S 1567 PPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
_ CITY OF CUPERTINO BUILDING.ELECTRICALPEg�11TNO,
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL l`7 67
15
BUILDING PROJECT IDENTIFICATION
BUILDING AIIDRESN SANII'ARYNO. AVPLICAI'11 N SUBMITTAL DATE!
05 S. e. GA 50! qPJ
OWNER'S NAME: MU !: CONTRACfOR'9 NAA1E; LIC NO:
-/ 3't 03 ' NIC CONTROL#
MW CHI'TF.CTIHNGINIiIiR LIC NO: ADDRESS: EJi ' CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECTPLUMB MECIT
k'ch4 Non 3- 03 `I. YL
LICENSE CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 nm licensed under provision..of Chapter 9lmsmmeming JOB DESCRIPTION
�aZ with Sestim17 )(Let Di......3nfthe fDo,ines,rod PmfesSlmns Code,.mJ my limroc is RESIDENTIAL:
Fes^- in full force and effect. PERMIT ISSUANCE
W ❑$FOWL CHIiN REMODEL
C—C) License Class Lica APPLIANCES-R IiSIDEN'I'[A], EIAPPLIANCES PLUMLING RE-PIPE
F Z w Dam Conlmcmr
MULTUNITnQa [-]STRUCTURAL.
ppH ARCHITECTS DECLARATION
PANELS MODIFICATION
Z O , I understand m,plans shAm
1 be used as public nrJs
OZ�G UP 170 200 AMPS El INTERIOR [3 CHIMNEY REPAIR
F-4 F'W Llcen:d Professional 201-E000AMPS IMPROVEMENT ❑SWIMMING POOLS
q k,F,-q OWNER-BUILDER DECLARATION pVIiR IlI1X1AMP5 ❑BA'TH RIiMODI1IJREPAIR DEMOLITION
j %g I hereby anion tiro 1 ran exempt from the Cantmctor's License Law for the
x6x�LV follawing reafess
wn.(Section 7031.5,Business and Profession Code:Any city or county SIGNS ELECTRICAL ❑OTHE0.
W 3 LL(• which requires a permit at contacted,alter,improve,demolish,or repair any orchme
0 prior o its issuance,also requires the applicant for such permit to rile a signednmemem SPECIAL CIRCUI'1/MISC.
fly that he is licensed pursuant o the provisions of the Contractors License Law(Chapter 9
(commencing with Section 9000)of Division 3 of the Business and Professions Civic)in TUNER MEN FR OR POLE INST COMMERCIAL:
as d c oG Nat he Is exempt therd'mm sad the basis for the alleged oman,a na.Any violation of ❑NI7W HLDG/ADDITION ❑DEMOLI'NON
�H Section 7031.56yanyapplicam farvpernit subjects he appticantlo a civil penalty of POWER DEVICES ❑TENANT El FOOD SGRVICH
of more than five hundred dollars(551X).
7�>. IMPROVEMENT'
Q wiLothewowner al'the themmnter,myernntended whffemd fair their sale compensation, SWIMMING POOL ELECTRIC
p=.'m will duthewons ande:The Contractors
tors License Law
do far apply to
Business (]OTHER
{.�j^m and Professions Code:The Commgnrs License Law docs not apply m nn owner of OUTLETS-SWITCHES-PIXTV RPS
property who builds or improve,thereon,and who does such work himself ar through
his own employees,provided that such improvements um not imende l or offered for NEW RISIDENTIALEI.I=R SQ FT.
wale.If,however.the building orimprovemem itself witbinome youisfomnplenon,the SQ.IT.FLOOR AREA $ISQ,PT.
