S 0979 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
- -•. BUILDING-BLF.CTRICAI, Nil
PE MI'1'NO
CITY OF CUPERTINO PLUMBING-MF.CHANICAi. 0979
BUILDING DIVISION APPLICATION/PERMIT
.BU11.01' PROJRCT IDENTIh'ICATI1)
SANITARY NO. APPLICAT]ON SUBMITTAL DATE
BUILDING ADDRESS:
CA
OWNER PHONE:. CONTRACTORS NAA9E: TIC NO; NIC CONTROL#
'f� ARCHITECT/ENGINEER: LIC NO: ADDRESS. /V:-1V x ❑
ilrp'1e1
CONTACT: PHorvG. ` r BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLi�UUMMBB MUCH
LICENSED CONTRACTORS DECLARATION QTY, - ELECTRIC PERMIT FEE ❑ JOB IPT
1 hereby affirm that 1 licensed d p f Chapter 9(commencing
- t - a
�CZO with Seninn'IBW)of D" .inn3af the Bu JProfesio Ciul,andmylcenmix RESIDENTIAL,
PERMIT ISSUANCE
a F
.1
full fnr •un eIf D SFDWL D KITCHEN REMODEL.
U. Licens C Lic# APPLIANCES-RESIDENTIAL ❑ADDITION 0 PLUMBING HE PIPE
N6 Dam Commcmr El MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION PANELS MODIFICATION
ZC y Z 1 undema,d my duce shall he used as publea mored, -
OZ42 UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F-�y,,_w Licensed Professional I 201.100)AMP5 IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
-� BATH RIiMODfjJR_GJB1R�:MGLI.IOY+ I-
tireOVEkIWBAMPS D rrrx 10 6644
yxC as Q 1 hereby reason.
B onfloI I ne rr tl C Imct e - Law for my ❑OTHER
W a�h-� toll g r (Section 70115 Business dP r..' Code;e y an county SIGNS F.LECTRICAh,
yvf
which capture,ape e In c no ) Its rap d so e h spa Y�Welure --�� --�♦)0
h t itssl issuance, 1 "y 'rc.p pal nU hperm at is 6 d tImpmr9 SP[CIAI.CIRCUITIMISC: ,Ir
/( J
Y thoth 1 :edp rs a Ncp : fah C t a L La (Chapmr9 COMMERCIAL' T�
�C (ommencingwth Set n9000)of Divnsem 3nrthe Bus'ne ndi f :Coaster TEMP.METER OR POLE INST.
W p�m that he to exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION D DEMOLITION-
W'M Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES uTENANT FOOD SERVICE
56 nl mom than five hundred dollars(8500).1 - 'IMPROVEMENT -
F. Q - SWIMMING POOL ELECTRIC
❑OTHER
wdld th w rkaMah t modure is notintended or offeredfo 1 (See,704L Business
G 3$ and Professions Cade The Contractor's I e . Law does a t a pply to an owner of OUTLETS—SWITCHES—FIXTURES ..
pr pent'who Imild,la impulses11 eon d wholemaimich work hilloctfuldromi
his own employees.provided tht. h'ropmeculares are intendednot offered for NEW RESIDENTIAL ELECIR Srr
FLOOR AREA 81SQ.Pf.
