S 0022 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-MECH MICA PERMIT NO. ^ 1
HUILmNcnrvlSloN APPLICATIONIPERMIT LIIMIIINC-MI[CHANICAI,
BUILDING PROJECT lDEN'FIFicx'IUN �qm
BUILDING ADDRESS.. SANITARY NO. APPLICATION SUNMIITAL DATE
OWNER'S NAME: PRONE. CONTRACT 'S NAME: LIC NO:
— LGL tC t S q;?S�� NIC CONTROL#
ARCHITECrENGINF,ER: LIC NO: ADDRESS: ❑
�
CONTACT PHONE 13UIIAINC PERMIT INFO
❑ Consultant Flies Paid by Applicant(Initial) If ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT I°F.F.
hereby arTmn that 1 am licensed ander pnrvianrns dr enapmt v aommcncmg JOU DESCRIPTION
D0Z with Section 00001of D,vision 3ofthe Business and Pnde,,itim Code.and mylicenmis RESIDENTIAL:
m O O PERMIT ISSUANCE,
F w full force and effect. ❑SFDW1. ❑KITCHEN REMODEL
QUyV License Class Lic.M APPLIANCES-RESIDENTIAL El ADDITION [I PLUMBING RF.-PIPE
F d w Date Carl.,a
ARCHITECTS DECLARATIONC1MUIM-UNIT ❑STRUCTURAL
zcdo
aOz I understand my plansshall he used as public records PANELS MODIFICATION
OZN� UP TO HXI AMPS ❑INTERIOR MNF.Y REPAIR
W Licensed Professional 2014000AMPS IMPROV17 IEM' SWIMMING POOLS
CYC; OWNER-BUILDER DECLARATION OVER Ial0 AMPS ❑BATH REMODEIJREPAI R DEMOLITION
'W Q 1 hereby affmn that I am exempt from the Contractors License Law for the
°' a U followin Section]031.5.Business and Professions Cole:An cit oma' ❑OTHER
X 3 6 reason.( Y Yoe Y SIGNS ELECTRICAL
4: LL y which requires a permit to construct,altar,improve,demolish,or repair any swdure
F�OQ pride to its issuance.also requires the applicant for such permit to file a signed statemem SPECIAL CIRCUIT/M ISC.
that he is licensed pursuan...the provisimm i f the Commemr's License Le.(C uiprer 9
(commencing with Section 7000)of Division 3 ofthe Business and Professions Cale)or TEMP.METER OR POLE INST. COMMERCIAL:
==,,X that he is exempt Wherein and the basis for the alleged exemption.Any violation of ❑NEN'BLDG/ADDrr10N ❑DEMOLITION
WM Section7031S by any applicant far a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT El FOOD SERVICE
not mom man five hundred dollars(5500).
F Z> IMPROVEMENT
=Q ❑ Las owner of the pmpenY,or my employws with wages as their tale armpensaion. MMING POOL ELECTRIC
�E..O will do the work.and thessuctu,e is not intended or offered for sale(See]OtA,Business ❑OTHER
W—m and Professions Code:The Contractor's License Law does not apply to an owner of O LETS-SWITCHES-IIXTURF_S
I d 3 property who builds or improves thereon,and who does such work himself or through B
his own employees,provided mat such impmvemems art not imended or offered for N ' FSIDENTIAL 1:1=11 SQ FT.
sale.If,however the building or improvement is sold within one ycarofurmpletion.the SQ.ET.F]gOR AREA SISQ.DT.
