S 3036 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEM RICAL PER`�fIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. CJ 3036
BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUIU)INO ADDRESS Q
D36 aduroaw 6oYuke 0
OWNER'S NAME: P}�ONE: CONTRACTOR'S NAME: LIC Ne: NIC CONTROI.a
11h FOo'ft %NE: ES1(Jre.7 c Q.��i
sARCHIT /ENGINEER: LICNO: A)�RES_ �^ /� / lx��c 1� ❑
G10 1s(/+�TONt �` SIG(/ bra"
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB M,.ECH
2X,6702 El 15 ❑ 2
I.ICENSlil)CONTRACOR'SDECI.ARA'I'ION QTY ELECFRICPERMIT FEL JOB DESCRIPTION
I hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing
OaZ with Section7")of Division 3 ofthe Husiness and Profession Code.and my licenso is RESIDENTIAL,
4100 wt PERMIT ISSUANCE
FW�P oculi fmcesnd elicet. i6(f _ ❑SFDWL El KITCHEN REMODEL
aVV 1.icenu Class - LinM APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REPIPF.
I-zw nate enttacror
rn<y ❑MULTI-UNIT ❑STRUCTURAL
ARCI IITECTS DECLARAT N
p-,ptn PANELS MODIFICATION
Z O I undemWnJ my pion shall be asst as public records
oz-o
UP'f0200AMPS [I INTERIOR ❑CHIMNEY REPAIR
r 4tt"„{y Licensed Professional ME
AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION 00AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
1 thereby of rat that 1 am exempt from the Contractor's License law for teaOLU following reason.(Section 7031.5,Business and Professions Code:Any city or erumY ECHtICAL u OTHER
which m paws a permit to construct,alter.improve,demolish.or repair any structureprior to ns issuance.also requires the applicant for such permit o file a siynedeamocat CI RCU IT/M ISC (�that he is licensed pursuant to the provisions of the Contractor's License law(Chapter9C (commencing with Section]111p)of Divisinn3oOhe Businosand Pmfeaiom GdO or _ ROR POLE INST. OMM R LAId q Cthat he Is exempt therefrom and the films for the alleged exemption.Any violminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
ySection 7031.5 by any applicam for a permit subjects the applicantto a civil penalty of DEVICES ❑'TENANT ❑FOODSERVICE
not mom than five hundred Mllaw(5500). IMPROVEMENT
❑ I,as owner of the property,or my employees with wages as their sole compensation. NG POOL ELECTRICwill Jct the wmserid dhesmucmre'isnrt nomidedorofleed hirsute(Set.7044,Business ❑OTHER
and Prcfessions Codc:The Confect is License law dons not apply to an owner of S-SWITCHES-FIXTURES
�' property who builds or impedes thereon.and who dces such wothimself or through
his own endployecs,pma cro
viJeJ Nsuch imprnvems are not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SO FT.FLOOR AREA EISA.FT.
iter-builder will have the burden of proving that he did not Wild or improve for per- 0
pose of sale.).
❑ ,I,as owner of the prupvn um exclusively contracting with licensed contractors to fOTAI.'
construct the project Sec.7M4.Business and Pmfessiorm Code:)The Contractor's Li-
reveLawdoesnmapplyoanowner of Infelicity who builds or improves therm,and QTY. PLUMBING PERMIT FEE
who contracts for such project with a contractors)licensed pursuant to the Cooaadors
License Law. PERMIT ISSUANCE
❑Iamesemptunder Sec. ,B&PClor Ni.wiwmx
AI TER-DRAIN&VENT-WATER(FB) VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PRGI'ECP.DEVICE
I hereby affirm under penalty of perjury one of are following declarations:
❑Ihave and will maintain uCertimcmenf Consenuo self-inure for Worker's Compcn- DRAINS-FLOOR.RUDER,AREA,COND. STORIES TYPECONSTRUCTION
cation,as provided for by Suction 3900 of the Labor Coda,for Ne perharnme a ar the
work for which this permit is issued. FIX'I ORES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Lahr Code.for the perforamnce of the work for which this permit is issued.
GAS-EA.SVSTEM-I INC.40U7LET5 'C.OR U APN
My Worker'. p Surat ecarnernnd Policy ny-i9hr_ytc//,�, GAS-EA.SYSTEM-OVER 4(EA)
Camcr: �_Polity No
R
CERTIFIC TE OF F.XEMPfION FROM WORKERS' GREASE/INDIISTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCH B 1 0DIVISION RIES
(This section need nod M completed if the permL is lorrne hundred dollars($LBO) GRHASETRAP
or less.) I'LANCHECK FEE
Icertify that in the performance of the work for which this permit is issued,Ishii[] SEWER-SANITARY-STORM EA.200 FT B
oat employ any Person in any manner m as m We cc sohjmd to the Wmkers'Cotnpen-
Z satin laws of California.Doc WATER HEATER WNENTBILECTR
0 AGRADING BYE
Applicant
y NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should WATER SySTEMRBEATING SOILS FEE
1'" 5 become subject to the Worker's Compensation provisions of the Lubar Code,you most
ai rs forthwith comply withsuch Provisions or this pemmitshill be deemed revoked. WATER SERVICE
Ik] Q
CUNS'I'RUCq'ION LENDING ACIiNCY NEW RESIDENTIALI'LMB, tiQ.FT. PAID
'7 � I herebyalion that the.iso construction lendingugency for the performance of Dste Receipt in
11U 0— Ne work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
0 V tender's Name .
fbl Leader's Addres TOTAL:
y I certify that I have mad this application end sate that the shove information is BUILDING FEE
(A correct.l agree to comply with all city and county ordinances and state laws refuting to QTY MECHANICAL PERMIT FEE SEISMIC FEF
U z building construction.and hereby corwrize represcnlmivesnfthincity to enter upon he
aMve mentioned property for inspection pmprses. as
(We)agme to save,indemnify and keep harmless the City of Cupeninn against PERMIT ISSUANCE. 1i1-11 RICO E
liahilities,judgmenls,costs and expemes which may in any way..me against suit City AITERORADDTOMECU PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I(I,000 CFM) MECHANIC BE
SOURCE REGULATIONS,
ti f. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUC'O NTAX
Signature of ApplicanuContrveem Due EXHAUST HOOD(W/UUCT) HOUSING MITI 'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thenppllcum fir futon,W diingoccapam 'I'm or handle hazaNaux nmteriul HEATING UNIT(10 I(H),WO BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Each and Safely
Code,Section 75532(x)7 BEATING UNIT(OVER 0W.00f)BTU)
[I yes ❑No VENTILATION PAN SINGLE HE MD) PAID
Dnlc Bcceiptk
Will the applicant or future building eecupant me equiptrmtn or devices which BOILER-COMPDHPOR 1131,01X1 BTU)
emit havandous air cotnamimams as defined by the Bay Area Air Quality Management TOT
Dishict9 BOILER-COMP(OVER 100.13341 BTU)
El Yes F1 No ^
I have read the hmarous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER V ISSUANCE DATE !
forms Health&Safety Code.Sections 25505,25533 and 25534.I understand thus If the NF;W RESI DENTIN,MECH. SQ.PT
building does not currently have a wont,that it is my responsibility to firmly the occupant
of the requirements which must M mit prior hat issuance of a Certifica¢of Occupancy.
Owner or amhomeed agent Date T L O ISSUED BY:
OFFICE