S 1204 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY-
CITYOFCUPERTINO BUILDING-PLUG I'RIC,AL PESIT NO, 12U4
BUILDING DI
APPLICATION/PERMIT PLUMBING-MECHANICAL ``7
BUILDING PROAEC'f IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:
I �nlU
O E 'S NAME. PHUN -3 1 C N'RACTON'.0 MAMF ' LIC NO'. NIC CONFROLk
�f AR HITGC'f/ENGINEER: LgLIC��NO'. AUDRF:SS', (n/�I\ ❑
11 CONTACT: PIIONE: BUILDING PERMIT INFO
L I y 1 b" �t '� ?,'l/�-��31� ❑ Consultant Few Paid by Applicant(Initial) nLllG -el CT PLUMB MUCH
El El ID
LICENSED CONTRAC TORS DECLARADON QTY � f � ELF.CiTRIC PERMIT', FEE
I hereby ufff n mut lam her wad d p " f Chapter 9(core rte vng JOB DESCRIPTION
WQO wim5tsun]IXro)af 11 v,on3ofthc Bu,rnv,and P'of sent ns G�JC,end nylce:ants pERMII'ISSOANCE RESIDENTIAL'
HSI
- in full fnrocandeffceG Z, j(�s2 0SFDWL DKITCHENREMODFL
�UL Lmcn,c Cln Licp 1', ��� APPLIANCES—RESIDENTIAL ❑ADDU'ION ❑PLUMBING RF.-PIPE
p.Zw Dv.o o� Camra !*(�J�
m6q T ARCHI I ECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
1,,,D m2 PANELS MODIFICATION
Z D y q I undefstvnd my plan,shall be used as pu E,accord,
Dzi,,,D UPT(1200AMPS []INTERIOR El CHIMNEY REPAIR
p.t vujFW Licensed Prore„ionad 201-Imx)AMPS IMPROVEMENT El SWIMMING POOLS
OWNER-BUILDER DECLARATION
a J OVER 1000 AMPS ❑BATH REMODljl/ PAIR ❑ EMOLITIO
tv]6 1 hereby affirm that 1 am exempt from the Contractors License Law for the
D C U following ma,n.(Section 9031.5,Business and Pmfeasions Code.Any city or countySIGNS ELECTRICAL ElOTHER
W R 1"' which requires it parent to consu'uct,Blear,improve,demolish,or repair any snnclurc
F^n06 prio t i '1 "Pares thoormilt Ecrion(to file a ogradvnitemend SPECIAL CIRCUI L/MISC.
math,: 'licensed "practical thp 'nflh Cream L Lw(Chvpm 9 COMMERCIAL,E5D0 team ncnctng with Secuon]000)of Division 3offle Bavne,and P f: nsCode)or TEMP ME')ER OR POLE INS"T.
d ryt a mal he i,e,unpl Wcrefrom and the husk rear the alleged exemption.Any viulmiou of ❑NEW BLDG/ADDITION [:IDEMOLITION
W m Seetion9031.5 by any applicant fear,Earn...snbjen,t he appheam euctvll perultynf POWER DFVICES EI TENANT ❑FOOD SERVICE
Z0Pot mom than five hundred dollars($500). IMPROVEMENT'
(] I,ve ownnrof.hepmpeny,onny enryloyecs with waged as thea solecompen,nlinq SWIMMING POOL ELECTRIC
Nwill do the work,mnd the structure is notinteded or oBcied Russia(Sao 7044,Desire,, EI OTHER
'y C m and Prnfe,vine Code:The Contractor,License Low docs not apply to an owner of OUTLETS—SWITCIII35—FIXTURES
C 6•'� property who hadds or umpmves merle n,and who docs such work himself or nrough
his own cnTlnycev,provided that such Improvements are not Intended or offered for NEW BESIDES AL HLSCTR SQ FI'.
sale.If.however lhebuildingm'improvecenti ,old within one yeerefcumrIv Tory the SQ AOHft AREA 5/SQ.FI',
mr-builder will have the burden of proving(hot ho did not build or improve for par- 1 4J
pose ofsalcJ.
