S 2154 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL. PE ITNO.
CITY DI G DIVISION S 215 4
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PR(UBCT IIIEMI'IFICATIUN
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
o Lig
OWNER, — CO CTOR:S NAME I.IC NOzzg�lx
N/C CO TROLA
ARCHITECTMNGINEER: LIC NO: ADDRESS
/O/ ❑
CONTACT: PHONE: BUILDING PERMIT INFG
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLO
—M/1y MUCH
❑ ❑ IC ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affimt that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QOZ with Section 9010)of Division 3 ofthe Businensand Professions Code,andmy license is RESIDENTIAL
E+ 0 Deer a Classnd effcete/ �� PERMIT ISSUANCB
G V(Fj License CIaS,a�_I.ic.H ❑SCOWL ❑KITCHEN REMODEL;
HZW Dale Contractor APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE.
car
co ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL.
z O pN z [undandred my plana shall be used as public opened,
O z 4 UP TO 200 AMPS MODIFICATION
F,I'-'q License)Professional El ❑CHIMNEY REPAIR
OWNER BUILDER DECLARATION 201-11s111AMPS IMPROVEMENT E]SWIMMING POOLS
1 hereby affirm that I am exempt tram the Contractor's License Law for the OVER In00 AMPS ❑BATH REMODELEEPAIR ❑DEMOLITION
O WU following reason.(Sectio r 7031.5,Business and Professions Code:Any city or comedy SIGNS ELECTRICAL ❑OTHER {P
O which requires a permit to constmcl,alter,improve,demolish,or repair any structure a 11
prior to its issuance,also requires the applicant for such permit to file a.signed statement SPECIAL CIRCUIT/MISC. K
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
IIIOO (commencing with Rection 9000)of Division the Business and Professions Gule)nr 'fEA18 METER OR POLE[NST. COMMERCIAL:
1 c Q that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4• Section 7031.5 by any applicant for a pemubjeets the applicant ea a civil penalty of POWER DEVICES []TENANT
m asTENANT ❑FOOD SERVICE
= not mom than Rve hundrW dnllvrs(85 W). IMPROVEMENT
X
E) SWIMMING contpeusiness SWIMMING POOL ELECTRIC '
IYYUWCW2L111+ anvold dnlhewons ande The ewreisnots License
Law does
osnot apply
air Business ❑OTHER
m and Professions Code The Contractors L nd w Law does not apply to if owner of OUTLETS—SWITCHES—PIXTURPS
A' his
property who builds or improves Thereon,and who dam a aM1 work himself m through
his awn employee,se provided Nat srov mens is old within thin nal intended m plleered foe NEW RP,SIDP,NTIAL ELECTR SQ
sole i!,however lhbase th broden l po stint ithat hed t buildyear of
or improve
the SQ.IT.FLOOR AREA $/SQ.FT.
nese-builder will have the buNen ml'proving 1hn,he did not build or Improve for pain,
p ae of sale).
❑ 1,as owner of the
onexclusvely contracting withlicensed contractors m
omwet baprject(Star J004.Business ad Professions Cnde)The T A
Contractor's Li-
seLawdoesnotapplylounownerofpropenywhobuildserimprovesthereon,and QTY PLUMBING PERMIT FEE
who contracts for such prnjeda with a co or ctorho liamsed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C fnr This reason
Owner DateALTER—DRAIN&VENT—WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of pujuty one of the following declarations:
El I have and will maintain a Cenificate of Consent to sell'-ireme for Worker's Camper- DRAINS—FLOOB,ROOKAREA,COND. STORIES TYPE CONSTRUCTION
artier,as provided for by Section 3J(NI of the lobar Code,fur the pm...are of the
for which this permit is issued. FIXTURES—PER TRAP
w 1 have and will maintain Worker's Cempensmien Insurance,as required by Section
(Martha Lahor Code,for the performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4Off['LETS OCC CROUP APN
Myierrk Ir ii' snr Poll Fedicynu r
Carries: Poll Nu: OAS-9A.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUS I'Rd.WAS]'E I
BUILDING DIVISION FEES
(Thiaseeliun neednol he completed ifthe permit is for one hundred dol lars(S 100) GREASETRAP I'
or less.) r 1 HECK FEE
I eenify Nat imine pin,hmmanccofthe work fnr which this permit is issuad,[,ball SEWER—SANITARY—STOR 200 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- Y FEE
O z sodium Law,of CaGfomia.Date WATER HEATER WNENT/E NO
0 Applicant R LNG FF.F,
NOTICE TO APPLICANT:If,clue(making This Certificate of Exa osion,you should WATER SYSTEMOKLATING
became saddest,to the Worker's Compensadne provision,of the Labor Code,you must FEE
Lit fnnhwith comply with such provisions a,his permit shall be deemed revoked. WATER SERVICEI Rig
Q
a' CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB.
U Q Thereby Off rtn Nal,here isaconx,mction lending agency for thepmfnrmarrce nl' Dam R ciptN
ca rr+ Le work for which,his permit is iasuW(Sec.309],Civ.CJ
Q FF^U Lender's Name TOTAL.
W Lender's Address TOTAL.
G 1 certify,hat 1 have read Nis application and state that the above information is BUILDING FP,P.
rr m comet.I agree to comply with all city and county ordinances and state lows miming to QTY. MECHANICAL.PERMIT FEE
V z building construction,and hereby ou,horize represenmOves of this city er enter upon the SEISMIC PEE
abovo-mentioned property fnr inspection purposes. PERMIT ISSUANCE
(We)agree to save,Indemnify and keep handless the City of Cupertino against ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTERORADDTOMECH.
quQ
in conseence of gaming of this pemrit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOUR. NS. MECHANICAL FE:
_ e7l, AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TkX
nutueof pplicam/Coreacce, Dem ` EXHAUST HOOD(W/DUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haamdnm material HEATING UNIT(TO 110.000 BTU)
as defined by the Cuperino Municipal Code,Chapter 9.12,send the Health and Safety
Cade,Sectio 25532(x)'! HEATING UNIT(OVER 100,1011 BTU)
E]yea E]No PND
V ENTILATION PAN(SINGLERESID) Dale Rot#
mi
Will the air comm m evi
future building occupant use equipment or dses which
et hmnmous air owminams as defined by,he Bay Arca Air Quality Management BOILER—COMP(3HP OR 100.000 BTU) a
DiatJaT
❑Yes El BOILER—COMP(OVER 110,!X0 BTU)
I
I have read the hamrdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
f mia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MELD. SQ.FT.
building downed m ail,have.Road,that it is on,responeibilitytonmify the cecupard / ^s
oftherequirmemswhichnmst I pdonri,suanceofu Ce'rifia teof cu ncy. - //
Owner ar amhorizcd agent le TOTAL: ISSUED BY:
OFFICE