S 2692APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELFICTRICA], - PERMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL S 2692
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL )ATE
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CON'IAM: PHONE:
BUILDING PERMIT INFO
II1LUGy IiLIiC'I' PLUM({ MlfC
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❑ Con..Itant Fees Paid by Applicant (Initial)
QTY ELECTRIC PERMIT FEE
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L CHISSED CONTRACTOR'S DECLARATION
I harebr arrrnl that I am lice ... d alder Provisions or chapter 9 (commencing
Scniun ]1X)07 of Dlvisinn 3 nt the liusine,N anA I'ml'ession, Cade and my Iiecmcis
'n fu111'oree and effc 1.
License Class I,ic.p
.JOB DESCRIPTION
RESIDENTIAL;
❑ SFUWI, ❑ KITCHEN REMODEL
❑AUDITION [I PLUMBING RE I'll'E
❑MULTLUNIT ❑S'IRUCURAI.
AfODIPICATION
❑ IN'I'I!RIOR El CHIMNEY REI'Allt
IMPROVEMENT (]SWIMMINGPOOLS
ElBAT If REMODEI/REPAIR [I DEMOLITION
❑ OTFlIiµ
PERMH ISSUANCE
AI'I'LIANCES-RESIDENTIAL
DamCommmo
m60.
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ARCHRHCI'S ❑F.0 .AItAI'EON
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F h I M uanD n
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PANELS
OF 10 21X1 AMPS
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Loan. Inues,ionm
OWNER-RUILDER DECLARA9'IONOVliR
1 hereby ofnn that 1 am samnpl from the Counselor's License Law (nr the
following renson. (Section 7031.5, Business and PodbssionS CoaE: Any city or county
201-1000AMPS
1000AMI'S
SIGNS RLECPRICAL
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which myuil'es. pemlil Ir conGmed, alter, imp000. dnnulish, or repairmy Nlmaerc
poor its issuance,also noPia, the a,,]room for such Omliun file a,,radsthmmem
Conames License Low (Chapter 9
that he in lieenmd pursuant to the provisions of them
Business and Professions Cooked of
(commencing with Section 7")of Division 3 officeC
that he is exempt fl,"cimm and the basis for Ne alleged exemption. Any violation ,f
Section 90315 by any applicant fora Iwrnnit,objects Ihouppli.mI In acivil pemdtyof
not mere man five hundred dollars ($500).
las owner of the is norm Ioees with woes as their sole colo Linn.
p rw r r enp r s PemNa
will do the work, and thestrvnure is not intended m adored for sale(See. 2lWl Resorts
vad 1'..Intonate; Code: The Contr clue, License Law dues not -1111 ,o an owner of
property who hueds or improves maroon. and who does such work bhn,eB or through
his , own urr,*w.a pr,o drd Nat suuh Improvemena um nut ... .sailed ur on and Gm
sale. It,however, the building or improvement is sold within one year of onnpIn, oa the
SPEC IAL CIRCO I' I'/MISC.
TEMMOR POI_H INST.
P. Fit
OMME CIA
[I NEW BLDG/ADDITION iAOIJTI0N
❑'TIiNAN"f FOOD SERVICE
IMI'kOVEh1EN'f
❑OTflliµ
POWER DEVICE
SWI M M I NO 1'00[, ELECT RIC
OUTLETS-SWITCfIES- FIXTURES
NI!W RESIDEN3'IA 1, ELECTR
SO. FT FLOOR AREA
$/SQ. Pr
mmar,builder will have the harden of proving that he did not build or improve for pur-
pose of vale.).
E]1, a.. owner of the PoPeny, an asthoively surf aciing with licensed contractors nt
TOTA
roamed he pr ren (Seo moa, Bmine,u amt Prof .. on, Code) The Contmaor.1 -
eeLtwdoes not apply to an ovocrot an,amY who builds or mlproves thereon.and
QTY. LUMB NO PERMIT' 'l
who contmns fonuch projects with a commnorE) licensed pursuant at the Connowt rs
PIiRMIT IS.
License nodus
❑I l vat eaempt under Sol, ,B& P C for this reason
Un.s
ACI'ER-DRAIN& TER IEA)
VALUATION
OQP
Wna
WORKERSCOMPENSATIfJN DECLARATION
is
BACK" OW PR(Y ,".1 fi
1 hereby affirm under Penalty of Perjury one (if the fallowing declarations:
STORIES '1'YI'E CONSTRUIa'ION
I
❑Ihave and will maintain a Certificate of Consenuo self -insure me Worker's Compete
,.tion...... ided for by Section 37(X1 of the Labor Owe, for the performance of me
DRAINS- FLOOR, ROOF, AREA, COND.
work Ra,hicn this pcnuf i,. iewcd,
PIXTURBS - PERI RAP
N
❑ I traversal will maintain Worker's Compensntion Insurance, as m4mo d by Secllon
3900 ofthe LaborCedc,forthe performance of the work forwhichthis permit is issued.
