30857 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUII,DING-EI.EC'fRICAI, PERMITNO. 30857
T O H S7
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xUu.mNG DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 3
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
(ol71 (7 'PLACE
O N R'S N A .
NIC CONTROLp
•SRCHIT' /ENGINEER. LIC NO: ADDRESS: - ❑
CONTACT PHONE, BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) G E PLUMB ECH
LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOZ with Section 7")of Division 3 offle Business and Professions Cade.and my license is RESIDENTIAL
1-ty= in full fomcun'ff"' PERMITISSIIANCF. ❑SFDWL El KITCHEN REMODEL
�E.UO Lico1--s Liao
NQi Date--1Convacmr APVLIANCES-RFSIUENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLAR PANELS ❑MULTI-UNIT []STRUCTURAL
Z O o,Z 1 understand my plum shall be used ns public repads MODIFICATION
OyFM UV'T02a)AMPS ❑INTERIOR CHIMNEY REPAIR
F�*5u: Licensed Professional , 201.1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
I hereby affunt that I un,exempt from the Contractors License Law for the OVER 1000AMPS
C � ATH REMODEREPAIR �DEMOLITION
K 3 a U falmwing mason.(Section 7031.5.Business and Professions Cade:Any city.,county SIGNS ELECTRICAL OL/
OTHER
ul O which requires a permit to continue,alter,improve,demolish,or repair any swchim
„I"J,-y prior to its issuance,also requires the applicant for such permit to file a signed.smemenl SPECIAL CIRCUITIM ISC.
thin ho is licensed promial,,the pro vlxions of the Cantrunors License Law(Chapter 9
X 50 OI(commencing with Section]000)of Division)nfthe Business and Professiom%Csi TEMP.MEIF.R OR DOLE INST COMMERCIAL'
a 6 c C tom he is exempt therefrom and,he basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a Permit subjects the applicant to.civil'imity of POWIiR DEVICES
FZY ,amore than five hundred dollar,($500). ❑TENANT ❑FOOD SERVICE
❑ Las owner of the Imperil or my emplayeex with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
(.. will do the work,and the structure is not intended moffmN for sale(Sec.)Oaa,Rosiness OTHER
w
and Professions Codd The Contractors License Lawdoess such
no,apply s if owner of OUTLETS-SWITCHES_FIXTURES
his o nY who built,or sided do Hereon,and who docs such ware himself offeredthrough
his own employees,provided that such improvements are not intended me or offered for NEW RESIDENTIAL[L[CTR SQ FT.
owner-bowevw.the building burenrrvemen,idat,he iidaone yemofcompledaothe S#1FYpf1QOJJREA VSQ.FT.
own
coftaldcr will hmethe bather of prmving,hat he did not build or improve for Aur- ��sYi o/
orAwe a[saline ���
I,w t the p of the popery,em exclusively contracting with:I Ua,Ccnmmemrs i-
o n,La the project(Sec.t)an Rosiness and property
who Inti Code:)Theves the tar's suit
3
c a:Lawdoesfor
chplr man with
a of ccrtmeory whored aoraintto emanon.and QTY. PLUMBING PERMIT FEE
who contracts for such pmjecs with a convanorfs)licensed pursuanuo the Commcmrs
01Law. PERMIT ISSUANCE 7r wNEyT�N
teat exempt under Sec. ,B&VCfonhmw
is on 0
am
ALTER—DRAIN&VENT—WATER(E
Owner DateA) VALUATION_
WOR KER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE I O�
1 hereby affirm under Penalty of perjury one of the following declars:
ation
❑I have and will maintain a Cerificateef Consentio self-insure for Workers Compcn- DRAINS—FLOOR,ROOF,AREA,COND. -
ration,a provided for by Section 3]00 of the Tabor Cale,for the performance of the STORI TYPE CONSTRUCTIOI
work far which,his permit is issued. FIXTURES—PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
J]a afthe Labor Come.For he performarecofthc work for which this Permit is issued, GAS—EA.SYSTEM-I INC.J OUT LETS OCC.GROUP AYN
My Worke a/lll�lnsumna carticrand Policy
Carrier: ��// Paliry Na.: GAS—EA.SYSTEM-OVGR4(EA)
CERTIFICATE OF EXEMPTION FROM W ORKEIO
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
(This stcdrn,teeJ oat b compined iftht permit is furore hundreddollars(SIM) BUILDING DIVISION FEES
nr less) GREASE TRAP
I coif that in the PLANCHECKI
y anymannro as
which lb is peen ltisis'Comen- SEWER—SANITARY—
not employ any person in any manner so m m become subject,a the Warken'Compcn- STORM EA.200 FT. ENERGY FEE
Z smirnaws of Califumia.Date
� � WATER HEATER WNENT/ELECI'R
Applicant z r-t pp GRADING FEE
rA
NOTICE 10 APP LICANT:IL aIle,mnsatiothis visios of of Exemption,you should WATER SYSTENUTREATINC
become subject w the Worker's Compensation provisions of the Labor Cade,you must
rosim comply with such provisions ordis Permit shall he deemed revoked. WATER SERVICE SOUS FEE
fa
aQ
Z) Z, CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT PAID
U O (hereby affirm that there is a construction lending agency for the performance of Date Receipt
II. pthe work for which this permit is issued(S¢.3097,Civ.C.)
Lender's Name
V Lender's Addresx TOTA)';L:
q 1 cerify that l have read this application and state that the above information is TOTAL: /•
F BUILDING FEE
Z? correct,legrccmar.malhhhancltyand county ordinances and atom laws reDOng a QTY. MECHANICAL PERMIT FEE
U bnivinmentiomdtirogend forchyectionsnposia, mina nfthiscity mcaterupon the SEISMIC PBB D
abavc(We)a agree
property for inspection purposes.
(We)agree to save,indemnify and keep harmless cite City of Cupertino , PERMIT ISSUANCE
pe gains ELECTRIC FEB
in'.i,ies.judg ns.coca and expenses which may in any way accrveagainst said City ALTER OR ADD TO MECIL
in arse'. e u the gr:mrng of thin permit. PLUMBING FEE
APPLIC� .T I' STA D WILL 'IMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.Oa CFM)
SOURC RF TION. MECHANICAL Fl:E
�? AIR HANDLING UNIT(OVER 10,101 CPM)
•/ i zz PB$7�
Signature of APPlicanJCan, for a S7W
HO(lD(W/DUCG
HAZARDOUS MAT Al ti DISCLOSURE
Will the applicant or fuwrc bats capamsmm or handle momoos material UNI'I'(M faiths)[ITU)
s defined by the Cupeninn Municipal de,Chapter 9.12,and the Health and Safety
Cake,Section 25532pd? UNIT(OVER 100,000 BTU)
❑Yes ONo
ION FAN(SINGLE.RESID)Will the applicant or future building occupant we equipment or devices which eceipt pemit hazarous air containments as defined bythc Bay Arca Air Quality Management COMP QHP OR 100,000 BTU)
Diaor" TOTAL:�Ym (]Nn COMP(OVER I(N.Myl BTU)I have read,he hasallous dome als requirements under Chapter 695 of the Cali- ITIONERfomiu Health&Safety Che,Sa,iow 25505,25533 unci 25531 I undersand that if the CE DATEbuilding does nal curently have a mnam.that it is myrespnnsihility,o nn,ily,he occupantDF,NTIAL MF,CH. SQ.FI'.of the requirements which mum N met priorm ismanmofs Cedde.ofOccupancy.Owner nr au,hnmred agent DTO'1'Al.:
OFFICE
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