99080009APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITYOF CUPF.]SION ^BUam^F-MECH MECHANICAL PERMITN
U.
RUILDINGDFVRTIN APPLICATION/PERMIT PLUMBING - MECHANICAL.
UU]:YVStlN
Co C -AV A v9-
r c 75Y T05
SAN 47nGF
❑ Consultant Fees Paid by Applicant (Initial)
LICBNS1LU con lagla ores ursCLARAIRiv QTY. ELECTRIC PERMIT
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
OaZ with Section]000)af DivinionJofthe Business and Professions Cod dmyhoortaeis
00 i PERMIT ISSUANCE
m n rm1 fame and it,.
u< a? 5 U S
QU�j LicenseC
I yFQOm=
APPLIANCES—RESIDENTIAL
ARCHITECT'S DECLARATION PANELS
n 1 une�d my plans shall hcrused as public records IZmZ
UPT020B AMPS
Ei
C ffGG
L UF.
C Na
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Section 7031.5, Business and Professions Cede: Any city or county
which requires .permit m consortia. inner, improve, demolish, or repair any swcturc
pilau its issuance..N. cquims the application Ausuch permit to file a signed sretemem
OVER HNW AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
J
3ythat
qaF'
Oe O
^� y
OO
�_
L 3
he is licensed pursuant o the provisions ofthe Committees License Law (Chapter 9
(commencing with Section 7")in Division 3 of the Business aril Professions Cme7 os
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section ?011.51, any applicant for a permit subjects daeoppnicant no a civil penalty of
not tome than five hundred dollars ($500).
1, as owner of the property, or my employees with wages us their sole compensation,
will do the work, and the atmcmre is not intended oroBcted for sale( See 7044, Business
mtors License law does not imply r. ea owner of
and Professions Code: The Comc
who builds or improves thereon, and who does such work himself or through
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWI TCHFS—EST
OCHIMNEY REPAIR
property
his own employees, provided that such improvements arc nm intended or offered for
NEW RESIDENTIAL ELECTR
El BATH REMODF;
sale. IL however, the building or improvement is sold within one year of completion, the
❑OTHER
-builder will have the burden of proving that he did not build or improve for pin,
/
pcaner
ose of sale.).
1, as owner of the property, am exclusively contracting with licensed contractors to
'TOTAL:
❑TENANT
instruct the perfect (Sec. 7044, Business and Professions Co )The C.mnmau's nJ-
IMPROVEMENT
comeLawdoesnotapplytoanownerofpmpenywhobuildsorimprow,i thereon, and
QTY. PLUMBING PERMIT
who contracts for such pmjeats with a mnbueol(O licensed pursuant to the Contractors
PERMIT ISSUANCE
License Law.
O l am exempt under Sec. ,B& P C for this reason
ALTER — DRAIN & VENT— WATER IFA)
Dat
Fwner
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTEGE. DEVICE
I hereby alarm under penalty of perjury one of the following deelamtiuns:
I] I have and will maintain a Certificate of C.nseoto self -insure for Worker's Camper-
DRAINS— FLOOR, ROOF, AREA, COND.
Nation, as provided for by Section 37M of the Lubar Code, for the performance of the
work for which this permit is issued.
FIXTURES — PER TRAP
0 I have and will maintain Worker's Compensation Insurance, az requited by Section
37M ofthe Labor Code, for the performance of the work for which this permit is issued.
GAS -13A. SYSTEM -)INC. 4 OUTLETS
GAS — EA. SYSTEMOVER 4 (EA)
My Worker's Compensation Insumnce carrier and Policy number are:
Carrier. Policy No.:
GREASEINDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
Olossecom,amed.ot he completed ifflepennh is forone hundreddollars($100)
,it Ices.)
SEWER — SANITARY — STORM EA. 200 FT.
I certify that in the Performance ofthe work for which this permit is issued, )shall
not employ any person in any mane, s�o to buhjm more Workers' Cnmpcn-
zZ sari.. LawsfC lRb' D 1�>Z'-
2 APPlica ��i0+'f'fi�
NOTICEt&0,AfPLICA4NT. If, aftermakingmaking rsOption. you should
a' become subject to the Workers Compensation provisions of the Labor Code, you must
{21 foMwith comply with such provisions or this permit shall be deemed revoked.
a
CONSTRUCTION LENDING AGENCY
UO thereby affirm than there is a constmetien lendCingagmcy for the performance of
P. Nthe work for which this permit i. issued (Set. 3W7, iv. C.)
Lcndees Name
WATER HEATER WNENT/LLECIR
WATER SYSTEMOREATING
WATER SERVICE
NEW RESIDENTIAL PCMB. SQ. FT.
TOTAL:
ULenders Address
1 certify that 1 have read this application and state that the above information is
�W correct lagreem comply with all city and county ordirmnces and state laws relating m
LIZ building conswction.and herehybutherin npnuntativesofthis city menterupon the
QTy, MECHANICAL PERMIT
PERMIT ISSUANCE
above-mentioned propeny for inspection purposes.
(We) agree tosave. indemnify and keep hornless the City of Cupertino against
ALT ER OR ADD' TO MECH.
liabilities,judgments. costs and expemea which may in any way areme toommt said City
in asequence of the grunting of this permit.
AIR HANDLING UNIT CIO IQO(gt CPM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE CATIONS
7
AIR HANDLING UNIT (OVER I0,0011 CFM)
Date
EXHAUST HOOD IWMUC)
,>gdome.fWammiCcombacm,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building eccupanrsmre or handle hazardous materiel
HEATING UNIT (TO I00,000 BTU)
as dented by the Cupenime Municipal Code. Chapter 9. 12, and the Health and Safety
Coda Seetlon 25532(.)7
HEATING UNIT (OVER I00,M) BTU)
VENTILATION PAN (SINGLE RFSID)
O Yes ❑No
if
Will the applicant or future building occupant use equipment or devices which
emit havrdous air contaminants as defined by the Bay Aha Air Quality Management
BOILER — COMP (3HP OR 100,000 BTU)
BOILER — COMP (OVER UMOW BTU)
District]
El Yes FIN.
AIR CONDITIONER
I have read the hanNous materials tequirements under Chapter 6.95 of the Cali-
NEW RESIDENTIAL MECH. SQ. ET.
noraw Health & Safety Code Sections 25505.25533 and 25534. 1 understand that if the
building ddceAm Unready now a tenant, th.rjt is my responsibility to notify the occupant
TOTAL:
OFFICE
FEE
9P I
INFO
BLDG ELECT PLUMB MECH
❑ � BWW ❑
. JOB DESCRIPl ION
RESIDENTIAL,❑SFDWL
O KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
O INTERIOR
OCHIMNEY REPAIR
IMPROVEMENT
F1 SWIMMING POOLS
El BATH REMODF;
REPAIR ElDEMOLITION
❑OTHER
/
O NEW BLDG/ADDITION ElDEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
C OTHER
SQ, FE FLOOR AREA
all
le
FEE
VALUATION
STORIES TYPE
DEC. GROUP
BUILDING DIVISION FC
PLANCHECK FEE
ENERGYFEB
GRADING FEE
SOILS FEE
PAID
Dam fYIA eipta
TOTAL:
BUILDWG FEE a
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Data
V A