99090098APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING DIVISION
APPIACATION/PERMIT PLUMBING -
IHALDING PROJE
AI DING ADDRESS:
'
I p, KS 8'
❑ MULTI -UNIT
I hereby affirm Thal I .,it licensed under prnvieimtc of Chapter 9 (cnmluencing
WOO with Seettan)gID)nf1bision 3nfac Businessman Potassium, Code.and my hooma, is
1-,_ O in full force and'Beet.
aUV Licence Class Lir. #
I- Q aW Dat' Co mull"
❑ Consultant Fees Paid by Applicant (Initial)
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECPS DF,CLARAI'[ON
Z Gy I
Z 1 understand my plans shall be,1 ,
OL—p
F .F., rel Licensed professions] '
�Y�.J OWNER-BUI1 F,CI.N%AIW 96
y ¢W'. Q I hereby affirm that I mm exempt from the Contractor's License Law for the
x 90. U following revisor. (seelinn 7031.5. Bnninu's Pro n. -I v
Irl y which requires a genua to amswn, aper, i i 1 0
FLLNO j'no".it, issnanee,ahnrequimsthe applica i .such .fi m n
E } 'hat he is licenced pursuant to We pmviainnso '. e e 9
(commencing with Section 90001.f Division3 ofthe Businessand Professions Crxhdm
A. a c C that he is exempt therefrom and the he 1
°^„ y Section 7031.5 by any uppli,z I for a u j a nm pc y
F Z Y not more than five hundred dollars (I
f=O ❑ I. as owner of the Prnpeny, or my ,'lot .. a v'to I
F will do the work, and the nmcmra is not intendedor arfrred for sale (So J(H4, business
6 3 = and Professions Code: The Contractor's License law does not apply n) an owner of
progeny who builds or improves thereon, and who does such work himself or through
his own empinyr s. ,,),idcd Ihu such improvements are not intended .r offered for
s�le.IL however, the building or impmvetr¢m is rola within.ne year.( completion, the
owner,buildcr will have the burden of paving that he did not huili or improve fur pur-
�wnof e
F.1 r of the progeny, am exclusively contracting with licensed contra<mrs to
constrict 'be project (Sec. 70,14, Business and Professions Codc,r the Contractor's Ll -
cerise haw docs not apply to an owner of property who builds or improves thereon, and QTY.
who contacts for such projects with a contracmr(s) licenced pursuant in the Contractors
License Law.
1 am exempt npdor S� ,B&PG�far I-hi:a,.
/Data 4 /J/YY
WORKER'S COMPENSATION DECLARATION
�T7—
1 hereby affirm umler penalty of perjury one of the following declarations:
1 have and will maintain a Ccnificale of Consent to sell -insure for Workers Compen-
as Provided for by Section 37W of the Lmlmr Cade, for the performance of the
pork for which this permit is issued.
❑ I have and will maintain Workers C.mpencnion Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My W'orker's Compensation Insurance carrier and Policy number are:
Cartier Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
- ('Thissec'imt nee at bca ldedif'hcpemcl o, kumehundmddollan(SIW)
is, lees.)
I certify that in the perfnnnance of the walk for which this permit is issued, I shall
valid, any person in any manner so auo-
s to become subject the Workers' Cumpe
C) cation Laws of California, Dale
Z O Applicant
h NOTICE TO APPLICA N'1': If, at making this Ccrilica a of Exemption, you should
? become abject'o the Worker's Compervali.n provisions of the Lahor Cale, you mon
forthwith comply with .such provisions onhis pennil shrill m
ll be devoted revoked.
aE
z CONSTRUCTION LENDING AGENCY
U O I hereby affirm tbar there is a x—pai ion lending agency fon he perfnrmance of
F the work I or which'his permit is issued (Sec. 3097, Civ. Cj
O U Lenders Name
Lender's Address
F6. I lenity that 1 have road 'his application ..it slate That the above infamaion is
Cl!) correct. I agree to comply with all city and county ordinances and state laws relating to QTY.
U7
G building conmmcl ion, and hereby emhorire representatives of this city's enter upon the
shove-nintrom l property for inspection purposes.
(We) agree'. save, indemnify and keep harmless the City of Cupertino again,,
habifidcc,jadgmrmta, coats and expenses w11iell may m any way acerae agairm said city
.asequence of be grunting of this pennil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE EGULATIONS.
k
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant mature building occupant store lir handle hazardous material
as defined by the Coconino Municipal Cale. Chapter 9.12, and 'he Health and Safety
Code. Section 25532(a)'!
(]Yes El No
Will he applicant or future building ..Pa.' use equipment or devices which
IL it harardous air emarrinann al defined by the (Say Are., Air Qu,,Iuy M magensom
❑Yes C] No
I have read the h orial unclonal.c requirements under Chapter fi 95 of the Cali-
fomia Health & Safety Cade, Sections 25505. 5533 and 25534.1 undeound that if the
building does not currently have a tenant, that it is my responsibility to notify the actPam
ol'he rsljuir�iq lit w ch most he met prior to issuance of a Cegirowe.(Occupancy.
OR POLE (NST.
OUTLETS - SW ITCHF_S - MIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
PLUMBING PERMIT
PERMHISSUANCE
ALTER - DRAIN & VENT - WATER EA)
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOF AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INCA OUTLETS
GAS- EA. SYS'IEM-OVER4(EA)
GREASILINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - S'FORM EA. 200 IT.
WATER HEATER WNENTELECIR
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CPM)
AIR HANDLING UNIT (OVER I0,0M CIM)
EXHAUST' HOOD (W/DUCT)
DEALING UNIT CDD 100.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VINTILA PION FAN (SINGLE REED)
BOILER - COMP (3 HE OR I godho It ru)
BOILER -COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENT IAL, MECH, SQ. FT.
TOTAL:
OFFICE
LEI
LE.CI' PLUMB MECH
E]D- ❑
JOB DESCRIPTION
RESIDENTIAL-
❑SFDWL
❑ KITCHEN REMODEL
[]ADDITION
El PLUMBING RE -PIPE
❑ MULTI -UNIT
❑ STRUCTURAL
MODIFICATION
El INTERIOR
❑CHIMNEY REPAIR
IM VEMENT
I] SWIMMING POOLS
ATH I EMODEUREPAIR EIDEMOLITION
1
❑OTHER _
�a.
OMM R IA
❑NEW BLDG/ADDITION EI DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
S FLOOR AREA EISQ.F
FEE /
yy VALUATION
BUILDING DIVISION FEES
PfANCHECK FEE
ENERGY FEE
GRADING FEB
SOILS FEE
ELECTRIC FEF.
MECHANICAL FEE -
I CONSTRUCTION TAX I t I
HOUSING MITIGATION FEE
PAID
Date Ricente a
ISSUANCE DATE
Q