30570 •APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPEI{ 30570
TINO, BUILDING-ELECTRICAL PERMITNO. O 5 7 O
- BUILDING DIVA'-IbN APPLICATION(PERMIT PLUMBING-MECHANICAL J{
BUILDING PROTECT IDFNrIFICA'1'ION
BUILDING ADDRESS: , -SANITARY NO., APPLICATION SUBMITTAL DATE
22 S25 2251 ;$
OWNER'$KN^1F.: PK Nn�� �•Z fl CONTRACTOR'S NAME: _ LIC NO: -
W I N/G CONfR01.#
\RC TECT/ENGI E LIC ND: ADDRESS: ❑
CONTACT - 1 PHONE: BUII,DING VERMIT INFO III
?pU'L_ Roawl�k Pies yBe• I 9gr a' $260 ❑ ConguhanLFees Paid byApplicant(Initlaq BLDG ELECT PLUMB MECH
o ❑ ❑
LICENSED CON'PRAETORS DECLARATION QIY ELECTRIC PERMIT I'P,E -
I hereby affirm that I licensed uads,p s of Chapter 9(commencing JOB DESCRIPTION'
E,06MMZ with Section 7000)ofD 'i nJ flhe Busi a JP f cions Codeandrhlicca s
�,O y - PERMIT'ISSUANCE T
in full farce and effort _
lk.uZt License Class hies# - OADWL []PLUMBIN RF-PIPE
NQS Datc Contin bre APPLIANCES-RESIDENTIAL OADDITION []PLUMBING REPIPE
a A P.CTS U CLA 10
Fly PANELS OMBLTI-UNIT O$TRUCTURAI.
y p y undcrsmnd my#hats t he usul nx is d _ OUfFICATION
OL4 [" UP'I'0200AMP5 4.'
Q�t u ed u-aro aal ❑INTERIOR al l'HIMNEY REPAIR
OWN R-BUILDER LARATION 201400DAMPS IMPROVEMENT
p OVER I"AMT'S E BATH REMODEUREPAIR O DEMOLITION
per�^(('' Q 1 he y affirm that P m exempt from the Canton,C's e:License Law county
'a-d 3 S U following reason.(Section]011.5,Business unJ Professions Cade:Any city or county SIGNS ELECTRICAL []OTHER
ttilil W which requires u permit bo construct,alcor,improve,demolish,or repair any smoun re "
F"��� prior to IN issuance,also requires the applicant for Such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
�} than he is licensed pursuant to the provisiansnf l he ConlracmGI License Law(Chapter 9 - _
(commencing with Section]11(0)of Division 3 oflhe Business and Professions Cots)., THEME'.METLR OR POLE INST. '
6 d ¢ that he is exanpt therefrom and the basis far the allege)exemption.Any violation of
nLL ❑NEW BLDG/AUDITION- 1DEMOLITION
act naa]oJI.Sve eayapplicantfarapermit objects the applicant 1m acivil Penalty of POWER DEVICES
not mom than live hundrnl dollars(15(m). _[]TENANT []POGO SERVICE '
}
ad ❑ Las owonk. nd themmya,my.imaeeawllhwages usthe(Suc.cumpensiness SWIMMING POOL ELECTRIC OTHER IMPROVEMENT
2 will dothewons and the he Cont isnon's License Lafichal w
does
of apply to an, wirer of OOTHF.R
0.3 and Professions Code:The eves due
u cos License Law rites Hat apply to if owner of OUTLETS-SWITCHI?S- XT
his o
no,am,who boils,or improves t such
i and who duce inch shirk himself or through -
his own employees,provide)that such impmvcments are not intended or offered for NEW RESIDENTIAL ELF. SQ FT'
sale.If,however,the building or improvement is sold within one year ofmmpbaionthe SQ.FT..FLOOR AREA S/SQ.ET.
