S 2569 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-FTEs'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING-MECIIANICAI. C nC
IIUILDINO YRUJECI'IDENTIPIL'ATIDN J G J
ROLE GADDRESS, SANITARY NO. APPLICATION SUBMI'Ii DAT I!
Y„ - f
O "NAME: IpHO E: ACTOR'SN fE: ENO:
4 ,V\ NIC CGMI'ROLp
�I ARCHITfiCT/ENGINEER: LIEN ADDRESS:
❑
CONTACT: PHONE: BUILDING PERMIT IN FO
O — ❑ Consultant Fees Paid by Applicant(Initial) BO ELE PIA MB
14CENSEIJCONTRACTORDECgARAT]OrIQTY. ELECTRIC PERMIT FEE
1 lawhy affirm that 1 am licensed!under provisions of Chapter 9(commencing JOB DESCRIPTION
In=Z witlm Seaimn]OfMp of Division Jnf the Business and Prolcssians Cadc,and mylicenvc is RESIDENTIAL,
Fo, in full force aerie I / ^yam '''(� PERMIT ISSUANCE
aUU Liccnu Class �'`hn(& Lic.#_J,�r•�" ❑SFDWL ❑KITCI{EN REMODEL
I—Zul e APPLIANCES—RFSIUENTIAL ❑ADDITION ❑
DatContractor PLUMBING RE-PIPE
cob ❑MUITI-UNIT ❑STRUCFURAI.
F.Gm ARCHITECTS DECLARATION PANELS MODIFICATION
Z c' Z I understand my photostat M1e red as public memds '
OZ`✓� UPTO20OAMPS ❑INTERIOR [3 CHIMNEY REPAIR
izi Licensed Professional 201.INXIAMPS IMPROVEMENT SWIMMING POOLS
�yf, OWNER-RUII.DER DECLARATIONOYER Il10oAM1'S C3 BATH RCMODEVREPAIR ❑DH (� TIO
'
M6 1 hereby affirm that 1 em exempt(,,a.the Contractors License Luw future U fallowing reason.(Section]U31.5.Egsinens and I'rofexsions CnJe:Any city or cnnmY SIGNS ELECTRICAI. OTHER
ywhich requires a permit m cnnswa,alcor,improve,demolish,aro repair any notation, S
prior to its issuance,also leagues the applicant for such perminn fmlea signed smlamom SPECIAL.CIRC UIT/MISC. Ts/rOL CA `
Wad Nat he is licensed pursuant to the provisions of the Coroner's License law(CleacT9 ('OMMERCIAL'
P4 (commencing with Section MILE)of Division J of the Business and Professions Code)or TEMP.METER OR POLI!ENS'[
6 y m g that he is exempt th m,fmm end me basis Ina me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ISXI LL
Section 7031.5 by any applicant for a permiisubjens the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
y not mom than Five handled dollars($50o).
!..Z} IMPROVEMENT
�Lo the work,the property.rmyemployees ed Or offered
asmeirame(Sm.mmpensiiess SWIMMINGPOOLHES—RIC
ad will do the arch he Comis not cemr, icenseraordofmsalclply otaJ,Business [I OTHER
W and Professions Cole:The Commuter's License Law does not apply s an owner of OUTLETS—SWITCHES—FIXTURES
�'a.. his o ny who ogees,or aided that
thereon,and who docs such wed himself nr through
his own employees,provided Nm such impmvemmmcnas art not intended ser pnood for NEW RESIDENUAI.ELECI'R SQ IT.
mIv.If.hawevee Ne Inildingor improvement viscid within enc year of completion,the SQ.IT.FLOOR AREA SINQ.Ff.
or-builder will have he burden of proving that he did not build or improve fill m r-
pum of sale.).
❑1,as owner of Ne property,am exclusively contracting with licensed comncton to as AL.
