S 2866 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING-ELECI'ISICAL PERMIT NO.
BUILDING DIVISION APPLICATIONA'ERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDE.NrIEICA'I'SON
BUILDING ADDRESS: ? ::SANITARY NO. APPLICATION SUI3MIT1'A DAT Ii
00 O 1Ju �D �P9
OWNER:SNAME: PHONE: CONTRA OR:S N({�f/�/j (� LIC NEE NIC CONTROL#
Ili
ARCIi1TELT/F.NGINE[R: LIC NO: ADDRESS: ❑
�
- S-�
CONTACT. PHONE: 7>11/ BUILDING PERMIT INFO
• �� / ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT LU❑MH ME❑CH
29,�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under prrvinarS Of Chapter 9 mancom rte as JOB DESCRIPTION
"ZO with Section 7lgB of Division 3 ofthe Business and Professions Cas,and my license is RESIDENTIAL
�F PERMITISSUANCE
'n full farce and eff 7 Q '� CSFDWL ❑KITCHEN REMODEL
gut License2' Lic.# c APPLIANCES-RISIDENIIAL CADDITION C3 PLUMBING RE-PIPE
F Z u] pros TS DEmr
y¢a El MULTI-UNIT ❑STRUCTURAL
ARmull hi Cove DECLARATION
F p sn PANELS MODIFICATION
Z O to Z 1 unJerstunJ my plans shall 6c uxJ as public records /
OZ—O UPT0200 AMPS 2a f:1 INTERIOR C CHIMNEY REPAIR
Fin Ir4 Liceracd Poemssi...I 200400AMPS IMPROVEMENT []SWIMMING POOLS
yX
OWNER-BUILDER DECLARATION OVER Iq7 AMPS []BATH REMODEL/RI?PAIR []DEMOLITION
KK a I hereby affirm teat,tun excmpt from the Contractors License Lnw for tlta
L O y U following mason.(Seel,.7031.5,Business and Professions Code:Any city oT county SIGNS ELECTRICAL CGTHIiH
3 LL y which requires a Permit to conswm,alter,improve,demolish,or repair any structure
Poor,.its l,aamec,alw,mgmm,the applicant forxuch permit,,fia.'ignednmtcmem SPECIAL CIRCUITIMISC.
�} mot he is licensed amum
nd in me pOoOi,iu.,mar,Cnmemr's License Law(Chapter 9
LLaCNO
(committee.,with Section 7g7)of Vivien Sof he Busincssand Professions Corn)or 'TEM P.M ETER OR POLE I NST. COMMERCIAL,
4 y CL Wm be is exempt therefrom and the basis far the allege)exemption.Any violvtion of - ❑NEW BLDG/ADDITION C DEMOLITION
W oo Section 7031.5 by any applicant for.,peorrasnhom,me applicant to Or civil Pcnalryor POWER DEVICES []TENANT ❑FOOD SERVICE
Cm more than live hundred dollars($580. SWIMMING IMPROVEMENT
A=C []Las nwnend(M1e pmpcnYor my cmpinyceswi(h wages ns their sole ntmpenv(ion. 1`001.ELECBIC
F will do the work,and the,matim is not mooded.ndfered Rsrxalu(Sce.700,Business ❑OTHER
63 and Professions Code.Tbc Commmm's License law loco not apply to an usner of OUTLETS-SWITCHES-IgXTURE
propcny who builds or improves therem,and who doses such work himself or through
his own employees,provided rout such imprrvemcn(s are not intended or offered for NEW RESIDENTIAL ELECTR SQ FL
svlc.If.hO O,O,,the budding nr improvement issold with,.one ye:vof euratntuan,the SQ.FT.ILWkARIiA EISQ.Ff.
cone,-builder will have the burden of poising that he did not build or improve for pur-
Imse of sale.). -
I,an ow net of the Property,am exclusively wnuacting wah Iimmort emarecmm to TO AL:
oncost he Or jwt(Sec."Ewa,Business mad Professions Code:)TIO,C.mmnnr'x Li-
censeLaw does not apply utall nwnerofproperty whanhild.or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a comrtaor(s)licensed pursuant to the Contractor's
Licenry law. PERMIT ISSUANCE?
