S 0390 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY p�u+,n
CITY OF CUPERTINO BUILDING P J IT NO. O�Q V O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJh1CT IDENTIFICATION
BUILDING ADDRESS: 'Dr . SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER:SNAME: PHONE: CONT R' A N �q/^
NIC COVI'ROL#
• ARCHITECTIENGINEER: LIC NO: p O• /_ --_ . ❑
CONTACT ZPHON �y� BUILDING PERMIT INFO
�/7 KA ❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLECT PLUMB 'C
El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
a I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z with Section of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
O O PERMIT ISSUANCE
In full force and[I R
t WF ❑SFDWL ❑KRCHENREMODEL.
<F V Lirense Cla Li'.K
hQ Dale Cnntmetnr APPLIANCES-RESIDGVI'IAL ❑ADDITION El PLUMBING HF:-PIPE
F.Dm ARCHITECTS DECLARATION PANELS [I MULTI-UNIT ❑STRUCTURAL
Z O n z- I understand my plans shall W used as public retards MODIFICATION
OZ p _ UPT0200AMPS
AIR
r iii Licensed Professional ❑INTERIOR ❑ IMNEYKEP
JJ OWNER-BUILDER DECLARATION 2111-I(XIf1AMP5 IMPROVEMENT SWIMMING POOL
W Q I hereby uffrnu that I am exempt from the Cnmtracmr's License Law for the OVER IIXO AMPS ❑BATH REMODE/REPAIR ❑DEMOLITION
a6 V following reason.(Section 7031.5,Business and Professions Code:Any city or coumY SIGNS ELECTRICAL ❑OTHER
0[� which requires a Permit to construct,alter,improve,demolish,or repair any stmaure
F.10:1 a/1/.-__��
q .7
prior he is
issuance, the o thefor Contractors
ontrasuch tors to file a Law ned(Chapter
SPECIAL CIRCUIT/MISC. —T -
i � (comma licensed pursuant hvhnodDi.vionsof theeBusins and Prue WwlC Code)or
YCI p0 that
a is(commencing thenivin and the iaiii for
oft he Business and Professions An ionsCMe)or TCMP.METER OR POLE INST. COMMERCIAL:
ayx c e that he is exempt rhemfmm and the beers for the sts the exemption.Any violation of ❑NEW RLDGIADDITION ❑DEMOLITION
W� Section l0JL5 by any applicant torn permit suhlects the applicant¢tacivil penalty of POWER DEVICES
Vi
[]TENANT ❑FOOD SERVICE
I„Z} not more than five
eproPhundred dollars
yemp' IMPROVEMENT
=a0 ❑Lothe owner k.the pmpeny,or remyemntnyecs nded stuwagesas rsaleirmle compensation, SWIMMING POOL ELECTRIC
will Bothe wons ands: he Core isnotkende Law red does not apply to an owner of ❑OTHER
L E6 and property
nth ons Cale:The Cns havec'x License Law does not apply s if owner of OUTLETS-SWITCHES-PI%TURIiS
.. his o ny who builds or improves thmen improvements and who docs such wtak himself or ermugh
his own employeese provided that such entis am not intended or oIT[red for NEW RESIDENTIAL ELECI'R SQ PT.
side.If,hawer will h ve building burden
of proving
is he id n one build
improve
far ithe SQ.pit.MOOR AREA SISQ.FT.
