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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO jRUIL
'UjsD:NG-F-LECI'RICM,
BUILDING DIVISION APPLICATION/PERMIT i'LUAIll NG - MECHANICAL.
BUILDING PROJEC'FIDENTIFICATION '
PESITNo. ����
J
BUIID1NO ADDR�EgSSrSANITARY
_5T I
NO.
APPLICATION SUBMITTAL DATE
r j�90
OW%'S NAM" PHONE:
CON 'IRAC'fOR'S NAME LIC NO:
NIC
El
CONTR(lLk
CHITEC HN I R: LIC NO:
sit
ADDRESS:
£pONTAC': PHONES pJ,9 (�
�"a"'t" ` Pz 141 1 { `� l ` `✓
❑ Consultant Fees Paid by Applicant (initial)
BUILDING PERMIT INFO
BLDG ELEcr / PLUMN MF.0
IFC -•J! 'cnf/
LICENSED Ia CONTRACTORS DECons of ION
under provisions of C odd. T9 (commencing
1 hereby amrm mor 1 am 0th, business
with Sa11emaX)del. slOn3Orths Bmincss and Professions Cole, and my license is
y in full force nnJ eRccL pt. a�
� License Lick
L Datc�Ccmracdr�
ARCHITECTS DECLA A ION
L 1 understand my pleas shall M used as public records
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTI
RESIDENTIAL
❑5' WL KITCHEN REMODEL
AUDITION L1 PLUMBING RE PIPE
❑MULTI -UNIT' ❑STRUCRIRAI.
MODIFICATION
[I INTERIOR ❑CHIMNEYREPAIR
IMPROVEMENT ❑ SWIMMING POOLS
$OP.TH REMODEUItEPAIR El DEMOLITION
❑ OTHER
PERMIT ISSUANCE
�O
APPLIANCES-RI5IDENTIAL
PANELS
I1P10200AMPS
Licensed Profcsuonal
OWNER -BUILDER DECLARATION
S 1 hereby affirm that 1 am exempt from ilio Contractor's License Law for the
following reason, (Section 90315, Business and Pntl'e..has Code: Any city nr county
p which requires a permii d construct, alter, improve, demolish, or repair any structure
Once d its issuance. else "crds the applicant for such perminn file a signed statement
that he is licensed pursuant to the provisions of the Commodes license Law (Chapter 9
J (commencing with Section 900(B of Division 3 ofth. Business and Professions Code) or
K that he is exempt therefrom and the basis for Ne alleged exemption. Any violation aI
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not ....ban five hundred dust. ($500).
❑1, as owner of ilia pmpcny, or my employees with wages as their sale tttmpensation,
o will dothe as k.andthesaucmx,ma imendedorall'Tred fmsnle(Sec. 9044, Ilusinms
and Professions Code: The Contmcdr's Liccme low does not apply m an Owner ofOUTIJTS-
property who builds or improves themon, and who does such work himself m through
his own employees, provided that such improvements are not intended or offered for
s:0o. If, however, the buildingorimpmventcnt is sold wilhioaneyearofoontple(ion.ma
u.ner-latildo, will have be burden mproving that he did nm build or improve for p.,
pone sale
❑I. as owner of me property. am exclusively contracting with licensed contractors to
consumer the project (sou. 7(H4, Busmen and Professions creat The Coulee ara Li-
conseLawdoesnut apply (loan ownefof Ptdperty who 1,61dsor improves melem,and
who contracts for such projects with a co nitacmrts) licensed pursuant o the Contracdra
License Law.
I am exempt under Sco. ,B& P C for this reason
201-1(XNIAMPS
OVER I(XIO AMPS
SIGN$ ELE 'RICAI.
SPECIALCll ISC.
TEMP. OR POLE INS'ECOMMERCIAL
C1 NEW BLDG/AUDITION El DP
❑TENANT ❑FOODSERVICE
IMPROVEMENT
El OTHER
POWER UE
SWIMMING PO 1. TRIC
SWI '1' - IXTURES
NEW RESIDENTIAL ELP.gilskl SO HT.
SQ. FT FLOOR AREA
/ [lTgryy
$/SQ. IT.
OTA.
QTY. .0 MBINO PERMIT ,FEE
PERM"l UA o
ACH:R-D 1 st -WA" (VA)
Owner Date
VALUATION
^'l /
V O 00
WORKER'S COMPENSATION DECLARATION
I hereby aRem under penalty of perjury one of the following declarations:
-'❑ I have and will maimainaCeraficaleof Consent dself-inanm lir Warke,Contpcn.
cation, as provided for by Section 370X1 of the Labor Code, for the performance of the
work for whichlbis pemtit is issued.