❑ tem escape ands See ,1&P C far thi,asion
ALTER-DRAIN&VENT-WATER(BA) VALUATION
Owner Date
WOR K[R'S COMI'ENSA'TION DECLARATION BACK FLOW I'ROi'ECI'.DEVICE
1 hereby affirm under Penalty of Perjury one Of the fallowing declarations:
I have and will maintain a Certificate of Consent to self-insure for WmkcFs Camps.- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
satinn,as provided for by Section 37M of the Lader Code,for the performance of the
work for which this pemtit is issued. FIXTURES-PER TRAP
0 1 have and will maintain Worker's Coasensatian Insuranm,as required by Senion
3700ofine labor Code,far the amforminam.fdo,work dim which this permit isissued. GAS-FA.SYSI'EM-I INC.O OUTLETS OCC.GROUP �APN
My Wor I...atusumLLee�carierand Policy nwnitey OO,y�/7 GAS-EA.SYSTEMOVt i(I?A)�.�--"'"
Carrier. PlXII ED""No.: LYA O t
s CER'f11IIAT_BOIrI F.MI'fIOI FROM WORKERS' GREASE/INDUSTRIWA.M 1N1TRCEPNR
COMPENSATION INSURANCE BUILDING DIVISION M-IS
(This sermon need not be completed iDhc lwmtit is fonmc homdmd J.Ilnm'(EI00) tst
� ur less) GREASE.TRAP � — PfANC11ECK FEE
l cavy that in the performance ofthc work forwhich this Perini(is issued,l shall e" T
.mem to non in (o bwnmc subject ,,the Workers'Compen- SEWER-SANITA STD F.A.R(7 Ff. ENERGY FEE
p yany,w any as
ZZ satinn Luwhof Califnmia.Dam WATER BEATER WNEINGISTECI'it GRADING FEE
Applicant
NOTICE TO APPLICANT:Jr.after making this Ccommate of Exemption,you should WATER SYS'HEM R-r Y SOILS PEE
h Mesme m1noc,nine Wmisee,Compensation pmvidom of the L.wr Code,you mus(
WEmhwith comply with such provisions or this Permit shall be deenmd revoked. WATER SERVICE
A CONST'RUCfION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
UOIhcrtbY'uflnm that mere iseemawc(ion lending agency Eatheperommtnceof D'et Reccip(p
{Lt— are wmk fnr which oris permit is ismed(See.3007,Cie.C.)
O U Lender's Name TOTAL
Lemdcix Address TOTAL:
y 1 certify thm I have real Nis application ad tate that me aMwc information is BUILD. .PER
J,, comet.l agree to emaly with all city and sou.tyomdimancus and stem laws relating m QTY. MECHANICAL PERMIT FEE SE?ISMICI
U Z buildinon
gcstrucam tr cifiyour nolTivesa It is et -.ter upon the
abase-me pmpeayf moon# ossa. TERM ITISSUANCE ELECT PEE
e)agree( e,indermly an 'rep hamaOss the City of nino against
abilhiesjud ts.cm,ai idle, s which nay many cony a a againstsaid City ASTER OR ADD IO MECIL PLUF1 ING FEE
onscya eofthegmmim is recruit.
APPLIC 'LINGERS . )SAND WILL .Y WITH ALL NON-POINT AIR HANDLING UNIT M)10,87 CFM) MEC11 ICAL FEE
SOURC iRF.GUL IS.
.5119 - AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
amreO A,,licanVCommmor Dam EXHAUST HOOD(WMUCO HOUSINC MITIGATION FIRM
HAZARDOUS MATERIAL S DISCLOSUR.
Will the applicant ar future building occupant state or handle baumdaus maimed HEATING UNIT(1010,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Sol'ety HEATING UNIT(OVER 100,000 BTU)
Gds,Section 25532(.)?
0 Y., VENTILATION FAN(SINGLB RF,SID) PAID
Date Receipt#
Wal the applicant ,furore building(Xcupant use equipment or devices which BOILER-COMP OLTP OR 110,000 BTU)
emit hautrd.i tmntemMaRIFilF'tle fined by the any Ana Air Quality Management TO 1.:
Disric r BOILER-COMP(OVER 107,001 BTU)
0 Yes
I have reall, as mumnid moments under Chapter 6.95 Of he Cali. AIR CONDITIONER / ISSUANCE DATE
�x
..is Realm& Coda Sect 505,25533 and 25530.1 undemand(ha irme NIiW RESIOIiNT1AL M i H. SQ.TE C/�
buddin oacanena a tenant that h is my espnnsihilirymnrnify(he � l= 7 /
requimme tc mustheme(ptimmissuancenf a Car f ancy.
cone nr..,ha iced agent Oa¢ TOTAL: ISSUED BY:
OFFICE