00010106 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _ U I V!
CITY OF CUPERTINO BUILDING.ELF,C'rmCAI. PBRMff NO.
B013UING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
i. y r{MfrBUILDING,PROJIiCT,IDENTIFCATION:,f^'r"I
BUILDING pjJI)R)SS1 1 O � O� / Lo� SANITARY NO. AP/P/LI�.CAT9ION SUBMITTAL.DATE
�Il Lf /V]/ f L�20 co lv
WNERS NAME: PHO E', CONTRACT4S NAME: LIC NO'.
NIC CONTROLp
CH I'fECI' ' tR: L NO'. ADDRESS: ❑ 7 y 9
CONTACT` PHONE: ).j'r/�,'�!jp;"7 BUILDING PERMIT INFO';"It
® / l ❑ Consultant Fees Paid by Applicant(Initial) Buil ELfE<1;y PLuf{y)—� MECH_
LHr NSFD COM CFORS DFCIARAI ION . QTY ELECTRIC PERMIT:) t t+ ""r FLbf�+i uT �`
Ihereby afr that licensed d p at Chanter 9 mamas g - / / . - f (' '0"!.: roti JOB DESCRIPTION
OWoz 0SIt avaa
lo)rfD a,J m9 Basin e.s andp ydnylce ate 11
aU� ntfull force all efiec s n /d�4 PERMIT ISSUANCE SF'DWL ❑KITCHEN REMODEL
QUU Licemc Cle. Lica / APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
�Z� Data Gmtmmnr
< ARCHITECTSDECLA ❑MULTI-UNIT C1 STRUCTURAL
zOrtiz lundersaandmy planeshii,frsWavpablicamoods PANELS MODIFICATION
OZ--Q UPT02MAMPS ❑INTERIOR L1 CHIMNEY REPAIR
a-o,FT Licensed Pinficoional 201.1000AMPS IMPROVEMENT SWIMMING POOLS
Ecd•.l OWNER BUILDER DECLARXI(ON
I tricky affirm that 1 um exempt from the Contractor's License Law for the OVER]Ok)AMPS ❑BATH RI'MODELREPAIR ❑DEMOLITION
Ecco U following mi am.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL (]OTHER
x131+-y1a-- which requires a permit to construct.alcom improve.demolish.or repair any swcmre
pdormits ssuunce,also requires the vpplicunt for such permit to file a signed statement SPECIAL CIRCUIT/MLSC.
thathe is licensed ptrount mike provisions miff,Cormamrn License Lies Cmf'dn9
go C, (commencing with Section)WB)of Division 3 of the Business and Prnfessinns Code)or '(limit MIT HER OR POLE INST. COMMERCIAL:
a 5.e C that he is exempt donator,and the basis fur the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
fa• Scnion 7031.5by:myippli.rt fora permit.wFlece,theapplideramn a civil penalty of POWER DI3VICE5
F.im ❑TENANT ❑FOOD SIiRVICI3
amore than Evc hunJrW dollars lSSfgl)' IMPROVEMENT
Hx-S Fl1.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL.ELECT'
E will do the work,and the structure is ran intended aroRered for aide(Sec.]014,Business ❑OTHER
oo m and professions fide:The Communist License Law does not apply to an owner of OU 11.2 —SWH CHES—FIXTURE
property wto builds or onpmvev them nfinal who docs sash work heratifor through
Itis own employees,provided that such improvements am not intended of altered for NEW RESIDENTIAL IIECTR SQ F
,001
sale.If,howevee Umbuilding orimpmvemeit is sold within one yearal'completion,the SQ.FT.FLOOR AREA E/SQ.FT.
owner-builder will Lave the burden of proving that he did am build or urni for par-
0 1.as
1 as owner of the pre,peray.am exclusively contracting with licensed contract t
mews the P'9e't f1 9044 8 :. J I f� C le)The Co nraun L
sc law docs nm apPlyf n rp pe rY n n Id or mpnwes mere. a QTY r I'll
r IG,PIRMIT�h�l.
hocontmnsfor mcM1p ojxcts with aconba mrts)licrnsed pursuvnuofhe Conw cors 'a ,r++ r
license Law PERMIT ISSUANCE.