❑ I have and will maintain Worker's Compensation humanee, us required by Section
3901 of the Labor Cod, for the perfarimtnce of the work for which this permit is issue)
My Wor 'a Con a cation lnsurjn� 'er and Policy uqy M: n ^ ,O` q1d/
Cone' B Ivv Policy Nn. (K,Lb&n IJL
42R TE OFEXEMPI'ION"Ost WORKERS'
OMPENSA'I'ION INSURANCE
(Thio neetian need nm he compined lFNetwnnit is fomne hundred Jnllurs($10B
or las.)
Ioyary,comNe performance ofthe work for which this permit is issmd,lshail
nmtanLoy,ny personin any manner sn nsmbcmmc subjecun ilia Wnrkcn'Cnmpem
Laws n'Ca ifomia Date
Applicant
nprheam
BACK FLOWYOXC4E '
DRAINS -FLOOR, RoKEA5ij GOND.
STORIES
TYPIi CONSTRUCTION
FlX'NRIS - PER TRAP Dyn
^
GALS -EA. SYSTEM -I INC. 4 OUTLET ,a
OCC.ONOUP
Q
APN
GAS -EA. SYSTEM -OVER 4fEA) _
GREASIVINDUSTRL WASTE INT �PfOR C
BUILDING DIVISION FEES
GREASE
PI NCHGCK PIiIi 2
yls
SEWER -SANITARY -STORM EA. L +'
I:RGY FEE
O
THIT HEA'I'HR WNENT/HL1:C1'R
RAUINC FEE
NOTICE TO APPLICANT.If, :Jter making this Cevificam of rxemplion, you Noad
subject tome Workers Compensation provisions of the Labor Cale, you must
Forthwith comply with such provisions or this penmitshall be deemed O,vaked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that INTO, is a cun.Troetien lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Ci¢ O)
lender's NaeI
T E A
qnWlissome Al
TJ 9ERVICI
W RF :NTIAL . FT.
sons FEE
PA
Dole Receipt so
OTA
go
Lender's Address
I certify that 1 have read this application and stoic Nat Ne above.......dation is
erect. I agree to comply with all city and county ordinances and stale laws relating to
building comtdetien, and hereby reform mprescnbnives ofthisc'ny to entcrulwn the
annve-mentioned property for inspection purynses.
(W g e u i e nify and keep hamtles Nc City of Cupre ino against
liabilities, dg en de pemm which may in any way accroe against said City
r ming thin pemtit.
APPIA s'1J T'A AN WILL COMPLY WI'T'H ALL NON -POINT
SO C RE t 1 _
O (�Dnm
TO L:
BUILDING FEE 2
QTY. MECHANICAL PERMIT FEE
Sf31SMIC Q Q
PERMIT ISSUANCE
EI.IicT EE
ALTER OR ADD TO MECfi.
NE
PLU E
MUCH ICAL FEE
AIR HANDLING UNIT (TD llt.(NX)CPM)
AIR 14ANDLING UNIT (OVER MAP CPM)
CO UCTION TAX
nature N'AI li nVCnnv:mmr
HAZARDOUS MAI ERIAI S DISCLOSURE
Will the applcamor future building ove.,r xasso foundle haradnus material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Scetion 25532(.)?
7Ye. C] NO
Will the applicant of future building occupant use equipment of devices which
. emit hatiordous Lir conLaminunts as defined by the Hay Area Air Quality Management
District'ict'ict?
❑Yee ❑No
I have mad the hamrdous materials requirements under Chapter 6.95 of the Cali.AIR
formic Health & Safely Cade, Sections 25505, 25533 and 25534. 1 undmtand that if that
buildingdncsom cutrentlynave a tenant. math lsmy O,sponsibility Torridly the eventual
of Nerd,groanamswhiehmolbetttcl poor to issuance afa Cenificme Of (koupancy.
EXI In ST HOOD(W/DUC)
HONING MITIGATION hili
TING UNIT (TO 109,001 BTU)
HEAHNG UNIT B)VER I(It1,1XX1 BTUt
lost
PAID
)ate Receipt#
VENTILATION I'AN(SINGLE RESID)
BOILER -COMP (3HP OR 4,(X10 B'fU)
TOTAL:
HOMER -CDMP(OVER IIXt,IXp BTU)
O I O
CONDITIONER
ISSUANCE DATE
pk �1
T'— �nJ JI
ISSUED BY: A
NEW RESIDENTIAL. MECIL SQ. Pr.
Owner Or alliance] agent Date
TOT
OFFICE