S 2233 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECT RICAL PE ITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2233
BUILDING 1'RO.)RLT IDEN'1'IPK'A'1'ION
BUILDING ADDRESS: SANI'I'ARY,NO, APPIACKHON SUBMITTAL DA]E
OWNER'S NAME: PHONE: CONTRACTOR'SMH LIC NO:
L ` _ N/C CONTROL
ARCH I UkC'VINGINHER: LIC NO: 'AII51111SS ❑
CONTACT': PHONE: BUILDING PFRjVMINI70
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELIi I' PLUMB MECH
0 1 s3 � 7 ❑ ❑ ❑
LICENSED CONTRACT OR'S DECLARATION QTY F,LECTRIC,PERMIT .I FiCH
I hereby affirm I inn licensed under provisions of chirpier 9(commenting - JOB DESCRIPTION
m
OwZth Seaion](XIO)of Uivisionl nfthe Business unit Professions CrWe,and my license is RFSIDFNTIAL'
Fop in full force and cff•r. PIiHMI'I'ISSUANCL
CSF �� O 3 GSPDWL C3 KITCHEN REMODEL
QUU License CJnl Lic.p APPLIANCES-HISIDENT1AL DAODITION ❑PLUMBINGRE-PIPE
-.7 M n�te� contractor
MACIII'IIiCT'S DECLARNFIO ❑MUCH-UNIT GSTRUCTURAL
yp 7, Iundersand my plums shall he usedus puhlle records PANELS O MODIFICATION
UP 1021X1 AMPS
OZ— Z Z DIN'ERIOR D CHIMN17Y REPAIR
f:.�F.W.4 Licensed Professional 201-1000AMPS IMPROVEMENT LJ SWIMMING POOLS
S4 X_IC w C Q 1 hcrehy affirm Thai I am lUILDER exe nim train the Con rxemor's License Law for the OVER]hot)AMPS D RATH RF.MODEIIRIiPAIR El DEMOLITION
0 W fill 6 ) 6,, 7031.5 Biviars,Tt i Vrom,ner,C I Any Ti,y or Tandy SIGNS ELECTRICAL D O'I'L R
^LL O FNe
which a ra,aln.,.it l tat' t It p damd,h.an mazy W.I re /
mJ Prim n Is.unpuinc,m,ififlairmf h invenit 1.(Ilan,iihaval.taemcnt SPECIAL. UITIMISC. j
Owrh Ica n'dp .. .h Pmvernes ofl Contractors Licrow Law Chapter
W R00 turmmeaangwth Section]IXXrynfDm,irm 3ofine Bowness snit lnfeaon.Cakhc TEhil'. OR POLE INST COMMFRCIAI:
Q. c C that he is exempt therefrom and the basis for the alleged exemption.Any viol; of ❑NEW BLDG/AHDI'I'[ON D DEMOLITION
^h
Section 7031.5 hyanyrilph,r I for a pernelwhjectslha implicate,inn civil pewltyof POWER❑IiVI GTENANT [IFOOD SERVICE
rot mom Oran 1,,a hundred dollmt(35011). - IMPROVEMENT'
❑ Las owner of the property,or my employees with wages as their Inde compernmie., SWIMMINCPOOL ; .TRIC
�15.Q will Jn the work,and the stmdurc is nal intended ar offeredfor sale(Seca.](114,Business DOIIIER
awl�m and Professions Code:The Cmarannrs Licem,,Law does rot apply to an-weer of DO[LETS-SWI1CHEIS-P F_S
3— property%ho builds or improves thereon,and who Jess such work himself or through
his we crnpinyecs,provided fled such improvements are nom inmular or offered for NEW RISIDEN'1'III IiL11C!'R SQ PC
sale.If.however,the buildingnrimprovement in sold within aneycmef onminiea.the SQ,F.FLOOR AREA 3/SQ.FT.
nwner-hnllet,will have rho linden ofpmv'aig that he did nor build ar Irnpmve for par
pose of sale.).
D L as sinner of the prnpeny,.,it exclusively contracting x ith licensed cmaramws w f01
construct the pnrject(Sec.7044,Resume,and 14ofesvions Code:) Contractors I.i.
