S 2824 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNo,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJE:CI'IDEN'I'IFICATION S 2824
BUILDING ADDRESS: SANITARYNO. APPLICATIONSUBNHT9'AL DA9'E
DD /E)5 . �6-Q
OWN;'jI NNAMH. IT Nli: 6 C.ON'FRA T)R'S NAMIi:C LIC NO:
CE NIC CONTNOLN
A ITECDENGINEER: LIC NO: ADDRESS: ❑
S3
CONTACT: PHONE: BU11.171NG PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MI CH
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LICENSED CONTRACTOR'S DECLARAHON QTY. ELECTRIC PERMIT FEE
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hereby union that I am Ilciawd ander provisions ol'Chapter 9(wmmeneing _ JOB DESCRIPTION
with Seedur70W)of Division 3oflhe Business and Professions Code.and my license is (•'� RESIDENTIAL'
in full faaeandeRcel. PERMIT ISSUANCE ,� •,SQ
ty- ❑SI'DWL ❑KITCIIIiN REMODEL
�Ub.�J License Class Lie.N APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
W Date Contracmr
L„pr� ARCHITECTS DECLARATION PANFIS [I MULTI-UNIT [I STRUCTURAL
ZOyZ I undernndmy plans,hull he uceJas public recnnls MODIFICATION
OZ4q GPTO200AMPS ❑INl'E [OR []CHIMNEY REPAIR
I:.4 F•Iy Licensed Professional 201-I003AMPS IMPROVEMENT C]SWIMMING POOLS
5; OWNER-BUILDER DECLARATION OVER IfNX1AMPS El BATH RGMODEIIREPAIR ❑DEMOLITION
rr��CL Q 1 hereby affirm that 1 um exnnpt from the Carlraatnr's License Law for the
Liy5 o 0.0 fallowing mason.(Section 7031 5,Busineca and Professions Cock:Any city or eminly SIGNS EL[GTRICAI. []OTHER
-/
F O y which requires a permit to mve
constct,ala,impro ,demolish.or repair any...elute
^� prior to its issuance,also requires Ne applicant for tach permino file a signed statement SPECIAL CIRCUIT/M ISC.
n} Lha.he ie licensed pursuant to the provisions of the Contmdor'x Licence Law(Chapter 9
Wt4 C) (commencing with Section 7110(0)ofDivision3 ofthe Business and Professions C.We)or' TEMP.METER OR POI r -sCOMMERCIAL:
N that he is exempt thercfmm wed the bums for the alleged exemption.Any violation of C)NEW BLDG/ADDITION [I DEMOLITION
bLLC1 Section 7031.5 by any applicant for a permit sulrymis the opplicanl it o civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
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not mare than five hundred dollars(55001.a I,ax owner of Ne pmpeny.nr my cmployws with wages us their sole cnmlxnsmion. SWIMMING L . CTRL. IMPROVEMENT
will do the work,and the structure is not intended oroffered lot sale(See 70,14.1h'I"
❑OTHER
junit Professions Come:The Contractor's License Law docs not apply to an owner of OU'f1.ET5-SW 'I
4' r property who build,or improves trereean,and who docs such work himself or.hmo1.
his awn employees,provided that such improvements are not intended or offered for IN BW RESIDENTIAL 1.1.E R SQ FI'.
sale.It,however,the bot lding or i mprovermat is sold wiahi it one year of completion,the SQ.FTI FLOOR AREA VSQ.Irl.
owner-builder will have the burden of proving that he did not build or improve for pur-
prne of sale.).
