S 1627APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATIONIPERMIT
BUILDING - ELECTRICAL
PLUMIIING- MECHANICAL
PEICIT NO.
1627
BUILDING PROJECTIDENTIFICATION
NJ
BUILDINGADDRFSS: aX ✓
SANITARY NO.
APPI. ATION SU MITTAL DATE
OWN 'SNAME: 4HN EC(
T)1:S AM
NIC
CONTROLp
ARC 1 E TR GINEER:
pl S,
711
5'
CONTACT P/✓IT,
E0:1Consuhanl Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BOG GLE¢ PLUMB MECH
IfFyJS
IV
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under Provision of Chapter 9 (commencing
with Section ](N0 of DivisinnJofthe Bwiness andP fsiogs vl anbny license is
mull force oln :�/i `//d
License a Lic. p —
y Date Core
RCHITEC'S DECLA N
L 1 understand my plans shall be used a publicrecords
QTY, ELECTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL
D SFDWI. ❑ KITCHEN REMODF.1.
[]ADDITION DPLUMBING RE -PIPE
ElMULD-UNIT 0STRUCTURAL
MODIFICATION
El INTERIOR DS CHIMNEYREPAIRPOOR
IMPROVEMENT E] SWIMMING POOLS
D BATH REMODEIAEPAIR D DEMOLITION
❑ O HF
e &"
PERMITISSUANCIi
16
APPLIANCES
APPLIANCES — RESIDENTIAL.
PANELS
UTTO 200 AMPS
y Licensed Pmfesuonal
J OWNER -BUILDER DECLARATION
m Li
Q I hereby affirthat 1 am exempt from the Commerce's cense Law tier the
fnikeving.eamn. (Section ]11)1.5, Business and Pmlessi'ns Code: Any city or cnunty
which.... toss a permit m consauct, aIle,. Improve, de nalish, or mpan any etmcture
pri'rto its issuance, also requires the appllcaat forsuch permiuo file a signed smmmem
that he is Ream ed pu morm 1. he peavisions of the Cmfimvomrs License Law (Chapter 9
(commencing with Section 7000) of Division 3 ofthe Businesx,rd Prdnsi'ns Code).,
Y that an is exempt tbere¢'nt and the basiv tar the alleged exemption, Any violation'(
Section 7031.5 by any applicant for a peril subjects ON, applicam ant a civil penalty'!
not nmrc than five hundred dollars 13500),
201-IIXXIAMPS
OVER 1010 AM PS
SIGNS ELECTRICAL
SPECIAL CIkCUIT/MISC.
TEMP. METER OR MILE INSI'.
COMMFRCIAI:
❑NEW BhDG/ADDITION ❑ DEMOLITION
DTPNANT DFOOD SERVICE
POWER DEVICES
s
SWIMMING POOR. ELECTRIC
Dl. as owner ofthe property, or my employees with wages as their sole compensation,
will do the work. and the structure is not Intended or offered forsade(Suc. 9044. Business
IMPROVEMENT
DOTH ER
e and Proaminn.s Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work himself or through
his own emPloyces, pane Jel that such impmmmoro ton t intended or offered for
rode. If,however, the buiddingor improvement iesnld within one year ofcompdetion.the
owner-huilde, will hove the burden of proving th.t he did not MuilA nr improve far put -
pose II saICJ.
OUTLIil;5—S W I TOIRS— 'U
NEW RESIDENTIAI. CTR SQ I
-
SQ. FT FLOOR AREA
S/SQ. FT.
D I, as owner of the property, am exclusively contracting wird licensed contrnemrs m
Al.
ennsuu n the project (Sec. 7044. Business and Professions Code:) The Imumnnr's Li --
an
cause Law docs nm apply no an tearrsdpraperty who builds or improvecrhereon, a.
who ... tied, for such Projects with a enaRa,me(s)live ed pursuantm the Cotnr.aa,
License Law.
❑lam exempt under Sec. .BAP
L BIN IT
FEE
IT Is C
OwnerA
Untc
WORKER'S COMPENSATION DECLARATIO
1 hnchy alar under penalty ofperjury one of the following
Iharc and will maintain aCenificme of Cnnsem to ttlf-insure for We SCnmpen-
soden, as pmvidul for by Section 3](X1 if de Labor Cud,, for the perfn
7R-DRAIN&VENT-WATER (EAI
FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOT, AREA, COND.