sale.IL however,the building of improvement is sold within one year of completion,the _
ne,latilder will have the burden of Proving that he did not builder Improve for aur-
pr f } TOTAL:
❑I a. of the P PrtY m exclusively contracting with f ed t t m _ � '
en Bcombine,th P jean(S '1044 Business"n d P f.:' .Cad )Th C mm t C - - 'i D
QTY- t ( :PLUMBING PERMIT estheCont ndue, 't 11
License Law. PERMITISSUANCE' �1O lamexemptunerSec B&PCfmhisreason -ALTER—DRAIN&VENT—WATER(EA) I1VALUATIDate
Owner WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE II Uh LUrt„IItyu
1 hereby affirm under penalty of perjury one of the following declarations: ,
�l have and will monarch,a Certificate of Consennomlr-insure for Workers Comper, DRAINS—FLOOICROOK AREA,COND. S'T'ORIES TYPE CONSTRUCTION
tion,us po lded for by Sodtion 37M of the Labor Code,for the performance of thn ,
work far which this permit is issued. - PIXTURES—PP.R TRAP
O 1 have and will maintain Workers Compensation Insurance,as required by Scetion -
3700oftheLabor Code,for the preforreane,ofth,work for which this permit is issued. GAS EA.SYSTEM-1 INC.40UTLETS OCC. APN
My Worker':C,m,ammma Insurance currier and Policy��I1�(�,fq
Canner: Policy No.: R 61612 S I GAS—EA.SYSTEM-OVER4(EA)
T2�CE 2TIFlCATE OF EXEMPTION FROM WORKERS' GREASPIINDUSTRL WASTE IN'I'F.RCEPTOk
COMPENSATION INSURANCE : '` ` `�BUIIW(1
rDUIVISi6N FEESsn,
(This seetionneed notbecompletedifthepermit is fmne hundred dollars($100)) GRF.ASETRAP n
edeas.) PLANCI I ECK FEE
I certify that in the part ormanmothrow ark fill which this permit is Issued,I shall SEWER—SANITARY—STORM EA.200 FT. -
not employ any person in any instance,per m become subject m the Weaker,Cnmpen- ENERGY FEE ,
z winos Laws of Calif cam Duro WATER HEATER W/VENTIELECTR -
Applicant I ` GRADING FEE
NOTICE TO APPLICANT:Ir,after making this ConlOcme of Exemption,you shield WAl'ER SYSTEMTRUATING
F become subject to the Workers Compensation provisions of the Latin,Code,you mita 901,9 PEE
o
Lail
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE -
Q
CONSTRUCTION LENDING AGENCY - NEW RESIDENTIAL PLMB. SQ.FT. PAID
I hereby affirm that is a wnstmction lending agency for the pe_.....nw of Dam Rcccipt#
W
the work which this permit is issued(See.3099,Civ.C.) -
O U L d r:Name - TOTAL'
W TOTAL:
Lend r' Address
ps I certify that I have red this application and state that the above informationBUILDING FEE
gn correct.1 agree to comply with all city and county ordinances unit statelaws relating to QTYJ t MECHANICAL.PERMIT, { FEE E SEISMIC FEE
Ll
building ct i and hereby antharim represerepacca ofthis cityt enter upon the
shou,nalleand property to,inspection p rposes. PERMIT ISSUANCE -
(We)agree m save,indemnity and keep harmless the Cay of Caperton against ELECTRIC PP.P.
liabiliaies,judgmems,costs andeldmmes which may in any wayvecrue.,mmt said CityALTERORADDTOMECH. PLUMBING FEE
in consequence ofthe granting ofthis permit. -
APPLICANT UN RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM) MF.CHANICALFEE
SOURCE
UOUA -
w AIR HANDLING UNIT(OVER'14(III( CPM) CONS'1'RUCTION TAX
Signature olApplicarefiComancen Dole EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant nr furore building occupant sneerer handle anomalies material HEATING UNIT CIO I00.II00 BTU)
as defined by alio Cupertino Municipal Coda Chapter 9.12,and the Health and Safety -
Code,Section 25532(a)1 HEATING UNIT(OVER 100,000 BTV)
Oyes, E]No VENTILATION FAN(SINGLE RES ID7 PAID
- Data Receipt#
Will the applicant or future building oucupana use equipment or devices which
. eBOILER—COMP(3HPOR 100,00ORTU)
mit hazallous air mmmin
aan¢as defined by the Bay Area Air Quality Management TOTAL
Dishict? BOILER.—COMP(OVER 101,000 BI U)
❑Yes ONo
Ihave mail the hazordousmagrdsls requirmew under Chapter 6.95 of the Cal l- AIR CONDITIONER ISSUANCE DATF.
fnmia Health&Safety CMe,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT
building does net currently haven sant,I atitjs myrespnnsibility m built,the occupant
lbamquie newhlchlus net prior t�issuance Jou_
Cnificate of ncy. -
'I
Owner mouth... agent Dut TOTAL: ISSUED BY:
OFFICE