S 2948 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.CI'RICA L PERMIT NO.
I UI11)ING DIVISION APPLICATION/PERMIT PLUMBING..MECHANICAL.
BUILDING PROJECT LDF.NDF'LCA'I']ON
PDILDING ADDRESS: SANITARY NO. APPLICATIONSUHMI A DATE
OWN' NAME: 1'HO E: "W 01 OMR [R'S NAME: LIC NO: �^
`� NIC CONTROL#
,H 'ECDENGINEER: .IC NO. ADD ISS: �� ❑
CONTACT': PHONE: Z BUILDING PERMIT INFO
r. ❑ CBDsaHaB[Fixer;Paid by Applicant(Initial) BLDG� F:1 T PLUMB NISCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTERIC PERMIT FEE Lr✓✓ Lrfd✓" rW✓'
I hereby affirm that fare ficitned under provisions of chapter 9 Wmmnencing JOB DESCRIPTION
wo, with Section of Divisirns&dlhe Business and Pmfeeeinns Coda.an my la,crece, RESIDENTIAL: TCHEN REMODEL
E� in fullforcc and eIfcc y�7� PERMIT ISSUANCE T
U Lhene Clas Lia« ❑SFDW'1,
yea Dale "arna'ut. l4 APPLIANCES-It F;SEDF.N'FIAL [I ADDITION El PLUMBING RE-PIPE
AR HITECT'S DECIA I ❑MULThUNIT ❑STRUCf11RA1.
Z Fp H 7J. 1 understand my plans shall Is,used as p thlic records i ANELS MODIFICATION
O Z-a UP70200AMPS 1�//��
F 4 t W Licensed I'rore,slomad L/ C:1 INTERIOR ❑CHIMNEY REPAIR
<W OWNER-BUILDER DECLARATION 201-10XIAMP$ IMPROVEMENT SWIMMING POOLS
W 6 1 hereby alum,Lha I am exempt from the Contractor,License Law Eu the OVER 1000 AMPS CI BATH REMODEIIREPAIR ❑DEMOLITION
5 O G O following ninon.(Section 711.115.Business and Professions Coda:Any city or county SIGNS ELECTRICAL �OfHLsk
F LL 0 y which requires a permit ,,conari Iimprove,demolish,or repair any swnurc
prior to its issuance,also requires Ilse applicant for such p mento file a signed statement SPECIAL CIRCU IPFIMISC.
yThal he is licensed pursuant h,the prosmlone of the Contmamrs License Law(Chapter 9
WG0O (commencing with Section AXIU)of Division 3 of the satin and Professions Code)or TEMP.Mie TER OR POLE INST. COMMERCIAL:
3.a c�' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^
Section 703156an
yy applicantfor.Permit suhjccstM1c applicant m any of aciv:l pcnPOWER DEVICES m ❑TE NANTIMPROV ❑FOODSERVICE
not more ILun Evc hundred dol this S500). IMPROVEMENT
SSC i] do the work,and the Mutation
myemntendedwith erect ostnei((Sec.
01It mess SWIMMING POOL RLE
will do the work,and the swmum is not intended nroOereJ R,nale(Sec.]034,Business ❑OTHCR
and Professions GMs:The Contractor,License Law docs not apply m an owner o OUTLETS-SWITCHES-FIXTURE 3 e
L pmpeny who builds or improves thereaq and who Jces such work himself or tnmugh
his own employees,provided tom such improve an,are manicured icured or oRcmd for NEW RESIDENTIAL ELEC IR Q P .