*X0.60 ^VA`LUATION
/�../ J/ Toa I�1Q
��-/// AAA///vvv (l
G'fWRB$
TYPE CONSTRUCT ION
wan r which this frmit is issued.
1 have and will main Win Worker's Compensation harmonic, ax rcyuircd b , action
fi,5700ofhe LoMr Code, train of rumarricine and workolicy forwhich
Worc )tan /p/c.itt I, issued.
FIXTURES - PER TRAP
GAS - EA. SYSTEM. I INC. 4 OUTLETS
n
4' MM ! I'
19
ILL RAWS,9
AI'N
r`this
Carrier: Polly No.: V LDO/
GAS - IEA SYSTEM OVh:R4(IiA)
V HI'IJ
CERTIFICA'rIi OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASEBNDUSTRL WASTE INTERCEPTOR
T Vr vvs BUBDIN'uDIVISIoN bErs
(This section Madam he completed tithe permit is forene hundred dollars ($100)
or Iexv.) Lramify that inOne mnno worktPermit iviuell
nce ilic
not employ ay person in my Manner so ratm becomeme subject to the Workers' Conotan-
satin. of Colifomia. Dale
Applicant '
GREAS17 rRAP
SEWER -SANITARY -STORM 13A. 200 N1'.
WATER HEATER WNIiMr2LECfR
PLANCIICK FEE
ENERGY FEE
GRADING FEE
NODCETOct it) the Work IL Co makingthis Ceninsof M Labor
inn,youu amen
subject ant the Wuchr o Compensation Provisions of the Whom Code, you must
forthwith
forthwith comply with such Provisions or this pcmtit spall he Jeemcd mvnked.
WATER SYSTEMIn HEATING
WATER SERVICE
SOILS FEE
CONSTRUCTION LENDING AGENCY
I herehyaflinntbm there isocontraction lendingagency Rude Ndcn,ance of
the wed for which hil Permit is Issued (Sec. 3097, Ci, (C)
NEW RESIDENTIAL ('LMR. SQ, F1'.
PAID
Dare eiptp
I,OTAL
Lender's Name
Loader's Address
1 certify that 1 have read this application and state that the.lnwe information is
comet. l agree to comply with all city and county ordinances and va¢laws relatingto
building construction. and hereby authorize representatives of this city to enter upon the
.hove -mentioned pmpeny for inspection purposes.
(We) ngme to save, indemnify.nJ keep harriers the City ofp
Cupertino against
IiaM1ilities,jodgments, costs unJ expenses which may in..y wty.,cmcagainst said City
in consequence of the granting of this pernal.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNOWPOINT
SOURCE REGULATIONS.
'TOTAL
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,1x0 CFM)
FEE
♦
BUILDIN' 1 '
SEISMI EE
ELECTRI FEE
PLUMBINGTE -
MECHANIC& FLE
AIR HANDLING UNIT(OVER 10.000CFM)
CONSTRUCTION TAX
Signature of ApplicantiContmctor Data
HAZARDOUS MATERIALS DISCLOSURE,
EXHAUST HOOD(W/DUCry
HOUSING MITIGATION FEE
Will the applicant orfumre buildingokcupunt store nrhanJdc hazardous material
HEATING UNIT (11) 10.000 ITT U) R
as defined by the Cupertino Mumcnp���LLL...CCCvote, Chapter 9,12, and the Health unJ SafetyIL
Calc, Section 25532ho?
HEATING UNIT (OVER 100,001) BTU)
D Yes
Will the applicam nr furore building.em cup.use equipment or devices which
mina
eit maMdus air variamms as d by the Bay Area Air Quality Management
District?
❑Yes
VENTILATION FAN (SINGLE RESOD)
BOILER-COMP(lfIP OR I(NL1Xp BTU7
BOILER -COMP HOVER 100,000 BTU)
PAID
Dote Receipt 4 f
TOTAL:
I have read doe hanmlous mmedilsAIR
requirements under Chapter 695 of the Cali-
hat if the
fnmia Health &Salty CMe, Station 255(15. 25SJJ and 25534. 1 unout terse
building dce nc ndy huvcatenan4lh:n it is my rcvpmsibility tnvtitytex Pont
of the le - which must hemet prior m iv,reneenl' I'< cy.
CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT
♦
ISSUANCE DATE
000rr�----��� n o
�. le s
ISSUED BY:
at ath ..cd agent D9e TOTAL:
OFFICE