99080013 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-19LEC'FRICAh PF,RMI
BUILDING DIVISION APPIACATION/PF,RMIT PLUMBING.MECHANICAL.
UI
BLDING PROJECTIDENTIFICATION' --
IIUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2 r NSD CU a
OWNFR'SNKME: - PHONE C NIRA IOR NAMI!:
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tCHI'IECFIENGI :F.R: LIC NO: AD S' J 1 l0 / ❑ /� -S
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CONTACT O e S BUILUINC PERMIT INFO
QQ 11 CT A
AJ MAa�91—�r N }}} GGGjj}
��G av1, (a�) 55- 6 73 u Consultant Fac'Paid by Applicant(Initial) BLDG � PLUMB MECH
LICENSED CONTRACFOR'S DECLARATION QTY. ELECTRIC PERMIT .FEE ❑ ❑
I heresy afdrn Nat I am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
C1aZ whh Seudon700 fDlvls!on3of the Bosineasund Prnfaxonnx Codc,vml In license is
° y RESIDENTIAL:
P in fullhaveeRea. PERMIT ISSUANCE
WF []SFDWL E3 KITCHEN REMODEL
�UU License Class Lic.# API'IJANCES-It ESIDI?NTlnl. ❑ADDITION [I PLUMBING RE-PIPE
y<W Date Cmandu r
ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURAL
2 C, I understand my planx'ball Ise used ds public records PANELS MODIFICATION
UPT0200AMPS
OZ—ytv07 Licensed Pndinnionul (3 INTERIOR [I CHIMNEY REPAIR
201-IIIWAMPS IMPROV EME V' ING POOLS
Ski; OWNER-HUILUER DECLARATION OVFRItIMI AMPS []BATH REM[] til ION
L C C C I hereby offmn that 1 am exempt from the Contractor's License Law for the
Il O M U following maxim.(Station 7031.5.Business and Profession,Code:Any city or.,only SIGNS ELECTRICAL []OTHER
u 3 a F" which require.a Fiction to construct,alter,improve.dea°B'n,or repair any structure _
tM prior to its issuance,also require'the applicant for such perain to file a signed statement SPECIAL CIRCUITNISC, ww
fIsey�P that he is licensed Pucmanuo the provisions of the Contractor:License Law(Chapter 9 V
u1a00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.M1"11HORPOLHINST.. COMMERCIAL'
at%e C that he is exempt therefrom and the basis for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
Seat 7031.5 by un,mithcvm for a Permit sunned'the cGriwnun Trod pennlly of POWER DEVICES []TENANT []FOODSERVICE
^ 0 a.,more than five hundred dollars($5107.
❑ Las owner of the pr°pcny,nr my employees with wages ax their sok compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
p. will do the work,and the structure is not intended or offered for.ale(See.70,14,Business []OTHER
L3 and Profession,Cade:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTUR
property who builds or improves Formula,and who does such work himself or through IF
his own employees,provided that such improvements am not breaded or offered for NEW RESIDENTIAL ELECTR FT.
'cle,flhowever,the building.,ingvovcment is sold wi Ninnne ymrofcomplencia,the SQ.PT.FLOOR AREA VSQ.FT,
sweat gilder will have Ne harden of proving that he did not build or improve for port
pose of sale.,
1,us owner of the properly,am exclusively contracting with hamised contractors to
construe Ne project(Sec.70TI,Business and Professions Codi"Die Contracmr's Li-
se Law does not apply In an owner of property who hurl&or improves(hereon,and QTY.,' PLUMBING PERMIT E-
wbocommctsforsu hpar Is with acommcmr(s)licensed pursoantmthe Conuncmr's
11
hie Jr
I am Law. PERMIT ISSUANCE.
p lam exempt un rSec. ,B&P C for this reason
- AFTER-DRAIN&VENT-WATER I VALUATION
Date O
w WO SATION DECLARATION RACK FLOW PNOTECI'.DEVICE n , v
I heathy affirm under penv Iy of pejoryone of The following Jalautions: i/
L]I have and will maintain a Certificate ofConscnno self-insure for Workers Cooper- DRAINS-FLOOR,ROOK All[I,COND.