owner-builder will have the burden of proving that he did not toodd 0,
improve for pury
c of sale.). I - -
as owner of the p "rel am exclusively contracting wit licensed eontmmors m SE
p 1 7'
construct me project(Sec.7(Fth,Business and Profession,Calc:)The Contmcto's Li- ` �Ol]�+
cease law does not apply it)on owner of prepeny who builds or improve m
erem,and' QTY. PLUMBING PERMIT FF /T s Y" 996
who contracts lurmch projects with a contractions)licensed purwant to the Contractors
License Law. PERMIT ISSUANCE 'vt Is 4s :H;y
❑lam exemptun on/ ,B&P C for thboas1
a% ALTER-DRAIN&VENT-WATER IEA) - -
VALUATION
O U '
W RdIt'SCOMPENSATIONDECLARATION BACK FLOW PROTECT,DEVICE
I herchy affirm under permhy of perjury one o(te following Jedumtions:
❑IhavcundwillmaimuinaCenilicnte of Conunnoself-inure far Worker's Conlpen- DRAINS-FLOOR,ROOF AREA,COND, STORIES TYPE CONSTRUCTION
satlon,as provided for by Section 3700 of the Lube Code,for the performance Of the -
work far which this perain is issued. R=RBS-PER TRAP
❑ 1 have and will maintain Worker,Compensation Insurance,as required by Section ,
3700of1he Loh nr Code,Car the perkamen,cof the work for which this permit is issued GAS-17A.SYS'T33M.1 INC.4 OUTLH'IS r- OCG GROUP DPN-
' My Workers Compensation l nsumnce carrier and Policy number am:
Curicr. Policy Na: GAS-PA.SYSTIiM-OVER 4(FA)
CERTIFICATEOFEXEMPTIONIROMWORKERS' GRL'ASI'JINDUSTRL WAS'TIi1M'ERCEITOR
COMPENSATION INSURANCE
(This section need not he completed!fine permit is for one hundred donors IS IIID) BUILDING DIVISION FEES
er less.) IGREASE TRAP PLANCHF.CK FEE -
Icerifylhminlhepeffnrmunce of Ne work far whichthis pemtit is issued,Ishull SEWER-SANT?p I1Y-S'IY)ItM F.A.2(Ill lef.
not employ any lersnn in any mnnncrsn nsmhecntne suM1Jaua the Wnrkerx'Compcn- ENERGY FRE
Z smion Lmsa or Califamie.Date -
C Applicant - WATER HEATER WNENTNLIiCfR GRADING FEE
y NOTICE TO APPLICANT.IL after making his Certificate of Exemption,you should WAHiR SYSTRMITRLATINO -
t`� become suhjcct to the Wnrkcr's Cmnpmtsmion provisions mthe Labor Cade,you must SOILS FEE
forthwith comply with such previsions or this permit shall is deemed revoked. .WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIMA. ESQ,Er.' ' PAID
U Q Iherchy uffrm that the.isaconsuuction lending agency far the performance of Data Rec<iptp
us (••' 1he work for which thiv pernil is issued(Sec.3097,Civ.C.)
Q U Lenders Name g
OTAL:
W Lenders Address TOTAL:
1 certify that I have rend this upplication and state that the above information is FEE ��-
V1 correct.l agree to comply with all city and county ordinances and slam laws relining to QTY. MECHANICALPERMIT FEEU3 building connmaion.and herchy amhnriss reprcscnmtives of thiscirylo eater upon the EE ��.above.nualionod property for impaed I EDrPuww.
(We)'agree to save,indemnify and klep harmless the City of Cupertino against PERMITISSUANCEt" FEE'liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADDTO MECH.in consequence of,he gmtnir,of this pemtit. FEEAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I OEM CPM)
SOURCE REGULATIONS. AL FEEAIR HANDLING UNIT(OVER IB,000 CFM) TIONTAXSignature ofAt,holulContracmr t Umo EXTAUSTHOOD(W/DUCTIMITIGATIONHAZARDOUS MATERIALS DISCLOSURE -
Willthespplicanmr future building accupatnsmre or handle hamrdousmatedaE HEATING UNIT LTO 100.00013'1'U)
as defined bythe Cupenina Municipal Code,Chapter 9.12,uad.the I Iwhh and Safely 'Cock,Section 25532(x)7. HEATING UNIT(OVER'Ig1,qMl BTU)
❑Yes' ❑Na VENTILATION VAN(SINGLE RESIDE' Date Receipt#
Will the applicant or future building by the H use ea Air u or devices which d1" BOILER-
. nit iet? s air contaminants w dcfneJ by the Nay Area Air Quality Management COMP(3HP OR 101),000 BTU)
'ialrim? TOTAL:
Oyes ON.
-
BOILER-COMP(OVER IIXI,OfIR BTU)
l:
I have read the heraNnus mmenulsAIR CONDITIONER ISSUANCE DATE
requirements under Chapter fi 95 of the Cali.
f ansa Health&Safely Cede,Sections 25505,25537 and 25574.I understand that if the NEW RESIDENTIAL MF.CIL SQ.FT.
tIffrbuildong does not emtvndy have a tenant,that it is my rcsponsihility m notify the occupant ��)//Jj��
of me rcquitenunte which roost be met prionoissuunre nfa Certilicate ofoccupancy. - - v A' y
_. l
Owner nr eumonuJ agem Uate TOTAL: ISSUED BY:
0. OFFICE.. "