S 1646 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,-N.LECI'RICAL PHBJ]'T N°. 1646
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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O R'S fi: PHONh:: NT '1' 'S NAME;: LIC
NIC CONTROL#
1 TECT/ENGINEER: LIC NO ADD ESS /
LS
AA ic
plimp
rv'rncT: �A/���J'pPaHONEE/�t 1{� ! BUILDING PERMIT INFO
P&P rap6tt /-V (i(/ -r� Consultant Fees Paid 6y Applicant(Initial BLDG :CECT PLUMB MECH
LICENSED CONTRACTORS IlF:C1.ARATION 4 QTY. ELECTRIC PERMIT FEE
,VcT'-(A,•
1 hereby arm that[..I licensed ander provisions of chaser 9 Rommendng JOB DESCRIPTION
��Z with Section 7000)bf Division 3ofthe Best and Professions Cede,andmy license ie RESIDENTIAL:
E,W� in full force andelfect. O PERMIT ISSUANCE ❑SFDWL 11 KITCHEN REMODEL
F.0 Leena Ise Lick APPLIANCES-RESIDENTIAL
H U l, Date Convacmr DITION 0 PLUMBING RE-PIPE
ARCHITECTS DECI.ARATION PANELS ❑MULTI-UNIT 0 STRUCTURAL
z p y 1 understand my plans shall he used as public records MODIFICATION
Oz49Z UP TO 2W AMPS El INTERIOR EI CHIMNEY REPAIR
1,4CM'W Licensed
g,1 Pmleslonol 201-10(N)AMPS IMPROVEMENT
E]SWIMMING POOLS
OWNER-BUILDER DECLARATION
a Q I hereby affirm that I lint exempt from the Courtroom's License Law for the OVER IOW AMPS 0 BATH REMODEL/REPAIR 0 DEMOLITION
W 3 O L U following reason.(Section 70315,Blame,,and Prof,ions Code:Any city or only SIGNS ELECTRICAL ❑OTHER
4h" which revahes 11 permit a coaswn,alter.improve,demolish,or repairany s, mre _
prior to its issuance,also requires the applicant for such Perini( filo a signed statement SPECIAL CIRCUIT/M19C.
{f pr thathelslicensedputmuanuo the provisions of the Commemr',License Law(Chap¢r9
f+l p0 (commencing with Section 7000)of Division 3 al'the Business and Professions Cade)or TEMP.METEROR POLE(NST. COMMERCIAL'
d y o C that he is exempt therefrom and the basis for the alleged'exemption.Any violation of ❑NEW BLDG/ADDITION []DEMOLITION
iLLCI 4: Semi 703 LS by any applicamfnropermit anhjedsthe appllcanuoacivil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
H z y not ore than five hundred dollar,($501).
a5d. as owner fthe property,or my employees with wages as their role eompeneation. SWIMMING POOL ELECTRIC IMPROVEMENT
Fe will do the work,and the structure is not intended or offered for sale fSec.76,14,Business ❑OTHER
and Prnfessiens Code The Commcmr's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTUR
property who builds or improves 0umon,and who does such work himself or through
his own employees,provided that such improvements are nu intended or offered for NEW RESIDENTIAL ELECT R
sale.If,hpweveq the buildingor improvement 1,sold within oneyearof completion,the a SQ.FF.FLOOR AREA $/SQ.EF.
owner-milder will have the burden of proving that he did build or bor improve for sur- �D Y
[tone of sale.).
la 1,u owner of the property,ren exclusively convecting with:)IheUI contractors m
msruet the prolcet($roc.7044.Business anJ Professinne GuleJ 9'he Camecmr9 Li-
riseLaw does nor apply toanowner ofproperty who builds orimprove,thereon,and QTY. PLUMBING PERMIT FEE
who contracts far such project with, twmor(s)licensed pamuantto the Cdoccmr's
License L'Rv:-1 PERMIT ISSUANCE
E] I'm exec p der Se &PCfonhis rcaann
t Ilam ALTER-DRAIN A,VENT-WATER(EA) VALUATION
WORKERS COM F.NSATION DECLARATION BACK FLOW PROFECT.DEVICE J r 1
I hereby edition trade,inaltyerperjurynncefthe followingdeclamdan / OJ '-'5-e Sr"
❑ I havcand will maintains Certificate ofConaenuo self-insurefor Worker's Compen- DRAINS-FLOOR.ROOF AREA,COND. STORIES TYPE CONSTRUCTION
work(as provide)for by Section 3ID0 of the Lobar Code,for the performance of the ��
ark for which this permit is Issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Cance of thew work
hi h required by Section
My of Labor Code.