u,builderwill have the burden of proving that he did not build or Improve for put- p ^
pose of sale.). P p ' G
❑I,as owner of the properly,um exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec 9044.Business and Professions Code:)Me Contractor s Li-
come Law does not apply to an owner of property who builds or improves theater,and QTY. PLUMBING PERMIT FEE APR 28 ANSI)
License
atim pmjects.'ah conrmCounselor'sor(s)licensed pursuant the Counselor's
License Law PERMIT ISSUANCE
❑ tum ex r n _—All �J
.B&PC for this reuwn
' ACI'F.R-DRAIN&VENT-WAI'IiR(EAI A, TJbN
caner Date
WORKER:SC NSATION DECI RATION BACK FLOW PROTECT.DEVICE
1 hereby idporn under perolty of perjury one of lie following dechanians:
I have and will maintain a Certificate of Consent o Belt-insure for Worker's Cmrpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 39W of the Labor Code,for the performance of the
work for which this Lumbut is issued FIXTURES-PER TRAP
❑I have and will andamin Workers Compensmian Fmsmmnce,as required by Section
3700ofthe labor Cade.far the performance fthe work far which this permit is issued. GAS-PA.SYS'T'EM-I INC.O OUTLETS OCC.GROUP APN
My Worker's Compenmtiom insurance ironer and Policy number are:
Grier: Policy No.: GAS-EA.SYSTEM OVER O IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thissection need not he armplemdif the permit is fetors hundred Jnllars($I(0) GREA$ETRAP - - --
i mlesx.) PLANCH[CK FF.F.
I cerify that in the volommnce ofthe work far whish this permit is issued l shall SFWER-SANITARY-S'T'ORM EA.200 FT.
not employ,any person in any manner so as to became subject to the Workers'Conifer- ENERGY FEE
OZ ration Wws of California.Date WATER I TAPER W/VF.M'MLECTR
Z Applicant
GRADING PIi Ii
Q
w+
NOTICE IT)APPLICANT:If,after making Nis Certifieme of Exemption,you should WATER SYSTEM?RFATING SOILS FEE
ati become subject m the Workers Compensation provisions of the labor Ede,you must
w0 forthwith comply with such provNitsmor his pendl,hru be deer cdoeaked WATER SHRVICB
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FT. PAID Date
LJ O thereby affirm t hatthere is a cornmcama lmongagency for the perfnrmanwo[ I;vccci
the work for which Nis permit is issued(Sec.3099,Civ.C.)
LL. F" Lenders Name TOTAL:
L) Lenders Address TOTAL:
>' 96 1 cirri by that I have read this application and state that the above information is BUILDING
FE,E corms l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
0ZZ huildingconsvnmtion.Imd hereby authorize aTresen oivnafthis city tnenter upon be SEISMIC WBS
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC F.
Iiabilides,judgniente,costs and expemseselach may many way ucoueagmam said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBIN FEE
APPLICANT INDDF}{STANDS ANL WILL COMPLY WITIf ALL NON-POINT AIR HANDLING UNIT TO 10,000 CFM) MSCI IANICAL li
SOUIiCl3 1J 'II�ZttjN51 y
AIR HANDLING UNIT(OVER IIl,1Xp CFM) CONSTRUCTION TA
- StgnalK73M PIi1vu CSntmet Date EXHAUSI'HOOD(W/DUCT) HOUSING MITIGATION .F
HAYARDOUS MATERIALS DISCLOSURE
Will thadif icant or future building necupmd,oreor handle hazardous material HEATING UNIT(To 100,000 BTU)
as defined by the Carol Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Section 25532(x)2 1 HEATING UNIT(OVER 100,1100 BTU)
Yes E3 No
VCNTILADONFAN(SINGLERESID) PAID -
I3me Receipts
Will the applicant or future building occupant use equipment or desires which BOILER-COMP DHP OR 100,M)BTU)
it hamrJnut air cnnmminants as defined by the Bay Area Air Quality Managcmem TOTAL
Lkv ;
lricl! BOILER-COMP(OVER 100,0110B"N)
❑Yes C]No
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
rami.Health&Safety Cade,Seed...25505,25533 and 5530.1 understand Nm if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a loam,that it is my resMmsibility to notify the resonant
of the requirements which must Ire met prior to issuance of u Certificate of Occupancy.
Dwnertx..thorizod agent Date TOTALISSUI!D BY:
OFFICE
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