S 1695 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY II
CxTY OF`;UPERTINO BUILDING-ELECTRICAL PEI ITN°. 1695
'%UILDIN( MVISION APPLICATION/PERMIT PLUMBING-MECIIANICA14
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANI"(ARV NO. APPLICATION SUBMITTAL DATE
. t)Wpyr g L., ez1� PIION^�Yi CONT ACffIR'S _ � `LIC
/�f'/,J•b^ /J�/YL iT✓/ l/-IGi�IfxiJ�ln)J' N/C CON'PROLp
ARCHITECDENGINEIiR: LIC NO: ADD�I'''o r&X 1X3 G1u0s
N'iACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG P%E^ PLUMB MLCCII
E yP +9
LICENSED CONTRACT OR;S DECIARATION QTY ELECTRIC PERMIT FEE
1 hereby alum that 1 am licensed under provtdons of chapter 9(commencing JO DESCRIPTION
WOO with Section]0mBofluvision3onna Business and Professions Com.and.,]team.is RESIDENTIAL,
Fly_ in full formis"L1m, ( PERMIT ISSUANCE. ❑SFDWI, ❑KITCHEN REMODEL
FU U Liv en I' G-'/D C- Lic.p
N<d Date 1= Commctor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIiPIPE
ARCHITECTS DECLARATION PANE(S ❑MULTIUNIT ❑STRUCURAL
F n y
Z O raj.Z. I undersmnd my plana shall be used as public re<nNs MODIFICATION
O Z..C UP TO 200 AMPS
I=�F'ul Licensed Professional F1 INTERIOR NT SWCHIMNEY REPAIR
❑SWIMMING POOLS
❑BATH BEHOOF
OWNER-BUILDfiR DECLARATIONm� 201-1000AMPS IMPROVEMIi
r� �a 1 hereby notion that 1 am exempt from the Cntmor.s License law for the OVER Top AMPS erm %JL1 I ? ETI
yU follnwialmalnrs(Serbian TD1.5,Business and Professions Code:Any city or coumF.k Y SIGNS Ii1.IiCENICA1. ❑OTH
W'3 LO y which requires a pit it)mi improve,c met,alter, prove,demstrustructurenikh,or repair any structure
prior to its issuance,also requires the applicant for such permiuo file a signedswhanno t SPECIAL CIRCUI I'/M ISC.
ped..
In.[he is licensed p imuunt m the provisionx of the Contractor's License Law(Chapter Y
gn (rommencin with Section 70(0)of Division 3 afrhe Business and Profcasions CodeCOMMERCIAL:
gwi pts '(EAR METER OR POLE INS'1'. —
L a o that be ix exempt therefrom and the brei or the alleged exemption.Any violation of ❑NEW BLDG/ADDITION U D ION
Section 703 LS by any applies.,forapcmtit xuM1jecxc the applicam waciril penalty of IroWF:R DEVICES
Ixzl m ❑THNAN'P ❑FOOD SERVICE
"" noo.tveunre
han five hundred dollars($500).
1,a
FZ}
$$Q Oax owner of the property.or my employees with wages as theirmle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is nut Intended oroffored for sale(See7044,Buainesv ❑O'EURR
W m and Profession.Code:The Contractor's License Law does not apply to an weer n( OUTLETS-SNITCHES-Fl%TURF
L 3^ property who milit,or improves thereon,and who does such work himself onhrough
his own employees,provident that such improvements are not intended or offered for NEW RESIDENTIAL ELECT R S FT.
sale.If,however.the building or improvement is sold within one year ofeompletion.the SQ,IT.IU.00RAREA $/SQ,vT
nerbuilder will have the burden of proving that he did not build or improve for our.
(rose of sole.).
