S 2578 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAL 7
BUII.DIN(;PROJIiLT IDENI'IF'ICA'FION J L 25 V•
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL.DATE
log ds (r2.01AA9 to
O EN:S AME: PHONE: CO RACF S ME LIC O'.
• NZ) NIC CON'TRDI.k
ARCHI'I'ECT/ENGINFER: ADRR .S: Y� ❑
CONTACT: Lee—
BUI iPERMIT INFO
kz ann y (ee ❑ Consultant Fees Paid by Applicant(Initial) NLDc ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARAT ❑ 1:1 ElION QTY. ELECTRIC PERMIT FEE
1 hereby ullirm Wm I.licensed undo pmvixinns ofChapmr 9(commencing JOB DESCRIPTION
�WZ with SCNOn ID00cDivision3()fWe Business and Pmfessions Code,and my littnse is RF I FNTIA
FW� in full force and effect. PERMITISSUANCE
FEau License Class LIe.a ❑SFDWL ❑KITCHEN REMODEL
tnQ0. Dale Cnmrecmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FraN 1mdersnandm plans
be m.DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
OZ�� YP;ury si,vll M+�xed as public rcnndx MODIFICATION
UI'T02FXtAMPS ❑ ❑
INTERIOR CHIMNEY REPAIR
F N.,L".,W LteenseJl'mfexsmnal IMPROVEMENT
211�R 10AMPS
OW NFs.ole L to DECLARATION ❑SWIMMING POOLS
y � 1 hereby allirm ions 1 em exempt tons the Cnmmctnr's License Law I'mr Fhe OVI!R IIX)O AMPS ❑BATH kEMODP.IIRF:PAIR ❑DEMOLITION
following reason(Section 7031 5,Business and Pmfessions Gale:Any city or county ❑OTHER Fis
SIGNS ELECTRICAL.
which s a ermt c ,obe,Innpmve,Anmollsh,()r repair ny anmmmOeprioit,i.. ulneynce,heev
SPECIAL CIRCUI UMISC.
� } that he is licensed ptt the provismi aftheContravenes License L (Chapter9
W OC
(commencing vulaSection 7oWb rDivision 3 ofthe B . ,Probconas Cale)or TEMP ME IPR OR POLE INST. COMMERCIAL
d y m es that hes exempt IhemGn n and the basis for the alleged exe opt on.Any violation of ❑NEW BLDG/ADDITFON ❑DEMOLITION
YXI 4N•
Soviet 7031,5 by any applicarn fora permit%objects the applicant to a civil Penalty of POWER DEVICES
FFz S, not more than five hundred dollars(S5 W). ❑ C
XxaO ❑1.dx owner at he property,or my employees will,wages ux their sole cmnpcusntion. SWIMMING POOL HLF,CI'RIC F
EM c
CF' will dathe work.0 stoic auaure is not intendedorolfared formle(See 7011,Business ❑nd Profession.Code:The Cmarectnr's License Law does not apply to an owner of OUTLEI:S-SWITCHES-FIXTURESwho builds tar improves Woman,md who docs such work hitnwdf or Furthhis own employees,provided[hot such improvementsarc nm intended()r offered for NEW RESIDENTIAL ELECIR SQ ET n A D Q 9 1QQQ3
sale.If,however.Ihebuilding orimpuvement in sort[withinonc year ofcompletion,the SO. RAk17.A `z Q.FT.
ownerhailder will have the burden eat prevent,that he did not sold or impnwe on puo-
ry,se of w1eJ.
❑ 1,as owner of the prnpeny,am exclusively contracting with licensed contractors to TOTAL: F'fV
amanmt the project(Sec.7(W4,Buxiaess rrd Profs..ons,lede:)The Connector',Li- By
ocres,Use does not apply to an owner of property who builds or improves thereon,and QTY. P ING PERMIT FEE
who Contracts for such prei with a commons)licensed pursuant the Contractors
Lice se law
❑Ism exempt under Sec. ,11&P C f() id,rcamn 1'17RMIT ISS ANCE
Owner ALTER-DRAIN&VENT- ATER P
Doc VALUATIfIN
WORKER'S COMPENSA'T'ION DI!CLARSHON BACK FLOW PRCHECT.DEVIC•
•� I herebya0am under penalty(perjury oneof the fimbovinB dedaradonx:
❑I have and will maintain a Certificate of Consenuo self-insure me Workces Compen- DRAINS-FLOOR,ROOF,AREA,CONI.