ty��I�' -owner of the property.am exclusively eamracling with licensed counselors to TOIAI.. 6. 60
Mi '
the pro cel(Sec.TA4,Business and Professions Cale:)Tim Contr ov 1I.i-
cease Law does not apply to an owner of BBmro=uums
improves thereon, it QTY. PLUMBING PERMIT FEE
who contracts for such prof witha r,Fimnmthc Comnncmr'sLicence Luw. /5P� PERMIT ISSUANCEOLamexemptu/�6ec. cR YC forthis yeasALI17R-DRAIN&VENT-WATER(HA) VALUATION
atc
ORKERIS COMPENSATION DECLARATION HACK FLOW PROI ECT.DEVICE:
I hereby affirm under penalty of perjury one of the following declarations:
❑Ik vennd will nminminu Certificate of Con,cmmselGinarefr-Worker's Cnmpen- DRAINS-FLOOR,ROOF,AREA,CONE). STORIES 'L'YPECONSTRUCTION
aalian,as provide]far by Section 3700 of the Labor Calc,for the perfonnonce of the
work for which this permit is issued FTXTURLS-PER TRAP 2 S
CI 1 have and will romossin Worker's Compensation luxuriance,as marked by Section
]700 al,he Labor Creta,fonhefarmm�ce of he work forwhichthisermit isiamd. GAS- INCAOUTLETS /
per p OCC.GROUP � F
CMy mWorker's Compensation Insurance cvmerand oliyNo.:number ane: GAS-EA:SYSTEM-OVER 4(EA) I rPJ
Caoicc Polity No.: s�
CEB TFICArE OP EXEMPTION FROM WORKERS'
_ COMPENSATION INSURANCE. CRhA51%INUUS'1'RL WASTE.INTERCEPTOR
BUILDING DIVISION EELS
(This section need not becompleted ifthe permit is feature hundred dollars(S 100) GRHASETRAP
or less.) PLANCFlECK FILE
Ittrtily that in in
prPonnanee nl the w. klnr which this permit iv issuul.i,hall SEER-SANITARY-STORM EA.21X1 IT
not employ any p marine ryquC�'s'fryMghnFjecno she Worker'Conifer. ENERGY FEF. 3I,s/0
�z e6aion Wws of Cuh aDm /�cff__ WATER HEADER WNIiNT/ELIiCIR
Q
Applicant rf GRADING PHIi
T~/J NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should WATER SYSTEMO REATING
become subject Ir the WorkeFs Compensation pmvi.cions of the WMr Cods,you must SOILS FEE
Wforthwith comply with such provisiornor this permit shall hedeemed revoked. WATER SERVICE
a ti-c 4 5 r
CONSTRUCTION LENDING ACCNCY NEW RISIOIFNTIALI'LMB. SQ.fT. PAID
V I hereby affirm that hem is a communpfomm
ion lending agency for the ,rnce of Dam Receipap
the work for which this permit is issue](Sac.3097.Civ.C.) /y..
�" F•'
Leaders Name TOTAL: 1116
VJ
��.s
� Isndefs Address TOTAL' S `GO ^-
L. 1 verify that I have rend this opidiamout and stem that the above infomation is - BUILDING FEF fi0s vV
l..
Zi cor at.I agree to comply with all city and county ordinances artisan,taws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby marrimrepoesenm.ives ofthisciaymentermor the SEISMIC FE' 6
innow-meminnedpropeny forimp¢tinnpurposes. - P13RNIIT ISSUANCEc�
(We)agree to save,indemnify and keep harmless the City of Cupertino against ✓ s ELECTRIC FE: 34-, 6-
liahiliaics,juJgmems.cosls ands en •which may in any way ucc.mgainsl said City ALTER OR ADD TO MECH.
in consequence ofa gmmin thisss PLO WIN S s
APPI.ICAN'1. %T )SA WILL I. )MPLY WITH ALL NON-POINT AIR HANDLING UNINI0111,000CFM0
SOUk1'CAuN /�'/ HANIC FEE r 6
6l6J/ r� AIR HANDLING UNI'I'(OVER 10,0MCFM) LcONSTRUCTI TAX )
XSigrioure of Appllcam/Cenlmclor Dote EX I I AUSTI(OODOVIDUCT) t.� Y] FE
HAZARDOUS MATERIALS DISCLOSURE •C:
Will theapplicum or fmure building camped more.,handle humiliates mnerial HFAI'ING UNIT(TO onotar ET U)
as dafir,d by the Cupenlm Mnnielpul Code,Chuptcr 9.12,rod the Ilcallr and Snl'cly,
Code,Section 2553200^ HEATING UNIT(OVER 100,03 BTU)
pYes ' VENTII.A'I'ION FAN(SINGLE RESID) 6, PAa
.� Recrap,N
Will the is co am or brute building recby am B use equipment of devices which BOILER-COMP(311P OR 100.1X00 BTU)
emit havardnux air cnmaminanee vs de0nal by the Ray Aree Air Quality Management TOTAL'. � ti
Dillrin9 BOILER-COMP(OVER LOO I)(Ih BTL)
❑Yes &fs
1 m c harardous romenals barmon rmho under Chapter 6.95 of dr,Coli- AIR CONDITIONER ISSUANCE DATE
forma k�Ih ruddy Cod s 25505,25533 and 25534.1 understand that if fisc NEW RESIDENTIAL.MECH. SQ.t1'.
to gJoc mmn0 eumn n,that it is my respmnsihilirymnotify lhe.ecupant ��
mus. ace of a Ceti fir I c
/Lf wne,mmahma.dagent Dam TOTAL /gb ISSUP.D BY: r- 4ti7J x'yC�
OFFICE