S 1058 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY r 1T NU.
CITY OF CUPERTINO BUILDING.FLEQ'RICA], 1058
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFIC'A'IIUN
SSANITARY NO. APPLICATION SUBMITTAL DATE
BD17335ES.
�o��ch zr a GuG'1
OW RES NAME' / ��� /� NTRACTOR'S NAME: LIC NO: NIC CONTROLX
•A CEC ( I\ LIC 4 DRESS: ❑
w
CONTAq' .,/PHONE: BUILDING PERMIT INFO
N�+�"-' R�J /_ply A ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby apron that I..licensed under provisions of Chapter 9(commencing RESIDENTIAL,
woZ with Sedian]IXN))ol DivisionJnf the Business and professions Cale,unJ mylittna is PERMIT ISSUANCIi
1-�O in full force and effect. ❑SFDWL O PLUMBINREMODEI.
FZ License Claes Uc.# � _5 � ' APPLIANCES-RESIDENTIAL ❑ADDITION C3 PLUMBING RE-PIPE
v16 URAL
ARCHITECTS DECLARATION OMUCTI-0Nff OMODIFICATIO
F= �°"�� a PANELS MODIFICATION
,Or2 edPda d pl ear puhlic record UPT0200AMPS ❑INTERIOR
OCHIMNIiY REPAIR
�t!f-u�l Licen. fessmna ]01-1000AMP5 IMPROVEMENT SWIMMING POOLS
OWNER-BUIL 'R DECLARATION OVER It%NI AMPS ❑BATH RIiMOEF;IJRF:PAIR 0 DEMOLITION
I hereby affirm that 1 um exempt from the Contractor's License Law for the ❑OTHER
O d U following mu an.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL.
S LL LL iH which requires a permit to consumer,alter,improve,demalish,or¢pair any structure
y-rn� prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
�} that he is licensed pursuant to the provisions ofthe,Contractor's License Law(Chapter 9 FOMMERCIAL
ti�p0 (commencing with Section 7")of Division 3 ofthe Business and Notessions Code)or TEMP.METER OR POLE INST. 'W BLD /AUDITION ❑DEMOLITION
k npG that he is exempt therefrom and the basis for the alleged exemption.Any violation of
ySection]031.5 by any epplicam far a pemtit sobjxts the vpplicam m v civil penalty of POWER DEVICES WT6SERVICE
O
ANT CT �i1 ice!
Fy tmorc than five d d
ve hundreollars($eco). I ROV ENT
2 O
q ❑Losowaerofureproperty.or myempinyces with wages as thcirwle compensation, SWIMMING POOL ELF
CTRIC ❑0TH CI
T r 22 willdothework.andthestructureisnet intendcdaraRemftorsale(Sm.]IM4.Business OI1lLE1,S-SWI'fCHPS-FlXTURFS lX r LJNEHill+1�
W and professions Code:The Contractors License Law does not apply to ua owner of
�•'3� property who builds or improves thereon and who does such Werk hiumcIf or through. NEW RESIDENTIAL ELECCR SQ FT.
his own employees,provided that such improvements are not intended or offered for SQ.IT FLOOR AREA S/SQ.FI'.
sale.it.hawever,the building or improvement is sold within one year of completion,the
10,
owner-builder will have the burden of proving that he did not Wild or improm for pmr-
pose of xalx).❑1,as owner of the property,vat exclusively contracting with IluenscA contractors 111 `/)IL
consumer the pmject(Sec.704.Business and Professions Cede:)The Contractor's U-
cense Law does not apply to an owner of property who builds or Improves thereon.and QTY. PLUMBING PERMIT FEE
mo
who mmcts far such projects with a comecomIs)licensed pursuem m the Communes
License Lew. ,B&I'C for this rc¢wn PERMIT ISSUANCE
I um exempt under Sec.
