S 0881 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOF CUPERTINO RUMBING- TE MECHA ICA reuMrr rvo.
'BUILDING DIVISION APPIACATION/PERMIT rl.unuurvc-MF;cunNlc,v. S 088
I BUILDING PROJECT'IUENTIF'ICATION' AP U V
SANITARY NO. APPLICATION SUHh11'PTAL DA'I'li
IUILDING ADDRT:SS:
p 8 o ve '�I�I_
OWNERS NAME: PHONE: C( RACE R'S NAM / LIC NO: NIC CONI to()].5 — /h Cr STrh S 6
AR I I' I:k INFER: LIC NO: ADDRESS: ❑
3 8 er c9
CONTACT: PHONE.: BUIL-DING PERMIT'INFO
❑ Consultant Fees Paid by Applicant(Initial) HIJ)G hLECr Pwh1n nutCu
❑ ❑ r, ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I aur licensed under provision.of Chapter 9(commencing 1013 DESCRIPTION
moowith Scrum TXXn of Division J of tic locarss tad Profc..o-Code.anwl my h one,Ix RESIDENTIAL:
Pf:RMIi'ISJUANCE
CmF in farce send cli'n,.0 ❑SFDWI. ❑ TCHEN RIiMODIiI.
'u, License Class Lica APPLIANCES—RISSIUIiNTIAL ❑AUUI'I'ION PLUMBING RF;-PIPIT
)am
'LS DECtat
'nQaM1fD11Tl-UNIT S'BUCTURN.
ARCHITF;CIlS UEC'LA ATION
I_7 m PANUS h10DIFICA'I'ION
Z O t4 Z I understand my plans small be used an public rtcarJs Oil TO 200 AMPS
p'L—� ❑INTIiRIOR ❑CIiIMNEt'RI?PAIR
F=Fm Licensed P...E.ninnA 201-IghAMYS 1MPROVF.MEN'I E]SWIMMING POOLS
OWNER BUILDER DECLARATION OVER IIXIUAMPS ❑BATH REMOUEUREPAIR [I DEMOLITION
al Q I hereby affirm that I am exempt from the Contortive'.License Law fnr the
X 6 U following mason.(Section 0131.5,Businaa and Pude,00nx Cade,Any mty or nmmy SIGNS N,LECIRICALA
THLR
Tic W Nwhich requires a pcnth m caramel,ul¢+.improve.demoEsh,or repair any someone
prianre itsissuance,atm mquims,he applicant for such purinn file a signedstatement SPECIAL CIRCUIT/M ISC.ythat he is license)pursuant to the provisions of the Comernr,License Law(Chapter9wC� (cummmming with gcation]IN(p ofDlvinionJ of lho Rusinesn and Pmfm,inns Codc)or TI_VB ME'T13R OR IY)L13INS"LMMERCIAL:aa C that he is eaemp,Therefrom and the hais for the alleged uaentpnion.Any violation of EW BI.DGIAUDITION ❑DEMOLITION
X Section]031.5 by any applicant fora Permit subjects the appliarum.civil penalty of T'ON'ER DEVICESENANT ❑E(N)D SERVICE
n mrn than five hundred dollnm(S50(d. PROVEMENT
F�61.ax owner of the propcny,or my can,lo,ov,with wag,,us lhcirsnle compensation, SWI MMING POOL.IiLLCTRICCwill do the work,and,hesaunmelmoo intended mothered fnr sale(Sec.](W.Business TIIER
Wm and Tommicions Ede:The Com o nnr's License Law docs not apply m an csurer of OUJJE1S—SWITCHES—FIXTURESropcny who mildsur nnpruvEs thereon,and who dues inch work himselfortbnn.ghhis own rmployce,,provided ohm uch intproven ant,am not immmdcd ur offered tow NEW RESIDEN'HAl.ELECTR
sale,If,however.the huildingnr irmomormad is sold wiuhinore yeanfcnmplelinn don
4SQ,FL FLOOR AREA SISQ.II'.
wneomilder will have the burden of proving that he did not build tor improve on par- x
lone of,ulcJ.