ver-Wilder will have the Named of proving mat he did not build or improve for put- (ryl//� ���
owner-Wilder
of sale.). v
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL. CI Y (J
construct the pmjmt(Sec.7011.Business and Professions Code:)The Cdnsamors Li- '1
cense law does not apply m an owner of prapcdy who builds or improves thereon.and QTY. PLUM GPERMIT FEE Uf- GUrI(111
who conuads for such projects with a consacmr(s)licensed Pursuant the Consumers Q
License hat. PF,RMIT UANCE
I am exempt a Mer Sec. .B&P C for this reason
ALTER-UR &VI!NT-WATER(EA) VALUATIONOwner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PR( i .DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑ I havearW will maintain aCertifcateof Consenttoselr-metre for Workers Comper- DRAINS-FLUOR.R REA.COND,
sation,as provincial for by Section 3]00 of the Labor Cade,for the performance of the STORIES TYPE CONSTRUCTION
work fur which this permit is issued. FIXTURES'-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance.as required by Section
37M of one laCbor Core,fore performance of the work for which this permit is inued. GAS-EA.SYSTEM-1 INC.J OUTLETS OCC.GROUP APN
My Workers u.��Insurance canis,and Policy n
C Policy Na:! rrie,}1404X-� GAS-HA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINUUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(ThneM
is section ed notcompleted ifine permit is for one hundred dollars(5100) GREASF.TRAP
or less.l I'LANCHECK I'1!li
I rxmfy that in the performance ofthe work forwhich this permit is issued.)shall SEWER-SANI'T'ARY-STORM EA.2(X1 IT.
not employ an,pccam in any manner so as m become subject to the Workers.Comped- ENERGY FEE:
ZZ sation Laws of Califomia.Date WATER HEATER WNENT/GLECTR
Applicant GRADING FEE
h NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEWTREATING
a ; Mmme subject to the Worker's Compensation pmviduna of the Late,Core,You must SOILS FEI3
forthwith comply with such provisions or this Permit Shall be dcemed revoked. WATER SERVICE
0
U0 CONSTRUCTION is aiIDNLENDINGAGENCY NEW RESIDENTIAL PhMtl. SQ.FT. PAID
UQ 1 hereby work
Butthemisaed(See.30lending agency 4a the performance df Date NmciptN
F the work for which this permit is issued(Sec.Jfn],Civ.CJ
Q Lenders Name TOTAL
Lender's Address TOTAL:
1 ecnify that I have read this application and stem that the above information is BUILDING PEE
aF".. LAI correct.I agree to comply with all city and county ordinances and state laws relaningto QTY. MECHANICAL PERMIT FEE
U gadding nmswminn,and hereby aathntiec repmwartativcsdrthi,Myra ether upon the SEISMIC FBI..
above-mentiuned property for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FOE
liabilitieajudgments,costs and expenses which may in any xvy aceme against said City ALTER OR ADD TO MICH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WHIZ AI NO' 'O N'I' AIR HANDLING UNIT LTO I Won CFM)
SOURCE!RIiCULA' tNS. MECHANICAL ITH
�� ` AIR HANDLING UNTI'(OVER 10.08)CFM) CONSTRUCTION TAX
/ Sinatur o pbcmVComoaua Date EXHAUST HOOD ONMUCT) IIOUSING MITIGATION FEE
HAZARDOUS MAIERIALS DISCLOSURE
Willmeapplieam orfimre building ocmtpamslumor handle monition,material HEATING UNIT'IT 0 INLOX)B'TU)
as defined by the Cupertino Municipal Ode,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)9 HEATING UNIT(OVER I(X),IXXI BTU)
❑Yes ❑No VEN'rILA'I']ON PAN(SINGLE RUSH)) PAID
Will mea ]a..,m lumm bandln,mea t use c I or devices which Dam Receipt a
pp g pad Area
a BOILFR-COMP(311POR I(to.ol Bru)
mit hazardous air cnnmminunts as Jclincd by the Bay Arts Air Quality Munagen¢m
DUAL
Dlxsloq HOILI!R-COM P(OVER I(X),IXro n'I'U)
❑Vcs �No
I huvc rcaA the hazardous materials rcgaircercnts ander Chapter 6.95 of the Cali- AIR CON,,IONER ISSUANCE,DATE
frim!,Ibealth&Safety Coda,Sections 25505,25533 and 25534.1 undemand hard the NI!W RPSIUL'NIHAL MECH. SQ.Isl'.
building dews not eurmmlly huvc a tenant,that i1 is my respmsibility wholly the ceeapunt
nl'the m,mo mene,which most be not prior m issuance of a Ccnificam of Occupancy.
Owner or authorized agent Date TYYI'AL: ISSUED BY.
OFFICE