S 1031 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP COPERTINO INILUIN(;-RLF:<:'1'RICAI. I'13Hh11T NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MF.CIIANICAL S 1031
BUILDING PROJELT IDFINTIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I'l-K)7 115-9 DA
OWNER'S NAME PHONE: CD RACTOR, N H: LIC NO'.
1 l- 1 e O N/C CONTROhp
lir ku L
ARCHITECfIIINGINEER: LIC NO: ADd Bliss: ❑
S v u
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) I+LDG ELECT PLUMB MUCH
❑ ❑ Com- ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 nereby afrrr Inas 1 am licensed ordmbim
title,prn of CnaPtef 9 barometer, .. JOB DESCRIPTION
WOODoo with Section 70 ))of Division 3 of the Business and Profe ....Cole,mndmyliceo.ci..
in PERMIT ISSUANCE RESIDENTIAL:
H W full force rood c0cm. ❑51'DN'L ❑KITCHEN RIiMODEL
License Class Lie N _
Uro Cnnl APPLIANCES—RE:SIDEN'1'IAL ❑ADDU'1ON MING RI PIPE
rF W ECL
44 ARC411TECI"S DECLARATION MULTI-UNIT ❑STRUMMODIFIURAIL
IO
F n y PANELS
OZ y Z 1 understand my plans snail M used as public record. MODIFICATION
.".1 UP TO ZINIAMPS
Licensed Professional [I[Nil ❑SWIMMING POOL
PAIR
Q IJ+ 201-IgNIAMI'S IMPROVEMENT SWIMMING POOLS
.I Oat I am exempt fr m Ce Cppdp ON OVER ION)AMPS ❑RA'I'II REMODELIREPAIR ❑DEMOLITION
W Q 1 hereby.(Ston that 11. exempt from the ContmctCoa License Lew romp
BC ac V following rcnam.($wBan 7113 L5,Business and Professions Coale:Any city nr munlYSIGNS I?Lf?C'I'RICAL GI Illat
w g' wmm�retrvbea a Permnh v.caonbocL nlwo Iu,prana acmminn.lir ropair any nmmaam '
prior wal SPECIALCIRCULOMISC.
that he is licensed punuummlhe pmvixinn.of the Contractors license Low(Chaprcr9
�00 (commencing with Section 7000)or Division 3 ofthe Business and Professions Cole)tot TEMP.METI3R OR POLE INST. COMMERCIAL;
L Q.c C that he is exempt therefrom and the basin for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION '❑DEMOLITION
Y• Station 7031.5 by uny apple.,for a rimpil wbjectslhc.,Iicamm.civil pcnaltyof POWER DEVICIiS
W m ❑'IMPROV ❑FOOD SERVICE
not more Nun Fivehundred
pro aly,ornymol)' IMPROVEMENT
❑La owmar of rax,rad hesitation
knit oyeexwiah wages xs..1,(Sm.7044,lc BrAnon, SWIMMIN(4I'(N3LELLQ'RIC
wdl dothework,mrd the he Ciocisnot, J,cm,Lal doforaide(Sec..144,Business ❑O'I'L{I?R
W Pretty who Cede:The Courtnereo Lieerv.e Lawdacenotrapply hi mlfownerof WTLBTS—SWI TCHES—PIX'H1RP
6 3^ progeny who hailss or improves thereon,and who nts such work himself or Innmgh
his own employees.e Provided that such improvements are not intended eprofror offerer for NEW RESIDENTIAL ELEC['R SQ
m1e.IL however,the building mrimprvcnsmin nolJ within nncywr n(completion,the SQ.EC FLUOR AREA YSV.IT.
owner-builderwill have the burden of proving that he did nor build or improve for pup-
O ''
P R!
poseofsalu). IFS D
A I4 I
El I,as owner ol'the property,am oxelv.ivcly contracting with licensed conmmmm to
construct thi pn'ject(Sec.7044.Pnnina.nnJ Ppfessioits Coxlua'fhe Convamnr's'h- - -curve Lew,does not apply to an owner or propway what Wilds or impowes dameam.and QTY. PLUMBING PERMIT FEE OCTwho contracts for such projects with a comracmr(.$)licensed parsama to the Compactor'. VC(1s0
15 O
Liccnse hw. PERMIT ISSUANCE 1 11L11
❑Iamexemptundcr Sec. ,B&I'Cforthismawt
Owner Dam ALTER—DRAIN&VENT—WAIER(EA) GP uftKiAz
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hcrchy alarm under penalty mf Penury one of the following declarations:
•Q [have and will maintain aCerrificapeol Comend loalf-insure lip Worker's Cnmpcn. DRAINS—FLOOR.ROOF,AREA.GOND.
