S 1329 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING.MECH MECHANICAL rls'y+'T"°. 1329
BUILDING DIVISION APPLICATIONIPERMIT PLUMB FROG cr IDE NIFIC SCJ
BUILDING PROJECT IDENTIFICATION
6UILDINO AIIORESS:
SAN[fARY NO. APPLICATION SUBMITTAL DATI
OWNIR'S NAME: 1'IIONE: CON'1'R/A'C,'I/'OR'S N/r�'MO:• /�f, L.I]C
�. / ✓ Q tSSo— 6 y ✓' (ic�JV�J1/l/L J NIC cUNTR�DL#/
CI 'f.Ci'l1iNGINfER: LIC NO, ADIIRESS: ❑' r/-If/I(TY//� V
G- a 12
CONTACT. Pxo"e: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLOC ELECT PLUMB M17CH
LICENSED CONTRACTOR'S DECLARATION
QTY ELECTRIC PF,RMI'I' FEE
I hereby alPrns that I an licensed under,pmvisinnx of Chapter 9(commencing JOB DESCRIPTION
E0wunSmdrtn 71ro0)orB'rvmion3mnbo Baxiness,md Profaraions e:tde,and mylmemm is R ID.NTIAL;
�I0- in full fremmul effect, PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
- UU License Class Lia# APPLIANCES—RF_SIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
F-Z W Date—Councemr
ARCHITECTS DECLARATION ❑MULTLUNI'f ❑STRUCTURAI.
p,O m PANELS MODIFICATION
Z O H 1 understand my plans shall be used as public reccurs
OZ4—a UPT0200AMPS ❑INT1iRIOR [I CHIMNEY REPAIR
W Lice ns ed Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
�yF� OWNER-BUILDER DECLARATION OVER 1000AMP$ ❑BATH REMODEUREPAIR ❑DEMOLITION
y CC OAC 6 1 nearby affirm that Ion exempt fmm the Cnnlrncure.License Law for the
p(O a U following reason.(Section 7031.5,Business and Professions Calc:Any city or county SIGNS ELECTRICAL ❑OTIIER
IY 3:"FF which requires a permit to comurct,altar,improve,demolish,or repair any structure
,1�0PeiuLL iss,once,ulsorequims theapplicam far such Permian lileasigncdamemem SPECIAL CIRCUIT/MISC.
t2ylhatbeislicensedpuauunitnlM1eprovisionsmltheComnmtnr'sLicenceLnwlChapmr9
WAC (commencing with Section 70(sBof Divi.cim3 ofthe Business and Protrusions Codger TEMP.METER OR FULL INST. COMMERL
a y m t•G that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NE /ADDITION E3 DEMOLITION
aXl 4y Section 7W l.5IS,.,upplinnt fora permtoljer,the applicant toe civil penalryaf POWER DEVICES +NAN9' ❑FOODSERVICE
pmot more than Eye hundred Jullart(5510). pµpVEMENT
q � ❑I,us owner of the property,(it my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
C ffGG"'.. will dothewark.andtheswcwrcisnm lmendedmodercd forade(Sce.7011,Business ❑OTHER
W m and Professions Cale:11re Conlmctor'.c License Law does not apply to an owner of OUTLETS—SWITCHES—IgXTURES
fl 3— property who builds or improves thereon,and whit does such work himself or through
his own employees,provided that such impmvnments um no intended or offered for NEW RESIDENTIAL.ELE IR SQ FT.
sale.If,however.the building or improvement is sold within one yearof completion,the
SQ.FT.FLOOR ARES 8/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pnm of sowne
❑Las owner of the property,am exclusivelydd contracting Ced licensed contactors m AL.