sine.If,howeventhe huildingorimprovcment is sNd withinone ye,unfemareetion,the SQ.IT.FLOOR AREA MIR),FT
owner-builder will have the burden of proving that he did nm build or Improve for par
peel sale}
1,as owner of the property,am exclusively contracting with licensed convectors In T L:
msauet the project Se,,]044,Business and Professions Gde:)'I'lot Connector',Li-
serve Law devs not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who commit,for such pooped,with a cermi d licensed purain0o the Character,
License Law. :PERMIT ISSUANCE Iss rQ
I am exempt under Sec. ,B A,TC for this reason
ALTER-DRAIN&VENT-WATER IIIA) VALUATION
her Date
WORKERS OMPENSATIONDECLARATIM BACK FLOW PROTECT.DEVICE 15-100-0 S� /�a'1tT
000
I hereby affirm under penalty of p je: J jury one of Ne following Jeclastion
]Ihavc and will nmimainaCenifemeof Consvnn myell-inure fnr Wnrkxr's Cnmpen- DRAINS-FLOOR,ROOF AREA,COND. Sri ORIES TYI'li ONSIt TION
,alum,as pmvlded fin,by Seel:,)37)11 of the Luber Code,for the perh ra ancc of the O
hjur which IWs Permit is issued. FIXTURES-PER TRAP
❑.(Lave and will maintain Workers Compenmion Insurance,as required by Section
3700nf jjth.e lobe,Cale,fri perfroarmtanceyfofine work far
nt" �whfichh driepennl is issued. GAS-EA.SYSTEM-I INC,4 OUTLETS C Aj OCC GROUPMyWm3S_/-A7
a��A I�r�
Caooicrrlc) Cci y OaA ti.nl,loan-li-etWa cy IS nL1C L1� GAS-EA.SYSTEM OVER 4(EA) 3
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA'I ION INSURANCH GREASPANDUSTRI,WAS IE INTERCEPTOR
BUILDING DIVISION PEES
(This sec:ihn need not he completd if the peomit is lnrooehundeaddORats(SUE) GREASE'I'R 1
or lees) / T' I�I PLANCHECK FEE
lecrify that in the perf...harvest Rowed,lorwhicluhispennir is iecucd.l shall ti: P.R-4AIGIITAJi -STOIIM EA.B P
not employ any person in any manner so as to hi .Fact to the Workers'Comped- �I ENERGY FEE
O Z salon lawsifCalifnanorDate ER F N
O Applicant , GRADING FEE
ti NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should TER: .MORF.ATING
a , harem,subja:m the Wmkers Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such provision or this pamtif shall be deemed revoked. ATER SERVICE
Q
.0.ti. z CONSTRUCTION LF3VUING AGENCY 11ES ET. PAID Date Receipt«
LJ O Ihereby for%hi h thi that issue ScI,30lendie.agency for pcofmmanceof
Ur. the work Na which this path::,Is issued f5ec.304],Civ.C0
Q lenders Name TOTAL:
W Lenders Address T
q.
00 I certify that I have read this application and late thin the above inform:pion is BUIL. NG -Ji
hat
(A red.1 agree to eemlply with III city and county o din...ex and state laws miming to QTY. MECHANICAL PERMIT FEE
UZ building conerrvetion.andhereby authorize representatives offlis city roemeroponthe SEISMIC FEE
obave-mentioned property for inspection purpose, PERMIT ISSUANCI:
(Wel ngrec to elle,indearmiy mN keep handles,the City ht Cupertino uguinst ELECTRIC 'I?
Iiahilities,judgmenrs,costs and expenses which may in any wuyaccrve against said City AISER OR ADDTO MECH. PLUS :E Z O
in consequence i f the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNITp'O I(LIk00CIrM) MECUA Ah FEE 80
SOURCE REGULATIONS, 5
AIR HANDLING UNIT(OVER 10,1X10 CFM) CONS MON TAX
. a° 30
SIgnY fAppliwHAZARDO � Date I!XHAUST f{000(W/DUCII HOUSI MITIGATION FEE
HAZARDOUS ildingR1ALSDISCLOSURE
I/I Willthe ythe Clicantor futurebuildingCode,
Ch smr 12,handle I haMousmalfety ]RATING UNIT(TO IOB,UXI IITU)
m de,Sec by the Cnpenino Municipal Cndc,Chnptcr 212,nnJ the I lealth and Safety
Cade,Scninm 25532(p)'! / HEATING UNIT(OVER 101000 BTU)
Yea PAID
VENTILATION FAN SINGLERF.SIUI Date Receipt#
Will the applicantor infuture building by the muse equipment or Management
BOILER-COMP(3HPOR 100,000BTU)
.ait'hauodous air contaminants a defined by the Bay Area Air Quality Management TOTA
-'Dlxvimp
❑Yes 1101LER-COMP(OVER 100,000 BTU)
/
I have read she hmmdmorrieerinls requiremenn under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
forma Health&Safety Cei Sections 25505,25533 and 25534.1 undersmnd that if the NEW RP.SIDF.NTIAL MECH. SQ.FIT / r
building I na mo currently have tenant,that::is my mspo xibility to notify the occupant r
nr Ne r qui ens wMcn m,t rte mel pdono ixsuana r t eni at o pansy.
T A b
tariff a c Coe ISSUIiD BY:
OFFICE