I,as owner of the property,am exclusively contracting with licensed conar,mrs to pp
construct the projmt(Sm.7WL Business uad Profir"K o CodeU The Gmtmnlnr's Li- A B
cense Law does not apply it)an owner ofpmpedy who build%or improves thereon,and QTY. PLUMBING PERMIT
who contacts fmsnch projects with a contmclues)licensed pursuant m me Commucmrs
License Law. PERMIT ISSUANCE WAY 22 ANSr
❑I am exempt under Sm. ,B&P C for this reason
Owner Data
ALTER-DRAIN&VENT-WATER(FA) 'I f VALUATION
/ f
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Ur l.Uf'Cr1I nK/
I hereby affirm under penalty of perjury one of the following declarations:
I have and it l maimuin a Ceni fiewrof Concent to salf-insure for Worker's Compere DRAINS-FLOOR.ROOF.AREA.GONDSTORIES TYPE CONSTRUCTION
as provided for by Section 3700 of the labor Cale,for the performance of the
aA for which this pemtil is issued. FIXTURES-PER'rRAP
have and will maintain Workers Compensation,Inmraram.as required by Section
37M of the Latsur Conte,for thePerformanceof the work for
which
d is lwmrit is issued. GAS-HA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
M,Wark�C gpey_ y Carrier: Tx'�arrie Pand lacy � 3�'r GAS-IiA.SYSTEM OVER Y(I:A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE(NDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION D?ES _
(This necdnn need not be completed ll'Ihe pennh is(Drone hunUreUdnllws($left) GREASF.TRAP
or less.) PIANCIIECK FEE
I certify that in the performance ofthc work lin which this pcmdr is issuct,Ishall SEWER-SANITARY-STORM EA.200 FT.
nor a.,I,any peon.in any maturer so as lir heaven,suhjevno the Workers Compen- ENERGY FEE
Z swine laws of California.Date WATER HEATER WNENT/ELECTR
7� Applicant GRADING FEE
G y NOTICE TO APPLICANk If,after making this Cenilicate of Exemption,you should WATER SY91'HMO BEATING
a^ become subject m the Workers Compensation pmvisio,of the Labor CMe,you must SOILS FEE
W Iti forthwith comply w do such provisions or this permit shall he dimmed revoked. WATER SERVICE.
p
CONSTRUCTION LENDING AGENCY NEW RISIUENI'IAI.PLMB. SQ.FI'. PAID
UO (hereby affirm Bathem is a con,rac6on lending agency for rhe pmfonnmce of Draw R ¢ip
the won,for which this permit is issued(Sm.3197,Co,.C.)
QF" tenders Name TOTAL:
ItUtl Lcndcrs Address TOTAL:
1 certify that I have read this application and state that the above infammtion is BUILDING 3F.
A comet.l agream comply with all city and county ordinances and some laws mintingm QTY. MECHANICAL PERMIT FEE
L) z abovengcotioned ionznd hereby authorizepurposes natives oRhlsrJry tocruor uprm me SEISM( PE
above-(We)a, property for io unfy a keep hs.
(We)agree w save,iedenmily lied keep harmless the City of Cupertino against PIiNMI'I'ISSUANCE ELECTRIC THE
liabilitiesjudgmemts,costs and expenses which may in any way acerae against said City AI.TERORADDTOMF,CH PLUMHINGFEE
APPLwgaencn rhegrunting of thispermit.
ICANT UNNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1100 CPM)
SOURCE REGULAI"IONS MIiCHANICAI.117
AIR HANDLING UNIT(OVER HEE( CFM) CONSTRUCTI4 TAX
Signature of ApplicuMContmctor Date EXHAUST HOOD(WMUCT) 14OUSING MI GATION PEE.
HA-LARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,100 BTU)
as defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safely
Cole,Section 25532(0)'! HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESIDE PAID
Dae Receipp
Will the applicant orfuturebuilding occupantuseeaAir Qat,rdeviceswhich BOILER-COMP(3HP OR IW.00U It IU)
emit hazardous air contaminants its defined by the Bay Area Air Quality Munagcmem TOT
i unct,! BOILER-COME(OVER 100.000 BTU)
❑Yes ❑No
I have read the humorous materials requirements under Chapter 6.95 of the Cali- AI R CONDI9'IONER JSSU4MjMD
Evans Bettina,&Safety Cale,Sections 25505,25533 aa125534.1 understand that if me NEW RESIDIiNT1A1.MECH. SQ.Il'.
building dors not currently have it tenant,that it is my respnmibility to notify the occupant
of the requirements which must be met prior to iomnce of a Cenifieate of Om..a.cy.
Owner or authorized agent Dme TYPAL: ISSUED BY:
OFFICE
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