S 0730 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE.SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EI.EcDUCAL PERM]r NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 0730
'BUILDING PROJECT IDENTIFICATION S
BUILDING ADDRESS: SANITARY NO. nPPLICATION SUBMITTAL.DATE
ivH2,5- PeAti-JOr-p, &_.
OWNER'S NAME: PHONI,,L 3527 CONTAM R:SNAME:
_12 'tat �I NIC ./CONTROI.4
tin ARCHITECf/F.NGINEER: LIC NO: ADDRESS: ❑ Y / / /
x�1ee. T/ fIV_
CONTACT: PHONE: - BUILDING PERMIT INFO
of �
1 ' ��"`� � ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
N ?oN TO ❑ Ty�� ❑ ❑
LICENSED that ID CONTRd made,S DECLARATION QTY. ELECTRIC PERMIT FEE ��+•
I ion 7 union)ofthat 1 am licensed under provisions of Chapter r,(commencing JOB DESCRIPTION
l 00OZZ with Section]0007 of Division the Business and Professions Code,and mylicense is RESIDENTIAL:
�F - in full force and afficerJr � / PERMIT ISSUANCE
aUV License Cla ` S Lich TII21'T t ❑SFDWL El KITCHEN RF,MODF.1.
rF�� Dam Contramory��w- ��� AYI'LIANCF_S-RESIDENTIAL ❑ADDITION El PLUMBING REPIPE
ARCHITECT'S DECLARATION ElMULTI-UNIT ❑STRUCTURAL.
zpHz I understand my plans.shall be used as public records PANELS MODIFICATION
OZ�O UP 902W AMPS
El INTERIOR El CHIMNEY REPAIR
Licensed Prof..final 2r11d INlf1AMPS IMPROVEMENT
�Sd OWNER-BUILDER DECLARATION E]SWIMMING POOLS
CCC 1 hereby affirm that 1 am exempt from the Contmanrs License Law for the OVER 1003 El AMPS RATH REMODEUREPAIR El DEMOLITION
3 LLF following reason.(Section 7031.5,Business and Professions Code:Any city or countySIGNS ELECTRICAL 2 O El OTHER _
vy� which requires a permit to construct.alter.improve,demolish,or repair any structure / 2
LS� prior tans issuance,also requires the applicant for such perming file a signed statement SPECIAL CIRCUFUM I SC.
y that he is licensed pursuant o the provisions of the Contractor's License Law(Cbapter9
GO (commencing with Section]W0)(if Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL,
4 y m that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^m Section 7031,5 by any npplicam far a permit subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Qno,more than five hundred dollars($500).
❑Las owner of the pmpeny,nr my employees aim wages as Meir sole contpensminn, SWIMMING POOL F.LEC'TRIC IMPROVEMENT
will do the work,and the structure is not intended or offered for sale(See.7044.Business ❑OTHER
and Professions Code:The Contmont's License Law does not apply to air..a,of OUTLETS-S 1'PCHES-FIXTURES
property who builds tar improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NE ENTIAL ELECTR SQ Fp
art..If.howevee the building or improvement istold within one year of completion,the SQ.FT.FLOOR AREA 5/SQ.FT.
wncol uilder will have the burden of proving that he did not hui ld or improve for put-
, pose orsale.).
❑ 1,as owner of the pmpeny,am exclusively contracting with licensed contractors to TOTAL
construct the project(Sec.0044,Business and Professiens Code)The Contmctnr'.s Li-
se Law does not apply to an owner of pmpeny,who builds or improves thereon,and QTY. BT RM FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law. PERMITIS A - DEC 11
❑ I am exempt mode,Seo. ,B&P C for this mason
ALTER-DRAIN& INT A R EA7 VALUATION
Owner �3Yr
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.OF.
have
andhereby arfmm under penalty of of Con one of the insure for declarations:❑ Ihave and will mainmineCertiticate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF AREA,GOND. STORIESTYPE ION
eair.,as provided for by Section 310X1 of the Labor GW,.for therfom
perance m the
k far which this permit is issued. FIXTURES-PER'I'RAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
OOgfthe Luble Cmle,fartheperennnnce gf the wad far which this permit is issued. GAS-EA.SYSTEM-I INC.4 OIUUE. S OCC.GROUP APN
My Work is Cnmpwsa;.9su am an and Policy nyp�b
Came, dT I YY1`• �O, Policy Nn: 1✓KIl^SoII Z GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thos section need not be completed ifthe permit is From,hundred dollar, SIO) GREASETRAP
or lase.) PLANCHECK FEE
Toys,perhat in the parany trmndusecimon, ,t becameork far wobje this pertains issuad,lshalf
en- SEWER-SANITARY-STORM EA.200 FT.
of employ of person in any manner so as Ig haeme subject m the Wnrkcrs'Compen- ENERGY FEE
O ,T. Armon Laws of California.Date WATER HEATER W/VENVELECTR
Q NCTI am 1 GRADING FEF.
ti NOTICE TO APPLICANT:If,after making this CeniOcam of Exemptimn,you should WATER SYSTEM/1'REATING SOILS FF.F.
F becomesubjecty the Worker's Cempeor his ptand ilial of the Labor Csde,you must
0 rnnhwilh comply with such provisions onM1ls pennot shall he deemed revoked WATER SERVICE
�O CONSTRUCTION LENDINGAGENCY NEW RHSIDENTIALPLMR. SQ,ET. PAID Date \ ' t#
1 hereby gffimuhenhere is a amswetion lending ngengy for the perfonnanw of
W Fthe work for which this permit is issued(Sec.3119],Civ,CJ
Larder's Name Name TOTAL:
WLenders Address TOTAL:
y I certify That I have read this application and state that the above information is BUILDING FEE
71correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U 7 building construction,and hereby anthorize representatives orthis city reamer uponthe SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC PEG
(We)agree ur save,indemnify and kap harmless the Cty of Cupertino against
liabilities,judgments, on,and expenses which may in way acme against said City ALTER OR ADD TO MICH. PLUMBING FEE
in consequence of the granting of this pentyl.
APP ANT UNDERSTANDS AN WILL COMPLY WITH ALL NONPOINTAIR HANDLING UNIT('TO IO,OIXI CFM)
SO RC. EGULAT S. MECHANICAL FE
AIR HANDLING UNIT(OVER 10,0110 CFM) COI STRIJ-D-
TP
Sighpaeg fApTlicanVCmarandor Dul EXHAUST HOOD(W/DUCT7 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
ill the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I W.11(10 B'1'U)
(action
by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
C ,Section 25532(a)? HEATING ON IT(OVER I00,00)BTU)
❑Yes ` PAID
/` VENTILATION FAN(SINGLE RESID) Data acceipt#
Will the applicantorfumre building occupantuseequipmentordeviceswhich BOILERCOMPDHPOR 10(1,00(1BTU)
mit hazardous contaminants air nminanas defined by the Bay Arca Air Quality Management TOTnL.
Dielncl]
❑Yes �o 0000d"' ,r BOILER-COMP(OVER I , BTU)
AIR CONDITIONER
I have read the hazardous materials requirements mark,Chapter 6.95 of the Cali- ISSUANFE DATE
forma Health ne Safety Curve,Sections 25505,is my end 25534.I t understand that if the NEW RESIDENTIAL MECH. SQ.FT. / 2-,
1
building does¤tlylieu ant,thus it is responsibility mnotify derstathcoecipam /
oft quire Issuance of a Certificate of a
2 Y /
Ow rartmeread ol Dole TOTAL: ISSUED BY: C/
OFFICE