71 lain exempt under Sec. ,B&PCforthis reason
ALTER—DRAT r-WA'ER IIIA) VALUATION
r
Data 3 ,
3, 13q,
n) WORKER'S COMPENSATION DECLARATION BACK FLOW PROLE C
I hereby affirm under penalty of perjury one of the fallowing ded�tins:
❑ (have end will melmelnaCetificmcuf Comcnnu self-insure Lt Worker's Compel- DRAINS—FLOOR,ROOF, RE D. STORIES CONSTRUCTION
cation,as provides]for by Section 3900 of the Labor Cole,for the performance of the
work for which this permit is issued FIXTURES—PER TRAP
❑1 have and will beenmin Workers Co pcn...non Insurance,as required by Section
p700olma Labor e'6mhe perform: c e work fm which thusp mgisis, ed. GAS—EA.SYSTEM-1 INC.4OUTL OCC.GROUP AI'N
My Worker's n ti uta 'e.. tle an
Carrier: 1:4 a GAS—EA.SYSTEM OVER 4(F.A)
CHTH KC T OF EXIT "ION FROM ERS'
C GREASE/INDUS rRL WASTE INTERCEPTOR
(T'his sedion need nm aeomplef W it the pemtit ix for one hundred Jallun($I(N) BUILDING DIVISION 1'tEES
nr lewd GREASE TRAP PLANCHECK FEE
I certify that in the performance of the work forwhich this pemtit is issued,l shall SEWER—SANITARY—STORM EA.200 FL
not employ any Person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
Zxution Laws of m California,Da
zC) Applicant WATER IIPATER WNENf FI,ECIR GRADING PER
ti NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/TRW ING
abacons subject of the Worker,Compensation provisions of Rte Labor Coda,you must SOILS FEE
lnnhwim comply with such previsions or this permit shall he deemed revoked. WATER SERVICE
U z CONS'I'ic isacRUCTION
mb LENDING AGENCY NF.W RESIDENTIAL PCMB. SQ.FC PAID
C.)0 l far by whihthithat tM1ircisaed(Set.30OG.dingagency tante performanceof Dam Recelpla
wF thewark far which thispermit is issued(Sec.9099,Cie CJ
p UL.endcr's Name TOTAL.
1,9mlor's Address TOTAL.
yI teribity that Ihave mad this application add state that[be d f t .i DING FEE
rn sari r.Iagreer ply w m all city unn ty rcld",-'a I f g t, QTY . MECIIANICAI PERMIT I fir; FFF
U z build g ummion,and herebytmhnriu p emauves oftti ecitymcnrerupm rhe t_ SEISMIC FEE
move-mentioned prepeuy for inspection purposes.
(WO)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC PER
IlnhilitiW��
and expenses which may many way uccrve against said Cify ALTER OR ADD TO MECH.
of
inof this permit. PLUMBING FEE
NDS ANU ,ILL COMPLY WITH AL NON-POINT AIR HANDLING UNIT(f0 10.003 CFM) MECHANICALFTE
'1 /�/ AIRF{ANDLINC UNIT(OVER IgfNI CPM) CONSTRUCTION TAX
mc I Ise EXHAUST GOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous namriul I[EATING UNIT(TO 100,(IfM)BTU)
as defined by it,,Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Calc,Sermon 25532(x)7 HEM ING UNIT(OVER 100,000 BTU)
❑Yes Na PAID
VENTILATION FAN(SINGLER[SII» Dam RuciptM �
Will the upplicam nr fmure building occupant use equipment or devices which HOLLER—COMP(JHP OR I(0.(M0 BTU)
mit he>ardon,air cumaminanI defined by the Bay Aram Air Quality Management TOTAL:
DiaVicl'l
❑Yes BOILER—COMP(OVER 100,000 BT'U)
AIR CONDITIONER
I have ad the hararWms mnlerixls reyuirennenu ander Chapter 6.95 nC the GJi- I$$UANCE D
fomia Heath &Sale ty fide.Sections 25505,3 I and 255JJ.1 undersmnJ that if the NEW RESIDENTIAL MECH. SQ.FT. n /
buildingd em ncrom dybaveatenanLm t' ponvtbility fo Drily
fr'e ¢.ipso mu.N '`sun
Owaermvmho r TOTAL: ISSUED BY
OFFICE