raise Law does nm apply to to owner ofpropeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who comms,,for such projects with a nmuamm(s)licm.ed pursuant to the Counselors
License Law. r PEI,MIT ISSUANCE
D I can exempt under Sec. .B&1'C for this reason
Owner Data AIJER-DRAIN&VENT-WATER IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK I99W PROTECT.DPVICE
I hereby affirm under penalty of penuryenc of the fnilnwing declarations:
❑ Ihave zinc]will mhnain a Ccnificate of ConsentITfar Wurkcrs Conpla. DRAINS-PLOOR,-ROOF.AREA.COND. STORIES '1'VI'H CONSTRUCTION
mtlnn,as provided for by Section 3]00 of the Labor Calc,for the pati rmance of the
work for which this permit is issued FIXTURES-PER TRAP
D I have and will maintain Workers Compcnmtion Insurance,m rcgnired by Sxtion
3700of the Lab..r Gdic lot the performance of the work for which this permit is issued. GAS-EA.SYS'T'EM-I INC.4 OWLETS OCC.GROUP MIN
My Worker's Compensation Insurance cannier and Policy number nm:
Carter: Policy FROM
CAS-PA.SYSTEM-OVER 4(EA)
CERTIPICA'fE OF RXHMP'ITON PROM WOIi KIRLS'
COMPHNSAT10N INSURANCE GRIiASIJINDUSTRI.WAS'1'17 IN'I'ERCI?PTOR
RIIILIIINQ DIVISION IllhS
IThls sectimn mel nm he cnmple¢J ifihe Armil ie fnnmc hundred dollars 1511X11 GREASETRAP _-� --
or le".) PhANCIIIiCK FEE
I ccnifymat inthe perfornenceofthe workforwhich this permit is issued,]shall SEWER-SANITARY-STORM EA.2011•E
no,employ anY Person in any numan s psI hcennlee le'I m the Workers'C."I've. P.NERGY PEE
,Z smion Lawn ,I Cut Um° WN[HIR HEATER W/VENT/ELIiCfR
z 2 APPlicam /- `/� - GRADING Ir1iH
= NOTICE T(1 AIDANT. after mdk g(K Cenmcate o[ ,P CEshouldou d WAT17R SYSTEMI TREATING
(•' > became subject m the Wnmds Compensation pmvisiom of th .uMv LT Me,you must SOILS FEE
IN
forthwith comply with such provisions or this pcomit shall be dren ed revoked. N'A'TIiN SERVICE
Q
CONS'I'RUCTION LENDING AGENCY NEW RESIDENTIAL I'LMI). SQ 17. PAID
L) O I livehynffven that there is a......marine lendingagenoy fn dre Perf...nncecl' ', Receiptp
the work for which this permit is issued(Sec.3097,Civ.CJ
I. E"r Lenders Name TOTAL:
WLenders Address T
I certify that 1 have mad this application and state that the above interaction is BUILDING FE'
((�jA cmnceLl ug,eemconlply with all city and nmmy nrdinencos and scam lows relatin8 to' QTY MECHANICAL PE •E
V a building COrWilction,and hcrehy unthnnre,rcprewatativa.d av,rhy In entermpon the SEISMIC PIIS
ahmeanenmioned experty for im'pectim purposes. PERMI'TISSUANCE
(We7 agree to save,indemnify and keep M1annless the City mf Cupertino ogain.r CTRIC FEE
liabilities,judgments,costs and expenses which may in any way accme against said City AUmR OR ADD TO MECI
I.c �p
onsequenceefthe gmnlirgnfmis permit. P 13 GFEE
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH AL1,NON-POINT AIN HANDLING UNIT'(' )M CIM)
SOURCE?REGIII,ATION5. [ ANICAL FZE
AIR HANDLING UNIT(OVIiR EMIT S'I RUCTION TAX
Sdozermof Ap,heivntlContracte, Dame EXHAUST HOOD(W'/DUCI] %USING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or revive building occupant store or handle hazardous material HEATING UNIT(TO 100,NX)HTIU
dcfi..ed
by the Cuperlm id hipade Health Coro,Chapter 9.12,and dHealth and Sldmy
C
Endo,Sr<rinn 25532(e)1 III?A'I'ING UNIT(OVHIt I 00,0M)BTU)
E]Yes 0N VENTILATION FAN(SINGLE RESID) PAID pate Rccei t
Will the air coal
or(mute building occupant use .Air Qu zit dMem which _
l emit hanillnhe air mmamir mum.,a defined by the Huy Area Air equipment
or evicei mem BOILER-COMP(3HP OR 1(10,(X10 RTU) OTAI
District]
C]Yes GNO HOILEIt-COMP(OVliIt IIXI,IXNI R'I'(l)
-
1 have re: e haznmt
dnus nerids requirements under Chapter CONDEI'IONER r 6.95 of the Cali. /] ISSUANCEDATE
forma fiW theallh&Safety Cwle,Smtinns25505.M533and25534.1ualem rstmdmatifthc NEW RESIDENTIAL ME:CII. SQ.FT. Y
building does not currently have a mann,mat it is my responsibility notify the oupent f
of the requirements which must he me,prior to i.s.mn.e of a Ce tifictm of Ox,ag amy.
Owner ar authorized agent Data TOTAL: ISSUED IIY:�n r
OFFICE