neof.1c.er will have the burden of proving that he did not build or improve fur pur-
pose
❑1.as owner of the property,am exclusively contracting wish )Hie d commctors TAI:
_
construct the project(Sea.9U14,Business anJ Profcssinns Code)'IheComractoisLi-
i-
ccnseLow does not apply tounowner ofproperty who builds orimproves thereon,=it QTY, PLUMBING PERMIT FEq BCEdVED
who contracts for such projects with a commetor(s)licensed pursuant to the Contmemrs
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&PCfor this reason
ALTER-DRAIN k VENT-WATER(EA) U
Owner Doc TIO
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby afro under Penalty of p jury one afore following declarations:
❑I have and will maintain u Cenifcme of Consent to cf-insure for Workers Camper- DRAINS-FLOOR,ROOF,AREA,COND. YI'G CONSTRUCTION
swion,as provided for by Section 37M)of the Labor Calc,for the Performance of the
a for which this permit is issued. FIXTURES-PER TRAP
w 1 have and will maintain Workers Compensation Immomer,as required by Section
37IX1 of the Labor Cale,for the pufomance of the work for which this permit iv issued.Simmer GAS-1?A.SYSTEM-I INC.4 OUTLETS W.C.CROUP APN
My Work M1ratin Fce ice and Policy,nypt�Jfs
Cartier: Policy N. U✓�OY� GAS-EA.SYSTEM-OVER 4(EA)
CERT ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASENNDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION FEES
(This sudor need not becompleted oldie permit is forone hundred dollars(1100) GREASETRAP
or less.) PLANCHECK ITE
I cenify that in the p[rfornameeol'rhe work lit,which this permit is issued,Is hall SEWER-SANITARY-STORM EA.200 FT.
not employ any petmn in any manner so us to become subject'.the Wmarns'Coapea- ENERGY FF.E
Qs� section"assof Califomin Doc WATER H17ATER WNENTNLECTR
O Applicant I GRADING FEE
yNOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEMOD EATING
abecome subject to the Workers Compensation previsions of the labor Code,you must SOILS FEE
{>a forthwith comply with such provisions m this permit shall IN,demand revoked. WATER SERVICE
�.Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL Pf.MB. SQ.f4. PAID
V p work
which
that there i.cae.construction0 lending agency fonhe p[rfnmance of Die Resetp
1-i the work lou which thou permit is issued(Sea J099,Civ.C.)
ndeta Name TOTAL:
Ulenders Address TOTAL:
1 certify In.,1 have read this application and state that the ahnve infnmwtion is BUILDING ITE
rq correct,l agree to comply withal]city and county ordinances and stoic laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction.andherebyauthorire representatives oincinerationiscity inceraton rhe SEISMIC FEF,
s.r ahnve-meminnedPimpmy fur inspection purposes. PERMIT ISSUANCE(We)agree m save,indemnify and keep harmless the City of Cu,,muna against _ ELECTRIC FEE
Iiabilities,judgmetns,costs and expenses which may in any way arcane against mid City ALTER OR ADD TO MECH. PLUMBING PEE
in consequence of the growing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 IB..CFM) O
SOURCE U) ON
TIS. / MECHANICAL FEE
�• /I . !//!` / AIR HANDLING UNIT(OVER 10,000,CFM) CONSTRUCI'IONTAX
return fApplicont/Contracmr !!!Dara EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE .�
Will theapplumnor future building occupant some or handle hararAms material HEATING UNIT(In I00,000 BTU)
as JefineA by the Cupertino Ma.' ail Csde.Chapter 9.12,and rhe Health unA Safety
Code,Section 25532(u)? //y� HEATING UNIT(OVER 100.000 BTU)
E)Yes LIf No PAID
V ENTILAI'ION FAN(SI NGLT:RERIpI pan RecciPtp
Will the applicator future building recopied use equipment or devices which
t hnvNnus nrenwamim as sued by the Bay Area Air Quality Management BOILER-COMPpHPOR 110,000 BTU)
'.[tar -70
DTOTAL:District? Yes BOILER-COMP(OVER 1(X1,100 BTU)
No
AIR CONDITIONER
l cave rendre[Cod.,
25505.11533 an under .1 understand
tthe Cwi- ISSUANCE.DATE:
].tato Health l yyfiy Cala ea tins 25505.21533 and 25534.1 undeatard that if the NEW RESIDEVf1Al.A1ECH. SQ.FT.
In
drev Bacot] [otertanL that it ismyresponsibility to ndfyt occupant
of rhe tar uwhrd ata be met prior to issuance of Cseiifi '179�e,pur}y. 111 1,^l
O e/ro/r ou rued aLg,att l//�--^ // ` /IDatee TOTAL: ISSUED BY:
OFFICE