E] 1.as owner of the property,am eadusrvely Con eco ing with licensed cormorants lin TOME: h
ctnuuct the project(Sec.7014,Business and Professions Ctdcp The CommmtP A nr's Li- II
re Law doe,nmmple,wan awner of propcny who be ld,or improves mereon,and QTY. PLUMBING PERMIT F13E M
who counters for such projects with a commmug9 licensed pursuant o the Contractors D ^
License Law, PIiRMIT ISSUANCE
❑ I am exempt under Sec. .B&P C for this re.son i
ACfEN—UR AIN&VENT'—WRI'IBR(EA) 1 VALUATION
Owner Dane
Uf
W'ORKER'S COMPENSATION IIECLARAION BACK FLOW PRUrECT.DEVICE
I hereby affirm under penally of perJury ono of the follnwing declarations t l
(] I have unit will maintain it Certificate of Context mself-inure for Wot ker'v Cou,un- DRAINS—FLOOR.ROOF.AREA,COND. STORIES 'TYPE CONS'IRUC1'ION
scion,as provide)for by Section P(X)of the lalxn Codc,fnr the perfomence of the
work for which Ihis peril is issue). FE(W RFS—PER TRA('
❑ i have and will nmirman Worker',Contpmuminu Insurance,as regrind by Sec'it
37W of the labor CA for
the peflo Yin. nfdu work for which Nis permit is issued GAS—EA.SYSTEM-)INC d OUl'L 'S OCC.GROUP APN
M1fy Workq .ion nsumnc(camier and i'olicy GAti—EA.5VSTEM-UVIiRJ(IiN
Currier: UUU Policy Nn.
C13RTIFICA'1'E(IN EXIiM1'TION PRO WORKERS' CRI?n$PJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PLES
1'Un,wmian need not he completed]if the Fonio is fortune hundred doth,($I W) GREASE I'RAI'
nr Icsn.7 I'hANCIIIiCK FCIi
Icedifythal in oheparformanecofthe work forwhich lhisperiont k nsurd,l shallSEWER—SANITARY—STORM It 2811 ,
not employ any Person in any outman so u
as to become abju: o the Widen' ompe
Cn- ENERGY ITE
Oz .wean Luw,of Culifnmis.Date WATER HEAI'IiR WIVIiNTIELEOTR GRADING FISH
Z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,yva should WATER SYSTFMRREXI'ING
Evocator, mbo',m the Workers Compensator provisions of the labor Code.you must Solis FEE
.0
{aEI forthwith r iTy wmth,teh nrovisions or This coed,uhall be deemed revoked. WATER SERVICE
d 0
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FLAIR. SID FT. PAID _
vO I herebyatYnau
n thin is a counteraction e ction hadingagency for the ponformancof Data RecnplM
the work Tor which this ecru Is issued(See.3097,CivC.)
TOTA h:
Lerch',Name
Ulenders Address 1t
d I c nify thin I have mud his replication and sum thm the aMwe infunn:nion is BUILDING FEE
F lin cotto1 agree to comply with all city and county oral orneca and sure laws riming to QTY MECHANICAL PERMIT FIiF.
n.
V z building construction,and hereby anthmim representative%of this city to enterurym one SEISMIC ItiE
abnv>mcatinned propcny for inspection purpaso. PERMIT ISSUANCE
(We)ngrcc m wn,Imnnlfy and keep hass rtnlethe City of Cupvonion agrin,I L'LELTItIC FGL
salct
liabilitiez,judgmems, oatssend apenses which mayinmty wayaccme agd 1I1,ud City ALTER OR ADD TO MECH,
PLUMBING FEE Ut.41n
inconsequence It
gmmingn is peril
AppLICA '- N BRST S AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT TO 10.000 CFM)
MECHANIGI.hili
SOU ltd' '1'1
AIR HANDLING UNI I'IOVER I(LWO CFb1) CONSTRUCTION"TAX
ur nfnpplicmNConlnaen Dam EXHAUST FOOD(WIUUC) HOUSING MITIGNIION FEE
HAZARI FRIAIS DISCLOSURE
Will the app licant or forum ingl'acupomsmanrhandiehw.of..mammal HEATING UNIT(TO 100.0I0 BTU)
us defined by the Cupertino Mnnm au Cion,Chapter 9.12,and the Hcrldl and Safety
CMe,Section 25532(adP ELATING UNI'('(OVER 000m)l+'1'U)
CI Yes [:IN. VENTILATION FAN(SINGLE RP_SI D) PAID
Doc RcttiplM
Will the e,,fieam or Dome building occaprm use cmd'ancia nr Acvirex whim
emit to.mNou.air cor arriter s as coined by the 13,Area,Air Quality Management I+OILER—COMP(dTTP OR 100,000 BTU) TOTAL
Diseicl'! BOILER—COMP(OVER 100.00)BTU)
❑Yes Olson
1 have read the hazvdous malerialk requirements under Chapter 6.95 of the Cali- AIR CONDIIIONER ISSUANCE DATE
fnmia Health&Safety Code.Sermons 2.5505,25533 and 255}1.1 understand than d the NEW RESIDENTIAL MITCH. SQ.FT.
humiJmng dues mo currently have To mica.l.That h o my ovsry roale ity to mod,the ncniPa., y�
of the requirements which sena the met finer to issuance of a Cunilicam of Occupancy,
Owneror amho,rd ogem Dam TOTAL: ISSUED BY: V/V�� ///{••{V/
OFFICE