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S 2421 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1'IiRMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL RM 2421
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRFX ��I/� SANITARY NII. APPLICATION SUBMITTALDATI!
�J�r -��
OWNERS NAryIF: ' PHONE: CONTRACTOR'S NAME: LIC N [[[
ll\J I T/kTITI NIC CONTROL#
NnM�HCHI'I IiCf/I!N INI!P �. LIC NO: fly L. ❑ Q/
CONI'ACP, 1910NIi: BUILDING'PERMIT INFO
GAN
© ❑ Consuhant Fees Paid By Applicant(Initial) B&'LDG ELFT
CTrLU MECH
LICENSED CONTRACTOR'S U;CLARATION QTY ELECT PERMIT FEE ICJL_7
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�KZ wilM1 Section]qXO of llivisirin3nl the Nusineaa ane l'rnfessinnsG Ic,and mylieen.w is RESIDENTIAL:
WOO
in full fore and eRe[ PERMIT ISSUANCE
W 7 ❑SB71WI. ❑KITCHEN REMODEL
aZU Li cense Clas.�Lpj,��Lica _ APPLIANCES-RESIDENTIAL UITION ❑PLUMBING RF.PIPF.
Hoa rime-1.-1`'1�_1rCHI=S ECL
ArlCIi1TE(.TS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
yZ l understand my plans shall he used as public records MODIFICATION
p,Z� —a Pu UPTO200AMPS [I INTERIOR ❑CHIMN17Y REPAIR
F y,CW Liecnwd Profcrsional 201-10MAMPS IMPROVEMENT SWIMMING POOLS
a '4 OWNER-BUILDER DECLARATION
a a Q I hereby affirm that I am exempt from the Contractor's License Law for the OVER IOMAMPS ❑BATH REMODI!IIREPAIR ❑DEM01.1'TION
6 3 F following reason.(Section]1131.5.Buvinexs and Pn.fico ns Code:Any chy or coumy SIGNS ELECTRICAL. ❑OTHER
y which requires a Permit to construct.alter,improve,demolish.or mpair any suucmre
,F,���'
Prior to it,issuance,oleo rcyuires the applicant,m.orch pennitm file aeigned stammem SPECIAL CIRCUIT/MISC.
� } that he is licensed pmsuunuo the provisions of the Contactors License Law(Chapter 9
W..GAO (commencing with Section 7flMn of[)I vision 3of the Buxinaeund Pn,feasiom Caldor TEMC METER OR POLE§5 COMMERCIAL:
a a o a 'hal he is exempt therefrom and the basis lin the alleged exemption.Any violation of ElNI!W 111,DG/ADDITION C1DF:MOLI'I'[ON
�y
Section 7031.5 by any applicam fora Permit eabjecm the applicant a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
I roc than five hendred dollars 050% IMPROVEMENT
SC, 1,to owner ofthe property,or my employees with wages m their sole compensation, SWIMMING POOL ELECT C ❑(ITHEN
will do thu work,and the stmcom is nor imended or offered forsele(Sec.ID4L Business
i1m and Pndi�seionx Code:The Conuactnr's License Law dnc..nm apply to nn owner or OI1ThISIS-SWITCIIF:S tl I1R.S
property who hands or improves thereon,and who does such w...k himself or through
his own employees,provided thatsuch improvements am nn'imm�ded nr offered for NEW RESIDENTIAL ELE IT.
sale.If,however,the building or improvement is sold within nneyemuf tt'mplminM1fhe '^ SQ,M.FLOOR AREA S/SV.FT.