sation,as provided for by Section 3701 of the Labor Cole,for the Performance of the STORIES TYPE CONST kI1C1'ION
work for which arts permit is issued. FIXTURES—1'I7R TRAP
C] 1 have road will maintain Worker's Compensation Insurance,as required by Section
3700ofthe Labor Cole.for the performance of the work for whichlhis penia is issued. GAS—EA.SYSTEM-1 INC.4 OLD LETS OCC,GROUP AI'N
My Wo sCm nsinir its r;m yrticrPolicy
Carie IJ Polioli num TCScy Nm.: GAS—P.A.SVSTEM-OVER 4 LUG
CERTH CATEOFEXIi I'NON PRO WORKERS'
COMPENSATION INSURANCE GREASIUINDUSTRL WAS'I'H INTERCEPTOR
BUILDING DIVISION FEES
(This section need not M completed ifthe permit is Lamm It oloeddollars(SUp)
or less) GREASE TRAP PLANCI I[CK PEE
Icenifythat in Ohepetformmce ofahe work(orwhichthispermil isissucd,l shall SEWER—SANITARY—STORM 2A.21X1 FT.
moa employ any person in any manner w a.,,,become suhject to the Workers'Compete ENERGY FEE
smion Laws of California,Date WATER HEATER W/VENT/P TC,'R
q O GRADING FHP,
NMICTO APPLICANT:IL after making chis Cenilicme of Exemption,you xhnniA WATER SYS'I'TNUTREATING
E
N
a ' become.comp m the Worker's Compensation provisions of the meds Cole,you most
SOILS I1iH
� fnnhwith comply with such provisions or permit shall be deemed revoked. WATER SERVICE
0
DCONSTRUCTION LItNDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
I hereby affirm that there is aeon construction lending agency for the perrm
faancc of Car, Receipt N
Q r.r. the work for which this Permit is issued(Sec.3097,Civ.C.)
0 V Lenders Name TOTAL:
H.7 Lenders AJdmss TOTAL:
y I certify that 1 have read this application and Stam that the above information is BUILDING FEE
y anren.lagree tocomply wird all city unJ county ordimnces and stats law.rel�tingto QTY. MECHANICAL PERMIT FEE
V Z Wildingconstmetion.and Wmbyauthon.p,rm,entativesnfdfiPOiry to enter upon the SEISMIC ITE
phaco-mentioned pmpcny far inspection purposes. PERMIT ISSUANCE
(We)agree or save,indemnify and keep harmless the City of Cupertino against ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way acere against said City AUFER OR A DO TO MECH. zip
in ean.equome of time granting of❑Js lwllto PLUMBING FEE
APPLICANT UNDCRSTANDS A 14 RILL COMPLY WITH ALL NON-POINT AIR HAN OLI NO UNIT(TO I0000 Cl'M)
SOUR ��ONS.e+ i0-r5 7 MECHANICAL FEF.
4 AIR HANDLING UNIT(OVER IO.010CFM) CONSTRUCTION TAX
Sigmtur ApplicanOCmdommr Dale EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle ramrdous mmcriul HEATING U N I'r(TO lghgy)ETC)
is defined by the CpMrthm Municipal Code,Chapter 9.12,and the Ilealth and Safety
Code,Section 25532(.)'1 HEATING UNIT'(OVER IOIkWO[ITU)
E]YO, Fl No VENT[LA'PION PAN(SINGLE RESID) PAID
Dale Receipt N
Will the air...prorfurore building occupant by]hese .Air .nt nf,vfces which BOILER—COMPUHPOR Ig1000MTU)
emit hmardom air romaminants as def ncJ by the Be,BArea Air Quality Alanagemem
Ld�anm
TOTAL:
. E]No BOILER—COMP(OVER IlN1,INN1 B'1'U)
read the bmanious mmerial.,requirements under Chapter 695 of the Cali AIk CONUI'rIONEk ISSUANCE DATE
&Safety Cede.Sections 25505,25533 and 255W.1 understand ohm tithe NEW RESIDENTIAL MECIL SQ.IT.
not currently have a tenant.that it is my responsibility to notify the oceupatnments which must be rmn prior m issuance of a Crmifrcate of Occupancy.0nrimd agent Dare TOTAL: ISSLJHD BY'
OFFICE