S 2272 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEBr'`7 1T NO. �w
BUILDING DIVISION APPLICATION/PF,RMFP PLUMBING-MECHANICAL
BUILDER;PROJECT IBRNPIFIC-A'TION 'LJ
72
BUILDING ADDRESS: SANITARY NU. APPUcA'DON SUBMITTAL DATE
I� ►'3 �4- y, - 30-g�
O R'S NAME: �A _ �PHONIi: D� CONTRACTOH'S?AM� ��H� LIC NO: O� NIC CONTROL#
c,Wn VL/ - / ❑
CHITECT/ENGINEER: LIC NO: AL�I)kESS: �
CONTACT: PHONE: /f BUILDING PERMIT INFO
`� ❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUUM.B�MECH
f ❑ ❑ L ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am Banned under provisiono of chapter 9(commencing JOB DESCRIPTION
Q0Z with Salion]Of10 of Division 3 ofthe Business and Processions Cale,and my license is R ID NTIA
O PERMIT ISSUANCE —I<
in full Tome and ellen.
�UU License Class I.ic.a OSFDWL 71 KITCHEN REMODEL
vFi6W Dam ru ❑
Comrsm APPLIANCES-RESIDENTIAL ADDITION 4ETM7Mft1SdG.RE-PIPE
ARCHITECTS DECLARATION ppNF.IS ❑MULTI-UNIT 0STRUCTURAL
Z E).Z 1 undersmnd my plans shall heusedaz public records MODIFICATION
OZ—Q UPTO2011AMRti
1'4k:W Licensed Professional [IINTERIOR [J CHIMNEY REPAIR
ye,
W�' OWNER-BUILDER DECLARATION 201-It")AMPS IMPROVEMENT []SWIMMING POOLS
y C� 1 hereby ofllml that I am exemth
pt form e Cumraor
d 's License Law far the OVER I"AMPS ❑BATH REMODEL5kEPAIR 0 DEMOLITION
y(36 U following reason(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL D OTHER
F^LLO which requires a permit m construct,alma improve,demolish,or repair any sumartim
gg m prior to its issuance,also requires the applicant for such permit to File a signed statement SPECIAL CIRCUIT/MISC. '7
gggg WWyy,�.. that he is licensed porsuam to the provisions of the Contractor's Liceme Law(Chapter 9
q20iuC]
mommencingwith Section 9000 of Division 3 ofthe Business and Professions Coalor TEMP.METER OR POLE(NST. COMMERCIAL:
d q M C that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
la. Section 911315 by any applicant for a permit subjects the applicant to a civil Pcmdty if POWER DEVICIS []TENANT []FOOD SERVICEs„Z} t marc Iban Eve hundred dollars(SSW).
Sp ❑ Las ownerof the pmpi or my employees with wages as their sole compensation SWIMMING POOL ELECTRIC VOPROVEMENT
F will dr the work,and the announce is nal intended oroffered forsak(Sea.]1)AI,Business DOTHER
;3 m and Pmfcsoms Cale:The Com ictnr's License Law does not apply to an owner of OUTLHI'S-SWITCHES-FIXTURES
peopeny who builds or improves thermn,and who does.such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELF.CPR SQ pT.
nate.if,boxer w the havbuilding bombe 1provement is at he did non old or t ntativetion the b R AREA t/sQ.1'1'.
owner-builder will have me hapten of proving that he did not buil)or impnwe for pur-
pose of sole.).
❑ 1,as owner of the properly,am exclusively commuting with i Meed ntomdoa t. TOTAL:
conswn the project(Sec.]O1Y,Business and Professions Code:)'Ihe Commmoh Li-
move Law does not apply it)an owner ofpropeny who builds or improves lhereon.and QTY. PLUMBING PERMIT FEE
who contracts for such pmjucts witha eontmemgs)Ilvens d pursuant m the Comrama's
License law. PERMIT ISSUANCE L
O l am exempt under Sec. ,B&P C for this reason
Owner Dale ALTER-DRAIN&VENT'-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I hereby affirm under penalty of pepary one of the fallowing declarations: C,U .�
❑ (have and will maintain a Cenilicam of Conscnno sell.insom tin Warkn's Camper. DRAINS-FLOOR,ROOF.AREA,COND. STORIES 'TYPE CON STRUC'l1ON
section,as provided for by Saloon 3700 of the Inbar Code,for the permormsoe of the
work for which this permit is issued FIXTURES-PER TRAP 66 gn _Z f
0 I bmu and will maintain Worker's Compensation Insurance,m required by Section ` J AoLaC4,/
3700 olthe bor C, ca inlhe perfnnnanc of the work far whish this pemtit is issued GAS-HA.SYSTEM-I INC.i OU'1LETS
My Wor amp res oma, ca it Policy
OCC GROUP APN
Carrier: L icy No.:.
