S 0419 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.HLECIfRICAL at
.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 0419
BUILDING PROJECT'IDEN'TIF'ICATION
BUILDING ADDRPSS: � J' SANO NSUBMIITALDATC.U.+�M Z t7 2 T gTTA d C9,(70/qNEWS NAME: PHONE: - CON'TRACTOR'S NAME. LIC NO:L^� — NNTH sLMkCH RCTB3NGINEER' LIC NO: ADDRESS:CONTACT. PHONE: IT INFO❑ Consultant Fees Paid by Applicant(Initial) BUMIf MECH
-sf -t6 tattj
LICENSED CONTRACTOR'S DHCLARA'1'ION QTY. ELECTRIC PERMIT FEE:
owzI hereby affirm that 1 am licensed under provisions of Chapter 9 mormo ndng JOB DESCRIPTION
won withSectinn7000)ofDivisiun3oftheBusinasandRofessionsCW.eJmylicen is PERMIT ISSUANCE. RESIDENTIAL
(-
won in fall finical effect.e
yUU ❑SFDWL [I KIT REMODELFQUrJ License Class o.N APPLIANCE S-RESIDENTTAT, ❑AUDITION ElPLUMBING BE PIPE
N Q W Dem Contractor
F,Drn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Zp 74- l underamndnry pimi,hull he used.,public re cords MODIFICATIONOZ-Q UP TO 21x1 AMPS ❑INTfiR[OR El CHI YIN EY RE PAIR
Licensed Professional 201-IWAMPS IMPROVEMENT SWIMMING POOLS
acs! OWNER-BUILDER DECLARATION OVER InX)AMT'S ❑BATH REMODEUREPAIR WOLITION
yG C t I hereby affirm that I um exempt from the Contractor's license I.uw for the
x 6 U following (Section 01131.5,Business and Professions Code:An t t OfI11:R
a] reason. y city or county SIGNS ELECTRICAL
3 0 which requires a permit re cnmwa,ppec improve,demolish,or repair any structure
�yy that hosfi,cuamce.also irtmoo uiresthe appmoffor such pContractors icensfile ae ned aw(stammem SPECIAL CIRCUIT/MISC.
�y (comate limned pSectionothu provisions 3thoeBusinessLicense Lions Code)Or
teat he is
(commencing Section and the
basis for
of the Nosiness and Professions Anynvi Code)or TEMP.MLTfER UH POLE INST. COMMERCIAL
6 a e C that io is exempt therefrom and the basis for the alleges exemption.Any violation of ❑NEW BLDG/ADDITION ❑['001)SERVICE
W m_o. Section 7th live any applfor a icant subjects the applicant macivil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more wne five t h pope dollars y Sap.
� IMPROVEMENT
=6 Chas owner of the popery,or my employees with wages as their sole compensation, SWIMMING POOL.ELECTRIC
f I„O will dothe work,and the sanctum is not intended proffered forsale(Set.7Wq Business ❑OTHER
L 3 and Pmsfcssions Calc:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through -
his own employees,provided that such intpmvements an not intended or offered for NEW RCSIDEMI'IAL ELEC'IR SQ IT,
sale.IL however,the handing or improvement is sold within one yew of completion..the SQ.FT.FLOOR AREA 5/SQ.IT.