constrct the project(Sec.AEW,Business and Professions CodeU The Contractor's Li-
rerm Law does not apply to an owner(if propeny who builds or improves Nmam,and QTY. PLIIMRIN RMIT FEE
who contracts for such projects with a cantmemr(a)licensed pursuant to the Contractors
License Law. PIiRMI'T ISSUANCE
❑ r N
1 am exempt under Sce. .B&P C fair reason
ALTER—DRAIN&VENT—WATER(E ) VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �/� c��a Oro
I herebyunit
under Penalty of of Cononeoflhefollre for decWorker's
Co d J
❑Ihave and will for by eCenil icon of Con sem mCode,orel'or Worker'sce of the
DRAINS—BOOR,ROOF,AREA,COND. NTO 'S TYPE.CONSTRUCTION
workfas hirlidul for by Ns i... l]IW of the latxn Code,for the Performance of the
wort for which Nis permit is issued. IIXTURES—PERI I RAI'
❑1 have and will maintain Worker's earc of mina Insurance,as his per by Section
37W nfthc Labor Gds,for the performanceoft ewod for which thispermit isissued GAS—G.NVNTF.M-1 INC.4OUTLETS OCC,GROUP AYN
My War s aat"'a Ina Denier Policy,, mer ale: CAS—EA.NYSTLM OVER 4(EA)
Cartier: 'Y Nm.:
CE 19CCOMPETE OF %EMPI'1 INSURANCE
E KE GREASE,,NDUSTRI,WASTE INTERCEPTOR
COMPENSATIONINN FROM
BUILDING DIVISION FEES
(This section need ern he emmpluul l[NcPermit is forone hvndreddollaa($100 GRP.ASETRAP
nr less.) PLANCHF.CK FEE
Icenirymm a ncperf,,nnancebf Newark(,,,which thispermitls iswcd,[,hall SEWER—SANITARY—STORM EA,200 FT. I
not employ any pern in any roomer.wm as to become subject m Ne Workers'Comped- !N
soERGY TME
Z ,Z waved laws of Cmirumia.Date WATER HEATER W/VENT/ELECTR
Q Applicant GRADING FEE
`Z1 NOTICE TO APPLICANT:IL after...king this Cenifcate of Exemption,you should WATER SYSTEM/TRI!ATING SOILS THE
F heeome subject to theWorker's Corapcmnmion provisions of the labra Grade,you must
WLoc iN comply with such Provisions or this permit shall he deenmed revoked WAIERSERVICH
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PWB. SQ.FT. PAID
Ll0 l berchyaNrm Nut there is a construction lending agency for the perforunceof Ute cciptp
fL the work lar which Nis permit is issued(See.3097,Civ.C.) TOTAL:
0 Lender's Name
(Zl Lender's Address T(HAL'
66 1 cenily that I have read this application and same that the above afro sitioo is
BUILUING FGE
h cnmect.l agree to comply with all city and county ordinances and main laws mlmingto QTY, MECHANICAL PERMIT FEE
UZ building constriction,and hereby authorize representatives of Nis city to enter upon the SEISMIC FE
above-muraloned pralx�ny fill Inspection Pilin s PERMIT ISSUANCE r O
IWe)agrcem save,indemnify and keep harmless to City of Cupeninoandire, t ELECTRIC ME
Iialudities,judgmemscious undexpenus which maymuny way amoseagaiowialdCity ACI'ERORADDTOMECH. PLUMBING FEF.
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILI.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IT'Land CFM) MECHANICAL FEE
SOURCE REGUI.ATIONS.
AIR BANDUNG UNIT(OVER 10.000 CIM) CONSTRUCTION TAX
Signature of ApplicanVCnmruci Date EXHAUST HOOD(W/DUCT) HOQSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant,,,future building occupant store or handle hazardous material lVENTILATION
UNIT 100.000 BTG)
as Mfned by the Cupeninn Municipal Cada,Chapter 9.12,and Ne HeaIN and Snfery
Curie,Section 2553__^(a)'1 NIT(OVER 100,1X10 BTU)
yes ❑No N PAN(SINGLE RESIDE PAID
Wi11 the upplicam aro tumor building cecupam use eyuipmem orAeviccs which OMPIJIIP OR BXI,DXI el'U)emit hazardous air nmmnduants as delinW by the Bay Arco Air Quality Management TOTAL:
District] OMP(OVER IOUJ%ID BTU)❑Yes ❑No 41I have read the hazmdoou mareriis rest x under Chapter695 o1 me Cali- TIONER I U NCED E
humin Health&Safety Code,Sections 2550j!25533 m 25534.1 unJenwnd that if Ne ENTIAL.Nit SQ.Ff ��7-7
^_-moi
building dacsmI ralyhavcamnam, liliamynes omibilitymmairy Neoecupant /
ofthe eyt)is encsw Thmuahemot formissuvac ofa Cenificaeof Occupancy.
Owner!/term Date TO L: ISSUED eY r T
OFFICE ` f