0 owner-builder will have the burden of proving that he did net hold or improve for put. V D /
1.as olcb �, C � �
❑L as t the p of the proceny,am eadusi and contracting s with licensed convacetrs to
mstrual the#raja[,(5ce 9144,Business and Pro([xaionx Code:)The Commetnra Li-
nve,Law does not apply to an owner of property who bulla,or fntprovex thereon,and QTY PLUMBING PERMIT FEE D X�
who contracts for such projects with a contrucmgs)licensed pursuant to the Contractors
License l,aw. PERMIT ISSUANCE
❑1 am exempt under Sec. .B&P C for this mason
Owner Dam ALTER-DRAIN&VENT-WATERFA) G VALUA'T'ION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ft / Q
.� I hereby anion under penalty of nation,one of the following declamtiets
❑I have and will maintain a Certificate of Canuntto self-insure fru Workcrs Crimper- DRAINS-FLOOR,ROOF.AREA. N STORKS 'TYPE CONSTRUCTION
satimn,as provided for by See ian 3900 of the Labor Cade.for the performance of the „-s
work for which this permit i.x issued. FIXTURES-PER'I'RAI'
❑I haws,and will maintain WarkeG Compensation Insurance,au required by Section
3700or11h[Iahor Cala,soothe perfonorimcof the work ftr wb0itho proof,iv isstrod GAS-EA.SYSTEM-I INC.4 OU-TLETS ('ICC.GROUP �ea AP4q
My WnrYAgr�Cnm m p"lypce{yra�ytiyN.'y u ``--(('"'
Carom rl Nll➢M 11at t GAS-EA.SYSTP.M-OVIiRJ(IiA)
CER'1'IIICA'I'1i OF EXEM I"1'ION FROMWOkKIikS' B 3
COMPENSATION INSURANCE GRI!ASF/INDUST'RL WASTE INTERCEPTOR
UILDING DIVISION FEES
(This n[elimn ncrA not he completed,(the permit ix lirnna lmundmJ Jallorx(8 100) Gftl!ASE'fRAP
or le".) PLAN P M
I ceni fy that tame performance m,ha weak for whichthis permit ix issued,,shall SEW17R-SANITARY-S 1'ORM F.A.200 FT.
not employ any soon in any manncrso as to Femmesubject C'o'npen- ENI Y '.
subjeco the Workers' F22
O zration Laws of California.Date WATER HEATER WATNT/ELECTR
Z 2 Applic:mt G N FEE
.N�. NOTICE TO APPLICANT:If,a0ef nuking this Ccnificute of Exemption,you should WATER SYSTEMfI'REAT'I NO SOILS EL
became subject to the Workcrs Compensation provisions of the Labor Code,you must
lonhwith comply with such provision or Ibis permit shall be deenmd revoked. WA'DiR SERVICE
0. Q
CONS'I'RUCUON LENDING AGENCY NEW RESIDENTIAL PLM. SQ.FT P
U O Ihi affirm that there in a comlraefion lending agency for the performance of Date Recd In If
Da 1"' the work far which thio perm;,is issued(Sec.3097,Civ.C.) o 0
C) U tender's Name
Lenders Address V' Z
I certify that I have read this application and state that the all information is BUILDING c�
Vim] correct.I agree m comply with all oily unJ county nNinances and vote Incas relining o QTY. MECHANICAL PERMIT FEE
Utz building construe'ion,and hereby authorim representatives of this city to enter upon theSEISMI v JU
abovomentioned pi in
inspection purposes.
(We)agree m save,indemnify and keep hmmlers Ibe City of Cupertino against PERMIT ISSUANCE r ELP R F i
Iiabilitics.judgment,costs and eapnses which may in any way accrue against said City AMERORADD TOMECH.
asequence nf,he gaming of this cemod. P M 'FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH At.[.NON-POINT AIR HANDLING UNIT(TO 10.000CFM)
SOURCE RT:GI4.A'I'IIINS. M1NICALFEE A 9Z
eMlk fulnc�fy AIR HANDLING UNIT(OVER 10.000CFM) C TNUCf10N TA% -
,Signature`of Applicant/Commm r v Uate I I EXiIAI]S
HAZ RDCVS MAT17RIAI S DISCLOSURE ^^ HOU. G MITIGATION FEE
Will the upplicam ser future building attvpnnt more or handle hmnnlaus'numriul HIATIN( t I (TOI MXkI U)
as defined byline CupeNnn Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)9 � HEATIba '(OVER 100.000 BTU)
❑Yeo VFNTIL I FAFEPBLJRqq E8D1qqPAID
Will the a Bean'or future building accts rant use equipment or devices which Data Receipt M
Pp b Area
BOILER OMP(3HP OR I IXI,IXNI
nit District?
s air nmmantinanu as refined by The Bay Area Air Quality Management D.A
Disnl[I? �J/
❑Yes LJ'V„ BOILER C I'(OVI!ft IIIU,IXX)B"TU)
I have hem lire haen'dous mumriuls rc ms r Chu 1. 495 of the Ci i AIR Co ISSUANCE DATE
qusmy r pts �.
fomia Health&Safety Cm1e edinns 25505.25533 n 2S. C I plat a nit that if the NEW RESIDENTIAL MECH. SQ.FT.
builJln soot currently-lid
Ih:ri'is rays #trot lit m city mbeoaculam
of lir cup 'it
no erne' nificalg id'ceup:'pe O
Ow uuthoviuJ ugem LL Uackk�� )T SSUED BY:
OFFICE