.EMME[]!it OR POLE INST. COMMERCIAL:
f
W y o y that he is cxcmpl menfrom and the basis for the alleged exemption Any violation of NEW BLDG/ADDITION [D DHMOLI'DON
W200 Section 01015 by any applicam fora pennil,abnet,[lie atpplicanIt,a civil penalty of POWER DEVICES [-I TENANT FOOD SERVICE
not mon than five hundred Jolters(5500).
IMPROVEMENT
=Q ❑ Lottie owner k.the propeny,ormyemployees with ed munched
fes ou tele(Sc.7flel Businessr sole compensation. SWIMMING POOL IiLIiCI'RIC
will dmhc work.ands r,Contractors
License Law de fonet apply to a,o Business of �THER
and I'mfevinnn Code:The Commaors License Low Jrwx net apply n%an menet of OUTLIRS-SWITCHES-FIXTURPS
�'.. prol'eny who builds or improves thereon,and who does such work himself or mmugb
his own employees,provided that such improvements am nor intended or offered for NEW RRSIDENTIAL CLECI'R SQ ET.
sale.If,hawever.rhe building or improvement is sold within one year ofcomplerion.the SQ.FT.FLOOR AREA $/SQ.ET.
owner-builder will have the burden of proving that he did not build or improve for pur-
poseof wits.).
❑1,as owner of the propeny,am exclusively enntraeing with licensed cnntmcton to TOTAL:
construct the pnject(Sce.70,14.Business and P..Erosion,Crsle:)The Contractor's Li-
sense Law does not apply sit an owner ofpmperty whit build%or improves thereon,and QTY. PLUMBING PERMIT FEE
who contract far such projects with a contractors)licensed pursuant or the Contractor's
Ucen.0 Law. PERMIT ISSUANCE S
F7 I ark"coma under Sec. ,Ii&P C for this reason
5-0
Owner Date Al:rl?R-DRAIN&VENT-WATER(EA) VAIXAHON
WORKER'SmundeCOMPENSATION DECLARATION BACK FLOW I'N(JI'Ii6T.DEVICE D Ov
I hereby affirm mai under penally to to'Con one of elffollowingim declarations:ns: .l OJT
❑ Ihnvc and will maintains Certificate of Consennn ulGinw.the Workers Com,en-
cnic DRAINS-I%LO(IN,HOOF AREA.COND. STO IES 'TYPE CONS'I'HUCfION
smirk,os provided for by Section J]M of the Wbnr Axle,for Om performance of the (�
work for which this permit isiinker' FI%TURES-VER TRAP /• C�
❑1 hmthandwill maintain Workers ante ofthe w Insurance,as hhis Per by Section
3700 of the labor Cole,for the performance of the work for which this permit is issued. GAS-EA.SYSTFb41INC. OUTLETS OCC GROUP APN
My Wo a M w m fir and Policy nym�ar�
Cartier o m Policy Nn.:1ZZ796� 1 GAS-EA.SYS'IT.M-OVERi(EA)
CCRTI CATEOFE%E PTIOIS FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION pGf6
(Thissecrion need notMcompletedifinepemir is funmc hundred dollars(EI W) - -' ---
kw) GREASE'1'RAP
or PLANCHF.CK FEE
I certify that inthe perfomarmeeofthe work for which mixpemit is issued,Ideal SEWER-SANI'T'ARY-STORM EA.2011 IT.
nm employ any person In anymanner so am Ince a,subject to the Workers'Cor,vw ENERGY FEE
,Z union Lnws nl'Cnlifania Date WAI R 1I1?RI'IiR WIVEN'1'/ELECTR
OO Applicant GRADING FEE
ti N(YFICE'1.APPLICANT.IL after making this Ceniliwmof Exemption,youxhould WA'I'HR SYS'1HM/TREATING SOILS FEE
1�
We it,subject m the Workers Compemmian Pmvisiorr of the Labor Code,you two
Wti forthwith comply with such provisionsor,his permit shall be deemeJrevoked. WAFER SERVICE 0.00
0. Q
CONSTRUCTION LENDING AGENCY NEW BESIDES DAL I'LMB. SQ.FC PAID
Dam Receipt p
U O I f r which
manhere is o col(Set.30 lending agency fm the perfomance of
the work for which this .,it is issued(Sec.309],Civ.C.1
LL. F•' Lenders Name TOTAL.:
Lenders Address T
I
1 certify that I have mad this application and.ume that the above information is
� IzI correct.l agree rn comply with all city and county ordinances and state laws Adding to QTY. MECHANICAL PERMIT FEE /^�
U ,Z building contraction.andhembyaurhortm representatives ofrhr,city to anter upon the EISMI
ubave-mentioned ,,,,my for inspection purposes. PERMIT ISSUANCE
(We)agree to.save,indemnify and keep harmless the City of Cupertino against iLLCfRIC FEE
liabilities,judgments,costs and expenses which may in any way areme against said City ALTER OR A DI)TO MUCH, S. flI&Ot2
inconsequowoof th gm I Othis pemil. PL199,q
APPLICA 'tIN SRSTA DWILL COMPLY sat I'll ALL NON-POINT AIR HANDLING UNIT(TO If0g0CFM) MECHANICAL FEE
S :G .ATION.
e7 AIR HANDLING UNIT(OVER ROOF CFM) CONSTRUCTION TAX
Signature r ApplicaDate HOOD ted/DUCT)
HAZARDOUS
HODS
HAZARDOO US MATERIALS a storeO handl
Will theapplicam or future huilJin6 recupam x¢trc or handle hmardrus material HEATING UNIT(TU IBB.IXIO BTU) ,
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Calc.Section 255320)^ HEATING ON]F(OVER 100,000 BTU) y '�YY
[3 Yes ❑No VENTILATION PAN(SINGLE RESID) PAID am Z -2l•/
Will the applicant or future building occupant use equipment or devices which
emit haeardoes air caramel nanrs as defmcJ byme Bay Area Air Quality Management BOILER-COMPLIHPOR 100,000BTLE TOTAL.
Dm°fir^
❑Ycx C]No BOILER-COMP(OVER 100.000 BTU)
AIR CONDITIONER
1 Health
read the h ode,S s tionsriatterial,requlm33 an under Chapter 695 of the Cali- ISSUANCE DATE
lismia Ilcalth&Safety Code.Sections 25505.255JJ;mA 25534.1 understood that if the NIiW RI.SIUIiN'TIAh MECH. SQ.FT.
LuIlJing duux nm ntrmntly hove o tGlvnl,mm it is my rnspnnsihility w notify the nwupant
of mo tttp:ircnmms which most be met prior to insunna of n CenlHcmc bf Occupancy.
Ownenonauthorimdagcnt Date TOTAL ISSUED BY ZOc AA T -lice,
OFFICE