craveLaw
comfort the project(Sec.70 44,Business add Py who builds
ds or improvesmeamon,Li-
whocoawdorsnotapply htan with
a cofpmla:di whcow,d utiount to
thereon,and Q'Ty. PLUMBING PER FEE
who contracts for such projmu with a cummdnr(M IicenseJ punanm m the Contramnrs �
License Law. PERMIT ISSUANCB-
❑lamexemptunderSm. ,If&P C for this reason
ALTER—DRAIN&VENT—WATER IEA) "GROAPI
AXA
Owner Dmc
WORKER'S COMPHNSATION DECIARAq'ION BACK FLOW PR(YI'ECT 1 DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1have and will maintain a Column,of Consent In self-insure for Worker's Comped- DRAINS—FLOOR.ROOF,AREA.COND. \labor,us provided lr by Stolon 3700of the Lahnr Code,for Lha Pa for error thework far whichthis permit is issued. PD(TURES—PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,m required by Station3710 of the Lulea Code,for the perlmmanccut the work for which this perit is issued GAS—EA.SYSTEM-I INC.4 OUTLETS OMy Worker's ppy�yatio�II n l Plicy numbe'tum
Carrier. T r -tiu i dicy Na: GAS—EA.SYSTEMAVER S(EA)
CF. 'I IFICATI:OP I;x TI ORKIiRS'
COMPENSATION INSURANCE GIIEASFJINDUSTRI.WASTE INTERCEPT OR IN DWISI _
('Thissection nceJnnt hecompfemd ifthe proot isforonchundreddollam(S OO) GREASETRAP
it,less) PLANCHECK FEE
I certify that in the performance of the weak for which this Permit is issued,l shall SEWER—SANITARY—STr IRM PA.200 FIE ENERGY Gurkri Ii
urnemploy any proud in any manner so as to become subject n the Workers'Compen-
02 .cellon Laws of Califteno.Dae - WA117R IIHATER WNENf/EFECI'R GRADING FEE
Z Applicant
sur. NOI CE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING SOILS FEE
a >
became subject to the Worker's Compensation provisions of the Labor Code,you must
{sl forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL?LMB. SQ.P. PAID
U Q l hoebyallirm thatnhere iso combecuon lendingugency for the performance of D:nc Receipt#
{L (.y the wok for which this .it is issued(Sec.3097,Civ.C.)
OU Lendm'a Name TOTAL:
} IT)TAL:
Lenders Address '
y I certify that I have read this application andante that the above information is BUILDING IIiE
F."y V1 correct.I agree m comply with all city and enemy nniinnnces and sate laws relining to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authurim representatives of this city to enter upon me SEISMIC FEE
ahoy-ntemioned pitfor inspection purpo c. PERMTT ISSUANCE
(We)agree m sma,indemnify a P hamdes the City of Cape it in.uyniust ELECTRIC R
liabilities,judgments,
culls and a W, c ra my eccmeagamstoid City ALTER OR ADD TO MECH. PLUMBI
in consequence of the Bnirti uPernit an
AI'PLIC UNDERS AND I. I'LY "H ALL NON- 1 AIR HANDLING UNIT(TO IO,(roOCFM) MECIIA ICAL FE
SOUR .REGULAT
AIR HANDLING UNIT(OVER 10.11(1(1 CPM) CONSTRUCT N
mree'ApplicantiCommeton Date EXHAUST HOLD(W/DUC'19 HOUSING MI IONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havurdous material HEATING UNIT(TO 100,00 BTU)
us defined by the Cupenimo Municipal Cade,Chapter of 2,dud the Health end Surety
UNIq'(OVER IIMI,IIW PTU)
tlliATING
Code.Section 25532(a)?
❑Vas
FIN. VENTII.AI'IONI'ANISINGLF.RIiSID) PAID
Dn¢ Be, I M
Will the applicant mfuore holdingoceupant mcapipmrm or devices which BOILER—COMP(3HPOR IW.IXO BTU)
unit hamrdous air cuntarrinants as defined by the Bay Area Air Quulily Madagemem A
District? BOILER—COMP(OVER 100,M)BTU)
❑Yes ❑No
I have
X
als re to Is m 'r Chapter 6195 of the Cull- AIR CONUITIONF.R ;SU E DATEfmmia Health —1 and 53191utWemt. d Nat if the NEW RFSIDENTIAL MECH. SQ.FI'.
buildingdocs n ,v mY msibilhyy7n, Ne up tof ircmsemis unfa Cen,lgll�r
vulhnriried agent Date TOTAL ISSUED BY:
OFFICE