99110155 APPLIG.ANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINTPEN ONLY
RICAI Ff -` I I S�
CITY OF CUPERTINO BEEF1 PliaMlT No.
RUIIAING DIVISION APPLICATIONIPERMIT PLUMBING-MF"CHANICAL SOOOI
ALAI DING PROJECT IDENTIFICATION
BUILDINGADDRESS ^ SANITARY NO. APPLICATION SUIfMI'ITAL DATE
�3 ,Pr
UW NAME.^� PIIUNE: C RA OR' AMI;; LIC NO:
n JC NIC CONTHOLp
CHITECIANG, PER; LICNO: AfdrlyFSS. CA Q ❑
116
CONI'AC 1': PHONE BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) RI. n ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CON]RACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed tinder provinitm.of Chapter 9(commencing JOB DESCRIPTION
Zd'Z with Salinn] fD si.m lof the Business fessinns Cale,% ylicemeis IU TIA
WOO ter/�� LL yyy{{p�� PERMIT ISSUANCE
F�. in lull torte alp nuxr ❑SPDWI. ❑KITCHEN RIih10DEI.
U F License x. l� List p
6 U �} APPLIANCES-RESIDIiNT1A1. []ADDITION El PLUMBING RE-PIPE
ar,Q L Dote Conlmnl
>,� ARCHRECTSD I PANELS ❑MULTI-UNIT ❑S'TRUCTURAL
TION
Z O H Z I understand my plans%hall be used as public recookAej�d/' _ ��[[kib CARED
OZ=- UPTU200AMPS ❑INTERIOR �SlCJA1MNEY REPAIR
W Licensed Professional 201-ISMAMPS IMPROVEMENT / 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVERIIXNIAMPs ❑BATH REh10DEUREI'AIR El DEMOLITION
C C Q I hereby rifmu 0vd 1 am exempt It n the Commerce,License Law for the
{Kp 3 LL F following reason.(Section]031.5,Bmines%and Pmfessinns C1Me:Any city or county SIGNS ELEC I'RICAL OTHER,l ir any succturt
F LL"Owhich requires a Permit to construct.alter,improve,demolish.or repa
a print it)its Issuance,also requires the applicant rot such permit file a%igneJ statement SPECIAL CIRCUI'TIMISC.
�'j J that he is licensed puesunnun the previsions or the Contractor's Lecow,"w(Chapter 9
kJ 0 (commencing with Section 700l of Division 3ofthe Business and l'rofcssmm%Code)or TGM1iP.MIffiiH OR POLE(NST COMMERCIAL'
a a e C
that he is exempt member,and the basis rot the alleged c.irptbn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLI'NON
��h
Section by anrapplicanl for a permit'ubjectsthe applicant to a civil penalty of POW(?R DEVICES ❑T&VANT [I Fool)SI?RVICI?
F ZJ.T not more than five hundred dollars($500). IMPROVEMENT
ee=Q ❑I,asnvnerofthepropeny.ormyemplomswithwegesa Neirsolecompcnswinn. SWIMMING POOL ELECTRIC
2 p.0 will do the work,and thu,tmemre Lone intended.,offered failure(Sec.]OJJ.Business ❑OTI{ER
I'd 3 m and Profession'Code,*no Contractor's License Law does nod apply m an owner of OUTI.ETS-SWITCHES-FIXTURES
reopen,who builds or improves thereon,and who does.such work himself although
as own encpleyees,provided that such improvements are not intended.,offered for N17W RF_SIDBNTIAL ELGCTR SQ D .
aide.If.bowels,the huidingorimpmvemmot issain within one,carolcnmpletiao.the SQ.FT.FLOOR AREA S/SQ.IZ
tier-builder will hove the burden of proving that he did not Said or improve for pur-
,,cutwile.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
smw0 the prrje't(See 9044,Busincsc and Pmnestles,CWc:)The Corsican's Li-
wnseLaw does net apply toanow'ner of property who builds or imprevcn thereon,and QTY PLUMBING PERMIT FEE
ho contracts for such projects with a commetor(s)licensed pursuant m the Contracmr's
1"iccnnc Law. PERMIT ISSUANCE
❑ I ma exempt order Sec. .If As P C for this reason
ALTER-DRAIN de VI?N I'-MA'I'FR(EA) VALUATION
Date _ /
weer grOHnderPCOMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE /— /i_J
1 herebyoffnnunder Penalty to pejuryone ofthefollowing declarations:
�Ihuve and will I..h maintain iilicmcof he LauoCocensmrele Workers Compcn- DRAINS-ItOOR.ROOI'.ARG.COND.
us pnrvidd for M1y SCetion 3700of he LaMa Cde,for the pedirtmuncc of the S'pOR1E5 TYPE CONSTRUCTIOI
r which thi%permit is issued. FIXTURES-E'ER TRAP
ave and will maintain Worker'a Compemmion Insurance,as required by Section
3700offific[,all C, run eper l'ormmnce of the work for which the 'issued. GAS-IA.SYSTEM-]INC.6OUTLETS OCC GROUP AP
MY WqH dj, %c caricr and Policy' (/`.