sution,its provided for by Section 37(X1 of the l.uhor Code,lin the performmace ol'the ST I[S TYPE CONS'1'R1ICTION
work for which this pem,it is issued, FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Csrde,lot he perfmmerecol'the work for which this permit is ix,ned GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP
qP
Wcrker//s cc''��n XmXpe//nsa��tinn Insurance artier and Poricv Mr -9-
r
Carrier.ynyc,�e�Poricy Nt�naon OAS-EA.SYSTEM-OVER a(Eq)
rrCIiRTIPIC O PE SATIO INN PRU l KERS'
COMPENSATION INSURANCE GREASI%INDUS'1'HI.WASTE IN[INCEPTOR
(this section need not be mmplaed if the pencil is forces hundred dollars(SIM) BUILDING DIVISION FEES
or lex,.) CREASF.'FRAP
1 certify Wain We performance of the wok for woke Win permit is issued,[,hall PLANCHECK FRIH
an
not employ my Person in any manner oazmlxmsubject
an
meto she WorkWorkers'Com _ SIiWER-SANITARY-S1YlRAf EA.2M FT.
on L
Z nmiow,of Cnlihsmia Dae ENERGY FEE
z0 A,hernI WA i'HR IWATER W/VENT'/IiLF.CTR GRADING FEE
Z NOTICE TO APPLICAM:If,after making This Cenificme of Exemption,you should WATER SYSTEMITRF.ATING
a ; become subject u,the Worker's Compensation previsions of the Labor Gale,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SIikVICE
4
z CONSTRUCTION L17NDING AGENCY NI!W RF_SIDENTIAL PLMB. SQ,ET. PAID
UD Thereby uOinn Wal Fhcre ixu cnmWcn'mn lending agency ha FM1e perfmmmmenf Dale R...ipna
Ik, F Fhe work fear which'his permit is issued(Sec.30sO,Ci,C.)
C
Ixndcr'x Name V TOTAL:
Londe/n'Address TOTAL,:
F 0. 1 unify that 1 have read this appbcmion and state that the above information is BUILDING FEE
N cmrtca.l agrm[()Comply with all city and counlyordirancen andsmm law,reining to QTY MECHANICAL PERMIT FEF.
C.J 4 building wnstmmiun.rnA hereby muhnrize mprescnuntives ofthis city nrcmer spun the SIiI$MIG IIiE /
above memioned property for inspection purposes.
PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupeninn against I!LEC9'RIC FEE
Ilubillticsjud,mems.coaxand expanses which may many way aocmcti,misl said Cly A 1:1 ER OR ADDTO MSCI I.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTA. S AND W .COMPLY WI '1{A A.NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
S( - f:REGUhATIONS MECHANICAL FEE
7
AIR HANDLING UNIT(OVER 10.INM)CFM) CONSTRUCTION TAX
Signvtumof App mans/ n,imcmr Dam 17XIIAUST HOOD OVMUCq
HAZARDOUS MATERIALS DISCLOI E IIOUSING MITIGATION FEE
Will the applicant ear fuwm building wcupanl,mre or hunJle baz.ukrsmmcdal HEATING UNIT(TO 100,001 BTU)
as delined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sealean 25532(m)'! IWATING UNIT(OVER 100.0X1011'I'U)
Fl Yes ElNo
VENTILATION FAN(SINGLE RFSID) PAID Dom Rcceip,p
Will,he a,llamt m future hoildie,occupum one eyuipmcm ear device,which
emit hemNou,air comamiants as defined by the Ray Area Air Quality Management ROILER-COMP LIPP OR 100.000 BTU)
Uimran' 'TOTAL:
❑Yes ❑No BOILP,R-COM P(OVER I W.IXIO BT U)
Ih�ve rt:ul,M hae:vdms matcriakmquimmenla under rh95 of tire Cali- AIH CONDITIONER ISSUANCE DATE
Wmiu Health&Safety Crile 'non'25 255JJ nnsl25. 4. nduamnd that If the NI!W RESIUFNTIAI.MBCII. SQ,Irl'.
b 'ngdoesnmeanem leave v tk nrym,gmsih ' nal'ytheccc,rm
We quire mew' r pea eeafn Ce Ifi
or auloerized ag Dam TOTAL: ISSUED BY:
OFFICE