�t-T 1yGO� GAS-EA.SYSTEM-OVERY(LA)
C17RTIFIC 'H OF EXE ION FROM WORKERS'
COMPENSh ION INSURANCE GREASMSIDUSTRI.WASTE IN'T'ERCEPTOR
(This section need not be completed lithe permit in foream hundred dollars ISI W) BUILDING DIVISION FF:F_S
it,less.) GREASETRAP PLANCHP.CK FET?
Loy any thaperm in cifinoanymmancrafthe becomeork far whichtho ranthe W rkcn'Conshall SEWER-SANITARY-STORM G.200F"E
not employ any person in any mmar ur as to become mbjat lu me Worker'Camper- ENERGY FEE
O Z ration Laws of Culifomia.Dam WATHR IIEATER WNEN'I'/EL ECTR
Z Q Applicant GRADING FEE
City NOTICE.TO APPLICANT:If,aper making this provisions
of of Exemption,you should WATER SYSTEM/1'REAI'ING
a ; become subject hr the Worker's
pm Cams.for d, pmvit Jud of the labor Calc,you man SOILS FEE
411 limhwith comply withsuch provisions tor thin permit shall he deems.)revoke.). WATER SERVICE
aQ
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT. PAID
V0 l forwhalh,hiicer.it
isaed(Sea H lendingagency for doe Data Receipt#
F-' the work Fina which min permit is issue.)(sec.BW],civ.C.)
OG I-ender's Name TOTAL:
Lender s Addmsc TOTAL: Q/s,yO
1 citify That I have rcaJ this application and stmt that the rMve information is BUILDING FEE
hcorrect l agree u.comply with all city and county ordinances and.aale laws relining to QTY. MECHANICAL PERMIT FEE
7
U rZ- building conswction,and hereby announce representatives of this city to enter upon the SEISMIC FEE
above-mentiuned pmpeny for inspersion purrymes. PERMIT ISSUANCE
(We)agate Io save,indemnify and kap hamlless me City of Cuprnino against ELECTRIC FEE
Iiabilities.judgmems,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in nsequmum of the grunting m1Lis Perini(. PLUMBING FEE
APPLICANT UNDERSTAN AND W J.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000
SOURCE REGl11,�yONSMEC ALIEE
AIR HANDLING UNIT(OVER IIIOil , 'M) ME I0 TION E
TAX
$rgnalu pplt�U(Com or Dam EXHAUST HOOD(W/DUCry 301011 1 MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wilidaimillcamnr future Wildingoccapanlamrc or handle haeunlommalcrml HEATING UNI'I'1 TO 1(11,1X0 BT
as definN by the Captions,Municipal Code,Chapter 9.12,end the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER 10.00)
❑Yes ONo f6 _ 7ZZ
VENTILATION FAN(SINGLE R --- PAID am Heceipt#
. Willthems applicamorfmure building(Occupantthe
eea Air
ordeviceswhich BOILER-COMP CHP OR 100,000 BTU)
amil hautrdous air ernluminnnts nn defined by the Buy Area Air Quuliry Mtmagemem ill yl7
OTAL:
Uismidl
C]Yes LIN. BOILIiH-COMY(OVER 101101)0111 BTU)
I have read the hmallous mumrials requirements under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE O
forma Hcalm&Safety Cale,Sections 25505,25533 and 25531.1 undersmal that if the NEW RESIDENTIAL MECH. SQ.EE
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements%Inch must af met prior to issuance of u Cendicam of Occupancy, y
Uwner or aommired.gem Date OFFICE ISSUED BY:TOTAL: t4k'/.'x-LCCy