sationhepmlecaneeofthework number are permit,issued. GAS-EA.9VSTEM-1 INC.4OUTLETS OCC.GROUP IN
My Worku's Compensation lnsuenco carrier and Policy number are:
Cmrier: Policy Nu: G iA.SYST 0 0 O
CERTIFICATE OF EXEMPTION FROM WORKERS' G ND STE IN CF.
COMPENSATION INSURANCE BIIr1.pING DIVISION PEES
(Thiswownneed but be completedifthepemtitisfor onehundreddollars(MOR G gTRAP
nt less) r—III dPLANCRECK FEE 27
I comfy that in the performance of the work for which this permit is issue),l shall
not employ any person iri any manna se ax tp become subject a the WorkersCompen- S ER-TA444 SifiRm9to ENERGY PE 1
Lit 2-
Z sation Lawxpf Cvlifoelo.Dao
0 ATER HEATER WNENDELECTR
Z 0 Applicant t GRADING FEE
fn NO'T'ICE TO APPLICANT:If,ager tanking this Certificate of Exemption,you should 'VSTEMITREATING SOILS FEE
a
become subjecttothe Worker's Compensation or this Ecrovisionl of be
Labor Code,yo most
W ...
Forthwith comply case such provisions or this permit shell he deemed revoked. Wp'1'BR SHRVICE
o�'ZS 4�9
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FF. PAID— �~oro Receipt t�
U0 (hereby afam that there is itconsmuetion lending agency Rnthc beformar.iq
W F the work for which this Permit is issued(Sec.3097.Civ.C.1
Q U Lender',Name "� Xl
OTAL:
Leaches Addressu
H0. I certify 1M1et 1 frivolled]this appliwlinn trod care the the above information is Ooar
rr fA wrrea I agree to comply whh Old,and cma y prdinances and state laws elating o QTY. MECHANICAL PERMIT Ffi.
U building ronsmmtion,nnd hereby natborize representatives of this city a enter upon the Q.
above-mentianad property lot irtpection putpeses, PERMIT ISSUANCE 60
(We)agree to save,indemnify and keep harmless the City of Cupertino against thabilities,judgmeus,costs and expenses which may in any way acme against said CityALTER OR ADp TO MECH.fthe gemmof mit. f?eA cense en INDF.RS1ANDS AND .L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT QO IQWII CFM) L FEF.SOURCE, ULATIONS. AIR HANDLING UNIT(OVER IQG(N1 CPM) ON TAXDam EXHAUST GOOD(W/DUCE) IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building compmn store or handle hazardous nmeriat HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cnde.Chapter 9.12,and the HwTth and Safety
Code,Sec0on 8532(,)? HEATING UNIT(OVER IM.000 BTI))
❑Yes VENTILATION PAN(SINGLE RESID) PAID -
Date Receipt#
Will the applicantendo or[vont defining by the B use equipment or devices which BOILER-COMP(SHP OR 1011,(100 BTU)
Dish hazardous air comuninantx as defined by the Bay Area Air Quality Management O
Dlsvim4
EI Yes BOILER-COME(OVER IMRW BTU)
� '
1 have mad me bw.ardsm,maedid,rc iremeats under Chiller 6.95of me Call- AIR CONDITIONER
ISSUANCE-DATE
4i eat dray Cnde,Sections 5 5533 and 25534.1 a,drostandmany the
the If the NEW RESIDHN'1'IAI.MECIi. SQ.Ff. .�,��� 7
ilJing dpext eurmmly hoveamnnnh math myresgrnsibilitymnoti(y the occupnm
othereq cots whichtmst be el pnprro sonceofaCntifrcallot Overall,
or uthn'rzd ag m pate 1 ISSUEDBY:
,:OFFICE