radion,as provided far by Section 3700 of Ne Labor Code,for the pact"ornatace°f the STORIES TYPE.CONSTRUCTION
work fur which This perain is issued. FIXTURES-PER TRAP
El I hove and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code.for the Performance of the work for which this permit is issued. GAS-EA.SYS'i'EM.l INCAOUTLETS OCC GROUP
My Worker's Compensation Insurance carrier and Policy number am: '7SAP N
Carier: Policy No.: GAS-EA.SYS"TEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION MOM WORKERS ce3
COMPHNSA'I'ION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
phis section Dred not becompleted if the permit is forone hundred dollars($1001 BUILDING DMSION FTifiS.
nr less&.( OR BASE TRAP PLANCHECK FEE
IcenifyPdin Nep ymanance ro itheworkfne subjectch to
perthe it Wrkere Conquer-
SEWER-SANITARY-STORM EA.230 EP.
not employ:ury penin in any manner so its m become subject m the Workers C°mpen- ENERGY FEE
0 Z cation Laws of Calimarba.Ilam WR'I'ER IT WNIIN'VE1.ECfR
7 APPliczm GRADING FEE
Gy NOTICETO APPLICANT'.If,nter making this Cmiftaa,of Exemption,you should a WATER SVSTI!M/IRIiATING becmeosubject to the Workers Compcnsstien provisions.1 the Labor Cala you must SOILS R!E
Forthwith comply with such provisions or this Permit shall he deemelreclad, WA'ITR S17RVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLhIB. SQ.FF. PAID
U 0 I hereby allirm Nal there is a construction lending agency for the performance of Data wescaN
M
l!. P the work for which this permit is issued(See.t(N7,Civ.C.)
0 U Lender's Name OTyTir
LSl Lenders Address TOTAL:
I cenily that 1 have read this application Ind mate thin the above information iv � BUILDING FE
h correct.l agree mcomply with all city and county ordinances and nate laws relating at QTY. MECHANICAL PERMIT C FEE
U M1uilAing cmn.amctioo,vnA hereby auNndze reprcsemmives of this city mcnrerupm Ne SEISMIC FEE
atu vomem!oned property for inspection purposes. PERMIT ISSUANCE
(Wm)agree to save,indemnify and keep harmless the City of Cupertino again ELECTRIC FEF.
Iiahllhies,Judgmans,caNDSAn
hich may in any stay acerae nguium sold City ACI ER OR ADDI 0 MECI I.
I.am>equence muse t. PLUMBING FEE
APPLICANT UNU ICI.COMPLY WITH ALL NON-POINT gilt HANDLING UNIT(TO 10.(N)fl CFM)
SOURCE REGULATI MECHANICAL PEE
AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
SignmmemAPplicanVComrecmr Dole EXHAUSTHOOU(WIDUCO HOUSING MITIGATION FF.[
HAZARDOUS MATERIALS DISCLOSURE
Will the applicator or future building occupant score or handle Fluctuations almost HEATING UNIT(TO 1000011)BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.and the HealN and Safely
Code.Section 25532(a)? HHATING UNIT'(OVER 100,00)BTU)
❑Yes r7 No
VI!NTILAIION PAN(SINGLE RESID) PAID pate 4ipl#
lWill she applicant or future building occupam use equipment or devices which
ad hnsmdnus air cnnmminantn as defined by the Bay Area Air Quality Management yOILER-COMP(3HPOR IW,IXIO BTI7)
District?
0Ycs [:1 No BOILER-COMP(OVER 100,000 BTU)
Ihave rwd 10Dle,t" equiremnns under Chapter fi.95 ofthe Cali- AIR CONIlIT10NER ISSUANCE DATE
foliaI(whh S y Ga 505 25533 and 25531.1 understand that if the NEW RESIDENTIAL MECH. SQ.FC ote r nx ,tkh a Hoto iseuonm of a Certificate of IRatpan.y.
Dam TOTAL: ISSUEU BY:
OFFICE