S 2450 APPLICA14TTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMrr NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2450
BUILDING PROJECTIDEN'1'IFICA'FION'
HUILDINGA)DRh. nd,64 l tA) SANITARY NO. APPLICATION SUBIAMAL DATE
5 L 3.-2 Kr 4
OW
. PHONE: CO IRA MOR
"PIZ Z:
SIC CONTROhM'
AItC : IC
NO: DRESS: �/aq� /� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Ca...Beat Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. 171-ECTRIC PERMIT FEE
I hereby arson that I am licensed under pmviriom,mrcha,mr 9 Rommenoimg JOB DESCRIPTION
O in full force and effect. si"""code.ours mylicen.di. R
wool wldt Section7UlxDufDivr`iun3ol the l{uxiness and l'n,fes
ty O I'1i12AfIT ISSUANCE TIAL
1"'ty- SPUWh ❑KITCIIIiN REMODEL
�U~ Licence Cl er Lm.X
h- V APPLIANCIS-RESIDENTIAL ❑ADDITION ❑PLUMIIING RE-PIPIT
Z D:nc Cnmrvcmr
4 "ICHI'lH I"S DECLAItATI) ❑MUI:I'I-UNIT El STRUCTURAL
,. o, PANELS
ZpyZO
I understand my plans shall be used as public records . MODIFICATION
UPTO 200AMPS Z-� ❑INTERIOR C3 CHIMNEY REPAIR
Fa it,q Licensed Pn,fcssioqml - 201-IqAMPS IMPROVEMENT E]SWIMMING POOIS
�yd mOWNER-BUILDER DECLARATION A'fll ltliMODELIRF.PA IR El DEMOLITION
CC I hereby affi ,that 1 am exemptContractor's from e Conuctor's License Law for the OVER❑Y]u AMPS ❑B
x6' a U following reason.(Section 70315,Business and Professions Code Any city creaunty SIGNS ELECT RICA]. OTIII:R
W O m which requires a,cont m construct,ulmn improve.demolish or m,uir any sbw...re L.i
pdnrtoits henmegatlsm rcaluire_s the applicant lou och petrait In fila e signed waterte'n SPECIAL CIRCUIT/MISC.
�ythan he isBeenxed,noomatothepr..i.toM1,ofotecontractors"ceno,Lawleh.""9
6100 (commencing with Section 7")of Division 3 of the Rosiness and Professions Code)or TF_NP.MEIIIRORI' IAIINSL COMMERCIAL:
a y o y that he is exempt Iherefrnm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLI'TION
^m Seddon7031..5bymrynpplicanl font permitsuhjonsIM1a applleon 1.a civil pdr,Ityot POWER DEVICES ❑TENANT ❑FOODSERVICE
m more than Five hundred dollars(SA1O).
F'Za1,as owner ofthe r.onn lo'ees with wa es a.Iheirsolecnm Winn. SWIMMINDPOOLISLIiC'FR IMI'ROVEMI3N'I'
❑ Pmpc Y Yet'tP ) g ,ensu
$�+F� will do the work,and the structure is not intended or offered for sale(Sec.714,1,Businc.is ❑OTHER
yj m and P ficsviuns Code:'IM1e Camrmmr',v Licca Law doer nal apply it an owner of OUTLETS-SWI'TCIIP?S-FIXTURES
6i propcny.Inthuildrof Improvesthereon,and who Jots-such work hinvolor through
his own employees,provided thin tush im,owentems am nrt intended nr offered To, NEW RESIDENTIAL.ELECTR SQ
sale.If.however,the building or improvement is sold withinone year of completion.the SQ,FT.FLUOR AREA 5/$Q.PF
owner-buildcr will have nhchuNen of,roving that ha did nun build or improve for pur-
pose of salu.l.
L] 1.as Owner of the pro,eny,am exclusively contracting with licensed contractors to 'IfFI'AL:
couswetIhe proi($is.7014.Business and Professions COde:7 The—ous-o' Li-
seLaw does not apply to an owner of Property who liiks or improves thereon.and QTY. PLUMBING PERMIT FEE
,It,,commas I'm such pl.Ico,with acorn wao,)Iicemsei Pursuant m the Cmntmmtirs
License Law. PERMIT ISSUANCE
❑I am eximiamader Sec. ,B&P C fur this remmn
ALTER-DRAIN&VENT'-WATER(GAJ VALUATION
Owner Date
WORKERSCOh1PENSA'1'ION DECLARATION BACKACK PLOW I'ROTG("I'.DEVICIi
1 hereby of oar under Penalty of,cjuq tine of the foll wing declarations.