er-hander will have the barren pf proving that he did non build m improve for it, qqq
1,as owner of the propenY,am exclusively mortaring with licensed amrocnsa m TOTAL:
construct
onstruct the project(Sec.7614.Business and Professions Galey The Contractor's Li- -
Coll
censeLaw does not apply tototowner ofprnpenywho builds or improves damon,and QTY. PLUMBING PERMIT FEE El) - SCD
who emnracts for such projects with a contractor(&)licensed pursuant to the Contractors
License Law. i 'T3,
❑ lam cxcmp under Sea .R&PCfor this reason PERMIT ISSUANCE I, Ur
Owner -r ALTER-DRAIN&VE - 'N(EAI _ WTION
WORKER'. COMPENSATIONLARATION BACK FLOW PROTECT.DEVICE
17—
1 hereby affirm under penalty of perimyr mo f the following declarations (9&Qar---
O Have and will maintain a Certificate ofComend to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF, Iii OND, STORIES 17N
station,as provided for by Section 37W of the tabu Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP'
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe labor Code,for performance of the work for which thispermit is issued. GAS-EA.SYSTEM-I INC.4 ODU ETS OCC.GROUP APN
My Workers Compensation Incur ce,carrier surd Policy number arc: -
Cantor Policy No,: GAS-EA.SYSTEM-OVER 4(EA)
,) C17RTIFICAI'E OF EXEMPTION I7ROM WORKERSGREASEVINDUS'UU,WAS 112 INTERCEPTOR '
COMPENSATION INSURANCE D LIN ISION PEES
(Thissection neednm becompletedifthepermit isforonehundreddollarTSIOR GREASETRAP
or less.) PIANCIIIiC FE 0—
Icenify Oran,thepOrmian, nlas the to
Ilse whichthis thepernotWresoed.mN.- SEWF.N-SANITARY-STORM EA.210 FT.
nm employ anY person in any manner an a m become subject m the Worker'Compen- ENERGYCE
ZZ sation laws of California.Date WATER HEATER W/VENT/ELECTR
O Applicant GR F.
ti NOTICE TO APPLICANT:If,after making this Cw ificam of Exemption,you should WATER SYSTEMOREATING
f✓ > becotte subject to the Workers Compensation provisions of the Labor Code,you man S ,E
Ws,y fonhwiih comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW NESIUGM'IAL PLMB. SQ.FT. PAID
LJ0 I hereby affirm that is a construction,lending agency for the performance ofILI m Perrino is
the work for which this permit is issued(See.3097,Civ.C.)
0 Lender,Name TOTAL'
V Lenders Address TOTAL:
y1 certify that 1 have mad this application and norm that the aMve information is BUILDIN FEE
IZI correct.l agree to comply with all city and county ordinances and stale taws miming to ,QTY. MECHANICAL PERMIT FEE
U Ze braddi ngconswction,and hercbyamhuriae re prcsentwive,ofthis city oemerupm the SEISMIC[TE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupenino against ELECTRIC FEF.
liabilities.judgmems,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBINGFEE
APPLICANT UNDERSTA DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT DID 10.000 CFM) MECHANICAL FEE
SOURCE -GULATIOy /' AIR HANDLING UNIT(OVER ULNDR CFM)
IL. ze 04-j CONS'TRUCTION'TAX
Signature of ApplicentlComoetor Date EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS OSURE
Will theapplicant orfmurebuildimO.orum store tar handle buv.odious mvmriul HEATING UNIT(TO INDITE BTU)
as defined by the Cup:rtarm Municipal Cale.Chapter 9.12,unit the Health and Safety
Code,Section 25532(,)? HEATING UNIT(OVER 1110.00)BTU)
❑Yes ONO VENTILATION PAN(SINGLE RESIDI PAID
'\ was, Ncceipl
Will the applicant or far.building..par use to uipmetn or devices which BOILER-COMP TRIP OR Ig1,g10 BTU)
unit baordous air contaminants w defined by the Bay Area An Quality Management TO'1
Dlstrit,? BOILER-COMP(OVER W,WO BTU)
❑Ye, 0 N
1 have reml the hawtrdous materials rrluiremems unJer Chapter 6.95 of thAIR CONDITIONER e Cali- ISSUANCE DATE
fomia IIwIth&Safrly Codc,Sections 25505,25533 and 25534.1 undersmnd[bat if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdoes not comendy have a remain,that it is my responsibility to notify the ssccupant /
of the reiuirenmms which must be mer prior to issuance of a Confirms,of Occupancy v
Owner or i m umb,cd agent Date TOTAL: ISSUED BY:
OFFICE