❑ 1 f the pouumy,to.c.chowely cinna,dii, In ficano.1 cour t m TOTAL:
commurt.h p ject(So,7044 Basins, ad I r . C d]HareC t 'I r:L'- - ANSr�
,IP,a Law coconut applyt f property who h 'ld ' prove,m d QTY PLUMBING PERMIT FEE CSIs
whommrams In....Itprojtw
, ithm
antracvmn
u0,)Incensed purthe Content
Liccnvc Law, PERMIT ISSUANCE UF �Urcn r my
I am exempt under Sec ,B&P C for this reason
AL'T5k—DRAIN&VENT—WA'fSR(F.A) VALUATION
Owner Date
Wm under
WORKER'S (IT
COMPENSATION DECLARATION BACK FLOW PRELl'.DEVICE,
I hereby sere ander penalty of perjury one of the following Jeclamtians:
❑ (nave andwill for
neCeni finae ofGc Labor Code,cue Por Worker'sce of the DRAINS—FLOOR,SOUP.AREA,COST. STORIES 'GYPS CONSTRUCTION
action,vs provided far by Section 39.H1 of 0o Labor Cale,far the paTarmnnm of the
work far which this permit is issued. FIXTURES—PER'I'RAP
Fl have and will maintain Workerb Compensation Insurance,,s required by Section
3700ofthe Login Code,for the performaneeoThe work for whkh mid penniti,isaued. GAS—EA.SYS'TEM-I INCA OUTLETS OCC.CROUP APN
My Wo J Pnllcy t
Carrier: ��rEtLryyr Policy Na: `D GAS-EA.SYSTEM-OVER 4000
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASE/INDUSTRI,WASTE INTERCEPTOR
(Thi,sectionucerf beceir el if peanut is foronehundredJolla a($100) 4 9-X t d sBIyI1TD(NG gIVI JOIN IIE(35,„ o} r v
or less) CREASE TRAP PLANCHECK FEE
I certify that in the performance ef.he work forwhich this permit is issued.)shall SEWER—SANITARY—S'fORM P.A.2N)FT.
not employ any person in any nwnner se as to bemme subject to the Workers'Compen- ENERGY PER
,Z satins Laws of California.Data WATER HEATER WNEN DE "Cri,
0 Applicant GRADING FEE
h NOTICE 1'0 APPLICANT:IL after making his Coatitieate of Excromme,you"bout,' WADIR SYSTEM/TREAUNG SOILS FEE
f~ become subject ,,the Worker's Ceepen„lion previsions of.he Labor Gore.,you malt
Wforthwith comply with such previsions or this permit shall he decreed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMIi. SQ.FT. PAID
U O Date Racaipt#
1 hereby affirm thatether i is a sed(Spe.30 lending agancy forme perfnnnanec nl
the work for which thi"permit is iewed(Sec.3fF)],Civ,C.)
C) Lender'.,Name 'TOTAL:
de
{U Lenr.,' AJdmsa 'I'OTA L: BUILDING FEE
P. I certify that 1 have read this applicvemn and score that the ntvwe'mfon imune is !
:jr) corect.Iagree to comply with a0 city and county inductions and state law,misainge -QTY MECHANICAL PERMIT FEE
U Z hulldo,conswction,unit friary authorize represrnmtives of.lnls any to amer upon the SEISMIC PER
abnve-mendnned property fur Inspection purposes.
(We)agree m save,indemnify and keep hafnJesa the City of Cape he,,agupre, PERMIT ISSUANCE BLGC'I'RIC FEE
liubllitlos,judgmcnts,may tad as,
y way eccma ugninstauid City ALTER OR AUII'fO SUCH.
PLUMBING FEE
mveyuonce of the gaming 'tA 'LICANTUNDERSTAN SY WITH ALL O POINT AIR HANDLING UNIT GO B(IOBCIM)
SC IN'E EGULATIONS. AAA MECHANICAL FEE
4 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION FAX
Sign.urea ppb'miwuractor Uat,
EXHAUST HOOD(WIDUCT) HOUSING MITIGATION PEE
(ALAR DOUS MATERIALS DISCLOb RP.
Wt cant offtire buildingas,r,at,em on handle mission.,material HEATING UNI'I'('10100,I1W BTU)
;is defined by the Cupertino Municipal Gude,Chapter 9.12,and the Health and Safety
Cade Section 25532(,)^ HEATING UNIT(OVER 100,000 BTU)
E:1 Yes E]No PAID _
VENTILATION FAN(SINGLR RP.SID) Data Rccaip.#
Will the applicant or fninre building occupant use equipment or devices which
em0 haenrdous air contaminants a,define l by the Bay Area Air Quality Management BOILER (3HP OR 100,(100 BTU) TOTAL:
Disln tP
❑Ye" ]No- BOILER—COMP(OVER IINI,IHNI RTC)
I have rte ad the ha,rial nmeatil,cquircmeaslmder Cnapmr 695nr thea Cali- AIR CONDITIONER ISSUANCB DATE
fnmi,Health h Safety Gde,Sections 25505,25533 and 25534.1 under dual t1ram the NEW RESIDEN'I'I Al,MECH. SQ Pr
building does not curren0y have tenant,that iti,my responsibflf.y to nobly me occe,ant
of the requirements which must he mel prior in issuance of a CerlOcvm of Occupancy. .
Ownennaumnrixd ogee Dae TOTAL: ISSUED BY:��
OFFICE