❑1 havcand will maimainmCeniflate of Conecmmself-Insure basic k,',Coin,ero DRAINS-FLOOR,BOOP.AREA,COND. STORIES TYPECONSTRUCfION
sali ,m
ne,nsvided lin'by Section 371X1 of the lath...Code,Iia lite perti,mmnaf nb
oe
1V1for itch thispermit is issued, FIXB'URIHS-PER TRAP
have and wilmaintain Workers Compensation Insurance,as acquired by Section
3710 of the Labor Cele.lit lhe,erformunc of the work y�for rywbhich¢�this,emot is issued GAS-EA.SYSTEM-1 C, 1, e( .GROUP .wt
C 1:11;t a alit �m swat I'nl cYN I' �'� /YD�P/� GAS-ITA S..TEMd)Ypbt 1LAI
CERTIFICATE OP EXEMPTION FROM WORKERS'
nTE I3COMPENSATION INSURANCIGREASIVINDUSTRLWAS
1LDINCDIVISION W'LS
Ffhxnretimn over]nm,brwutod
it the permiCix limnre handfed Olnllors($IIXB 4l
or less.) GREASE'I'ItAP � I'LANGIECK Eli
Itt'nify lhatimhc performan<eadthe work for which this permit is iesuW,l.ha11 SEWER-SANITARY-S'MRM HA. T.
m
not employ any person in any roamer so as to become subject ,the Workers'Con,a m- ENERGY IEE
Oz anfion LuwiolCalifforain.Dale IllWATERHEATERW/VE1,17M,LECI'RDING FBB
Z 0 A,plicam r
a ; NOTICE TO APPLICANT:If,after making his Certificate of Exempllmn,you rhilJ WATER SYSIEM?It IIATING
Ivcome subject to the Worker's Compensation provisions of the IvMr Cade,you must SOILS hili
W
forthwith comply with.talt, m,ikiian,or this permit shall be deemed revoked. WAFER SERVICE
d Q
UO CONSTRUCIION LENDING
ng agony NEW RESIDENTIAL I'LMB, SQ,17, PAID Date acceptN
1 hereby affirm Dal here is a conawminn lending agency for the performance of
the work fnrwhich this permit is issued(See 3097,Civ.C.)
Lender's Ni at TOTAL
O V LendersAddress 'I(I'P'A L:
d1 cMify 1M1at 1 have read this mpplicmion and state Ihm Ne abwc infmfmatimn is - BUILDING 'L
V) convect.)agree to comply with all city and county ordinances and state laws relating it, QTY. MECHANICAL PERMIT i FEE
U ,2, building eon.motor,and hereby; [orimacpreamnmivcsof the,,ilym criwarym de, SEISMIC ITE
above mentioned property fin inspection purposes. ]'[IBM]]ISSUANCE'
IWd agree to save,indemnify and keep harmless the City of Cupcnino against ELECTRIC I
liabilities,juJgments.c...1,and exKn,ca which may many way accrue agoinstsaid City ALTER OR ADD TO MECH.
In c
omeymunwmflhegmon I'Ihlsperan. PLUMBING FEF
SOURi F ppS'I'ANI S AND WILL COMPLY WITH ALL.NON-POIN"f AIR HANDLING UNIT(TO 111,111111 CPM) MECHANICAL FEE
I :G L '1'I)1S.
SOUR
.L? ;O � AIR HANDLING ON]r(OVER IIkIXIDCFM) CONSTRUMON TAX
Signature of Applican'Conttac'courr 'DVI, EXHAUST' IOODIW/DUCT) t HOUSING MITIM'1'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wilhite application,as.building atccupam smmor handle hamNomnnoodal BEATING UNIT(TO 100."BT(1)
as defined by the Cuprnimo Munici,ul Cede,Chapter 9.12,and the Walsh and Safety
Code,Se tion 25532(a)'/ HEATING UNIT(OVER 11111,000 If I U)
❑Yes ' VENTILATION FAN(SINGLE RESID) PAID
Date Receipt X
Will the ea,con tit of future huilding by the B ...A ea Aw sm Quoit,Mica,wldch BOILER-COMP OHP OR Ig1,INN113TU7
mit barurJnur ulr mnuuminanu ux dufned by Om Bey Area Ar Quality Mamtgcnu;nt 'FOI'AIO
Dim cR /
❑Yea 'rVld BOILER-COMPIOVIiN Ig1,INNI BTU)
I hive read thelo",
Win rmcrin1 myull'mnnot.undar Chapnrb95oftho Cali- AIRCONDHIONITO ISSUANCE DATE
Ii,mia health afet ec ons 235052553]and 25534.I undersord Thal if the NEW RPS IDENTIAL MECI I. SQ.FT. Qbuilding JOns a v e a, ant.Wm it is my mspomibilily to tui ylhe occupant 2 V`?m is h rl 1
c{6r1orm irsumnce ofu Cenifrvm tree l �— `T
Owner ora sed cm (/( Din I TOTAL ISSU13D BY:
OFFICE