Ca Policy No. GAS-EA.SYSTliM-OVBRJ(BA) r`3 J
CERrH9CATE OF EXEMPTION FROM WORKERS' Z ..J
COMPENSATION INSURANCE GRHASEANDUSIRL WASTE INTERC5FroR
(This union need not be completed if the pcont is forone hundred dollars(811X0. BUILDING DIVISION FEES
or Ems.) GREASETRAP PLANCI IECK FEF.
I codify[list in the performance of the work for which this Permit is issued.I shall SEWER-SANITARY-STORM HA.200 IrL
not employ any Person in any manner scn%do became subject In the Workers Compere- ENERGY FEE
zz satlon Laws of Califnmi..Date WATER HEATER W/VIiNT/ELECTR
2 Applicant t GRADING FEE
`
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMTRHATING
a , Iwmome subject to the Workers Compensation provisions.(the Later Code,yon moa SOILS FEE
{A forthwith comply with such previsions or this psnot%hall h deemed revoked. WATER SERVICE
Q
.aU Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
UO hereby which rm thatthemi%aed(SeetS30lending agency for the performance if Date NeceNtW
LL E✓ 'he av Lrodrak for which this pcmdil is issued(Sec.409],Civ.CJ
Lender's Nanta TOTAL:
U E I<ndcrmTO JAL:Z) I many
rtify td hat I have read this
iyiniapplication and mate that and ah—
,am information rmmid,is Bl11LU1NC FEF.
Z corral]agree ommctcomply win ail cityand countynNtives of and store cawsr upon the
QTY. MECHANICAL PERMIT FF.F.
U Z building constmnion.and horny uuthorim representatives olihis sty to enter upon the SEISMIC PGE
atwve-mctnianed property for inspxtimn Patty,,,.
(We) me to.nave,indemnify keep hmmlessthe City of Cupertino against i'ERMI'I'ISSUANCL
and ELECTRIC FEE
liabilllic%,judgmcros rens andexpemcs which may in any wayaccmcagainst said City ALTER OR ADD TO MEC({.
in consequence of the germing of this permit. PLUMBING FEE
AI'P, ..-r UNDERSTSAND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.1110 CFM)
mecF :G I. r1 MECHANICALFEE
/+
y AIR HANDLING UNIT(OVER 10,110(1 CFM) CONSTRUCTION TAX
ignmure of Applicant` —to'
Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF.
IIA RDOUS MATERIALS DISCLOSURE
Will the applicant or furan building cession,scare or handle haorthar mmerixl I(GATING UNIT(r0 100,000 B U)
as defined by the CupcNno Mucci 1 Cale,Chafer 9.12,and the Health uad Safety
Code,Saturn 25532(.)1 HEATING UNIT(OVER 100.0ip BTU)
❑Ycs 11 a
" VENTILATION FAN(SINGLE RES) PAID --
Will the applicant r rumrc building occupant use equipment or devices which Date Receipt n
mid hazurl.u%or comaDioneC bre' fired by lee Bay Area Air Quality Management BOIL(?R-CU. P(MIR OR 100.000 BTU)
E]yes
ran a ROLLER-COMP(OVEH 100.tY10 HTO)
lh:rvcro.ddhe mrdnusmatcHaLrc tsunde,Chu 695oflhe Cali- AIR CONDITIONER
ymmncnn und ISSUANCE DATE gP
nrnia Hca1N&Safety ale,Sections 255115.25513 and 288]].1 anJcrsmnJ thm if the NEW RFSIDENI'IAL MECH. SQ.Fr. /
buildi natcunemlyh mn ilismyre•`Mnibilitym no'yWeoe Pact ,
oft N:mnlpn...u7uancerfu Ceniftcl fO.C'cu
O c rauthon. ug Date TOTAL
ISSUED BY:
OFFICE