GAS - EA. SYSTEM- I INC 40UTLIiTS
OCC. GROUP 'N
GAS- EA. SYSTEM OVER 4(EA)�,/G
MYWnders Comps yn�Insumncc carver and Policy numpe`IrL�
Cartier: id/ It=WI(Q.L'D� Polley No.:IAJP Z07A{A
CERTIFICATE OFEXEMPTION FROM WORKERS'
COMPE.NSAI ION INSURANC17
-6po
GI213ASI!IINDUS'f81, WASTE IN'IHRCRfTOIt
BUILDING DIVISION FI!ES
('f his section need not beccmpteted if the permit is Prime hundred dollars 1$1 pit
ode's.)
GREASETRAP
PLANCIIIiCK FEE Z
SHWER-SANITARY-STORM VA. 2W FT.
ENHRGYFEE t Q
Oz
I codify that in the performance of me work for which this permit is issued, I shall
not onpiny any persml in any mmma,oase becotims.hjedm the Workeli Comrar-
colon lnwsof C.lifnmia. Date
Applicant
WA'IiIt I IEA'I'HR W/VENDELEC'112
GRADING LIEF.
NOTICE TO APPLICANT: IL after parking mil Certificate of Exemption, you should
become subject to the workers compensation provisions of the tabu Code, You must
forthwith comply wins such provisions Innis permit What] b, decimal revoked.
CONSTRUCTION LENDING AGENCY
l herobympmvhat construction is a constetion lending agency far theperfonnme,cof'
me wad rnr ween tat, Permid i, i,xned (see. 309), cis. c.)
Leader, Name
Larder, Adam„
L
WATER SYSTEMR REAHNG
WAI'Ia SERVICE!
SOILS 19i1i
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PAID Date Receiptp
NEW RESIDEN'I'I Ah('LMB. SO EL
TmAI.:
TGTAI.
Buu.D1 G 'EE 7 3 /
I rectify that 1 have rend th'I, oppliunion mad tone dun m, mnovn.nrom,mltl�
come,]agree to comply with all city and county ordinances and stud, laws relating in
building construction, and hereby aflariae mpowmatives of this city if) enter uPon the
-
QTY. MECHANICAL P17RMIT FEE
SEISMIC T '
I, MI'1'ISSUANCE
ELECTRIC P, E
abovomcntionedpmpony forimpeetion p r,i
Cupertino (We) agree to save, indemnify and keep harmless the City of againsd
PIAMItINGF B
Iinhdilles,judgment,costs and expense, which may In any way acerae against said City
ALI ER OR ADD 10 MECH.
AIR HANDLING UNIT (TO IQ(NNI CFM)
MECIIANICAI. FEE
APPLICANT UNDERSTANDS AND WIL1. COMPLY WITH AL1. NON POINT
A APPLICANT NDEgrunting SANps WILL
SOV .. REGUI�nTIONS.A
AIR I IANDLING UNIT (OVER 10.000 CFM)
CONSTRUCTION' TAX
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cr(�
lAbcanl/Cuntmto )vat
Signinn' pp
EXHAUST HOODIW/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MS! ER1ALS DISCLOSURE
HHA'I'ING UNIT (101(to" HTIA
Will the applicant or future Wilding occupantwnae or handle hazardous material
as defined by the Cupenino Municipal Cale, Carder 9.12, and the ilealih and Safety
Cate S,ifian 25532p)9 '
HEATING UNIT (OVER jadf,r FIJI)
VIiN'1'ILA'I'ION PAN fSINCI.I!kIiSIDI
❑�Yes �N„PAID
Will the applicant or future building occupant use equipment or devices which
emit hazardous an commaimm, as defined by the Bay Area Air Quality Management
Data H ,iptN
)
BOILER -COM(' (MIT OR 100.001 ITU)
BOILER- COMP (OVER I do,but) B'I'U)
District?Y.^!
AIIt CONDITIONER
I have read the honammmom,riaIn requiremens under Chapter 6.95of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SO. Fit
I
f ncia Health & Safety Cale. Sections 25585, 25533 and 2553J. I understand mat if the
building does no erlrenoyhave atenant mm it is ter reals'namb 6, tomotiry me acals'nd
or theg irymaryy4hlch mugbaAno. Hjammce of Cenihc:nc �O¢yy_Cy.
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ADDITIONAL PERMIT FEES Z Q L
BUILDING PROJECT IDENTIFICATION •� VALUATION
N.
5- ti[ C FEESUMMARV
iAC Ofl eflC
BUILDING
u!
ELECTRIC PERMIT
1TLETS- SWITCHES -RECEP
GHTING FIXTURES
'PLIANCES - RESIDENTIAL
,NELS
GNS
GNS TRANS.
FGIAI CIRPI IIT
EMP. METER OR POLE IN
PERMIT VALIDATION
ISSUANCE DATE
MOTORS SEE FEE SCH.
SERVICE CHANGE
�'QFEE/
TOTAL
OTV. PLUMBING PERMIT FEE
PLOD. ELECT.
❑ ❑
PLG.
❑
NEC.,
❑
ALTER -DRAIN & VENT -WATER (EA.)
tE
EMP. METER OR POLE IN
PERMIT VALIDATION
ISSUANCE DATE
MOTORS SEE FEE SCH.
SERVICE CHANGE
TOTAL
OTV. PLUMBING PERMIT FEE
PLOD. ELECT.
❑ ❑
PLG.
❑
NEC.,
❑
ALTER -DRAIN & VENT -WATER (EA.)