ALTER-DRAIN&VENT-WATER TEA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROI'ECI'.DEVICE
• 0I hereby affirm under penalty of perjury one of the l'oliowing dectrommos:
I have
ve and will mormin a Cenificate of Consent to.®IFinsum bow Compen- DRAINS-FLOOR.ROOK AREA,CON STORIES TYPE CONSTRUCTION
sation.as provided for by Section 3700 of the Low,Codefor the performance of the FIXTURES-PER TRAP -
work for which this perdmt is issued
O 1 have and will maintain Workers Compensation Insurance,an militated by Section INC.40UI'LETS
37M ofthe Labor Code.for the performance of the work for which this permit is issuGAS-EA.SYSTEM-I ed. OCC.GROUP MIN
My WarlufrjQmraRggwY �nypp carafe aarrie PoltC N1oY^ T �a�� GAS-EA.SYSTEM-OVER 4 G)
Gorier. %%GG''� J
CERTIFIC
COMPENSATION
OMPSATIONIINN INSURANCE M W
ORKERg' GREASIANDUSTRLWASTE INTERCEPTOR BUILDING[) SIONPM
(ThisarionnerdnoW<ompieedifLhopmitisfnronehundrerattn
(g10U) GREASETRAP PLANCt{ECK FE �
or leas.)
(certify that in performance of the work for which this permit is issoCd,l shall SEWER-SANITARY-STORM PA.200 PI'. ENERGYF E /a
not employ any pcnon in any manner sn ry'y-begp uIU1TFt to the Wnrkeri Contpen-
O z cation Laws of r�Ja t71ua/P1=moi ✓/� WATER HEATER WNIiNT/ELECTR GRADIN 'F
O Applicant_y _ycf ��
z y NOTICE TO APPLICANT:IF,utter diXt.ing this Cemficate of Exemption,you.should WATER SYSTEMiTREATING SOILS I' :
1� [" heoomo.onbjea to the Worker,Compensation provionno of the Labor Code,you must
forthwith comply with such previsions or this permit shallW deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Dat Racipt X
O
V z Ihefehy^Rrm that them is a constriction lendingugehey for the performance of
U. [[[tors.. the work foo which his permit is issue)(Sec.3U9],Civ.C.)
UT'OTAL:Lender'e Name TOTAL:
Lenders Address BUILDING E
I certify that I have read this application and store that the above information is
W correct.)agreemcomply with all city and county uNinvnces and stem laws rengm Q'I'Y MECHANICAL PERMIT FEE SEISMIC F.I,,
U Z building construction,and hereby uutherien representatives of this city to enter upon the
abovamcntioned property for inspection purposes. PERMIT ISSUANCE ELECfRI FEE
(We)agree to save.indemnify and keep hartnlecs the City of Cupertino against
liabilities,judgments.costs and expenses which may in any isayaccric against said City ALTER OR ADD 1'0 MECH, PLUMBIN 'EE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICA :EI:
SOU 'REGO \TIONS. -`-'^�`xaa"z
A=?w. AIR HANDLING UNIT(OVER IILIM)O CPM) CONSTRUCTED A%
Signbtte of Applicom/ on Datc EXHAUS"f HOOD 1W/DUCT) HOUSING MITIGAT IN FEE
HA AkTIGUS MATERIALS DISCLOSURE'
Will the applicant r future Wilding occupant store or handle hanorolous imenal HEATING UNIT(TO 100,000 BTU)
as)dined by the Caperton Municipal Cedc.Chapter 9.12,and the Health and Sm'ety HENEING UNIT(OVER 10i BTU)
Code,Section 25532(al] - PAID
Oyes ON. VENTILATION FAN(SINGLE BUSED) Dae aciptp
' Will the applicant or future building occupant use equipment or devices which BOILER-COMP 0HP OR 1 W,INNI BTU)
emit huzvdon,air contaminants as defined by the Bay Area Air Quality Management 'TOTAL:
Distric"' Yes Otho BOILER-COMP(OVER I W.000 BTU)
AIR CONIy1TIDN1iR ISSUANCE
1 have mad the h=mm%mammal..requirements under Chapter 6.95 of Jw Call-
fomia Health&Safety Cole.Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does nm curendy have n ommnt.that h is on,rtxfeasibility to oaify Ne occupant
of the rgaimments which must W met print on issuance of a Cenificae of Occupancy.
( A '. ISSUED❑Y:
Owner or authonsdagem Oma
OFFICE