B 0448 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY {h{�
CITY OF CIIPERTINO BUILDING-ELECTRICAL PERMIT NO.�O
BUILDING DIVISION APPLICATION/PERMIT PLUMBIrvc-MECHANICAL S000l
448
BUILDING;PROJECTIDEN'fIFICATIOry
BUILDING ADDRESS: SANITARY NO. APPLICAT ON SUIiMI'I'fAL DATE
,� �1�1Q�
OWNER, N P UNE CO �R'CI'OR'9 NAME: LIC NO
OJJfr NIC CONTROLN
CHIT ECT/ENGINEER: LIC NO: '" A UkF.. x' / El
CONTACT: PHONE: - :BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MELD
' ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECPRICELRMiT t �FF.E t� '
1 h by affirm th I 1 x licensed d p f Chapter 9( c' g SOB DESCRIPTION
OaZ 'th Seep 90007 ofD A fih Bus and Profesvi m'C d and my lice se sSIL:
W O PERMIT ISSUANCE
Fn full Tom,Ia and�eRmt./�W . SPDWI.
El KITCHEN REMODEL
�UU Lice 3* .,a,fur/4 Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
y d 4 Datc Com
F Py ARCHITECT'S DECLARATION PANELS [IMl1LT1-UNIT El STRUCTURAL
so
z O y''6 1 understand my plans shall The used as public records MODIFICATION
Oz�.O , .. UPT0200AMP5 ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
�d OWNER-BUILDER DECLARATION
C' L hereby afftmr that 1 am exempt from the Contractors License Law for The OVER 1000AMPS y❑BATH REMODEUREPAIR ❑DEMOLITION
O F V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL 'O MIER t
1+13 R 1"r which fegnircs a permit to construct,alter,improve,demolish,or repair any ewemre _ /♦"G/ `�Ji R� y�
F♦90 priorm its issuance,alsomquires the applicant forsuch pemdt to fileasigned statement SPECIAL CIRCUFFMISC.
p pm. that be is licensed pursmn1.lhe provf,mr,of the Contracture LiA, eLaw(Chapter 9
(commencing with Sectio 9000)of Division 3 ofthe Business and PrOmasions Code)or TEMP.METEROR POLEINST. IV
COMMERCIAL' '
CL y M that he is exempt therchnm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
$LLE7 Scmia,01191,1 hyunyappliunt malpermh sobjectstheapplicuntm acivll penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not mom than five hundred dollars($500). IMPROVEMENT
d ❑I,as owner f has property,or my employees with wages vs their solo compensation. SWIMMING POOL ELECTRIC
O will do the work, d the sanctum is not intended or offend sale(Sec.70TI,Business El OTHER _
and Professions Code:The Convector's License Law does ant apply m an owner of OUTLETS=SWITCHES-FIXTURES
�' .. property who builds or Improves thereon,and who does such work himself on-through
his own employees,provided that such improvements are not Intended or offered for NEW RESIDENTIAL ELECT R SQ ET.
cdc.If.howeverrhemining or improverralise.ld within oneyefirof,oropletim',he - SQ.FT.FLOOR AREA $ISQ.Irf.
ownenbuilder will have the burden of proving that he did not build or improve for Pur-
pum if sale.). '
❑1,as owner of the property,am exolmively r mraaing with licensed commemrs In _ TOTAL: -
construct the project(Sec.7044,Business and Professions Cade:)The Contractorv's Li-
roveLawdoesnotapplytoanownerofpropmyw ho builds or improves therm,and QTY, PLUMBING PERMIT ( FEE
who contracts for such Interco,with a couthei licensed pursain t.the Characteds
License Law, PERMIT ISSUANCE
1 at.exempt under Sec. .B&P C for this reason
wour Date
ALTER-DRAIN @ VENT-WATER(EA) VALUATION
WORKER COMPENSATION DECLARATION BACK PLOW',PROTECT.DEVICE
1 herebyoff ranander pantry tifeperjuryoneofthe following orker'iCo
I haveand will malmain aCenifican.f Consentmnel[insure for Worker's Compen- DRAINS-FLOOR,BOOP,AREA,GOND.
STORIES TYPE CONSTRUCTION
"ration,as provided for by Section 3700 of the L aKir Code,for the performance of the
we k for which this pemdt is Issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section - -
WoftheLaborCode,foHhe pdronmanec ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN -_
y Work Co. 95 tion Ins ler and Policy 9ypr�$�$,
Carrier: (s+IfQL�N�7� Policy No:
/�5./_/J � GAS-EA.SVSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(Thlssecdon need..becompleal ifthe permilis form,hundred dollars($100) - a a `-BUILDING,INVISION P2H5
or less.) GREASETRAP PLANCHF,CK FEE
I certify that in He performance ofthe worker.,which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT.
- of employ any person In any manna so as to become subject to the Workers Camper- ENERGY FEE
Nation Laws of C.liPoram,Date WATER HHATER W/VENTIFLECTR
Applicata ) GRADING FEE
q NOTICE'f0 APPLICANT:IL after making this Certificme of Exemption,ymr should WATER SYSS'EMGREATING
become Imptne the Worker's Compensation provisions of the Labor Code,you mSOILS FEE
-
WFar forthwith comply with such provisions or this permit shall To deemed revoked. WATER SERVICE
1 Q
CONSTRUCTION LENDING AGENCY NEW kESIDENJ'IAf.PLMR. SQ.PC PAID
U z Iherewhicht ithecenti isnad pice.30lending agency for the performance of Dam RcceiplM
U 0 the work fur whits this paroit is issued(Sec 3097,Civ.C.) -
u"' H Lender's Name TOTAL:
W Lender's Address TOTAL , S
1 codifying 1 have rend this application and sum that the above information is BUILDING FEE
ra/1
correct.I agree to comply with all city and county ordinances and state laws mating to QTY. - MECHANICAL PERMIT, t FEE
U z building construction,and hereby norhaize representatives of this city to enter upon the SEISMIC THE
move mentioned property for impedium purposes. PERMIT ISSUANCE+
(We)agree..save,indemnity and keep harmless the Cityof Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way reduce against said City ALTER OR ADD TO MECH.
in omoc t aec of the g.art,of this permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIRHANDLING UNIT(T)10,"WCFM)
MECHANICAL PEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature oJ'ApIdeard/Cmitheran Date EXHAUST HOOD(W/DUCO HOUSING MITIGATION PEE
'HAZARDOUS MATERIALS DISCLOSURE
Will thevpplieenror future buildagnaupantsme,or handle hazmmus mmnuil HEATING UNIT(TO 100,000 BTI,)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Surety
Cold,Son.25532(x)7 HEATING UNIT(OVER 100,00)BTU)
❑Yca El No PAID
VENTILATION FAN(SINGLE RHSID) lc a flip
Will the applicant or furore building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
.wit hazardous air contaminants as defined by the Buy Area Air Quality Management AL:
Dislficl7 ' I BOILER-COMP(OVER 100fo(p BTU)
E3 ye, ❑No
I have read the Reactions materials requirements under Chapter 6.95 ofthe Cali- AIR CONDITIONER il�SLJANrE RA
fAldid�
Safety Code,Sections 25505,25533 and 25534.I understand Nat if rhe NEW RESIDENTIAL MECH. SQ.FT.
to ray haves mnaut that it is my responsibility tonorify theomrpam
hton mal pnonolssuanc..fa Ger leg! e p
mcr%
F///
ori' TOTAL: IS :OI
OFFICE