S 3825APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
LJ Q C- LI
BUILDING - F.LF.CTR
BUI DINC DIVISION
APPLICATIONIPERMIT
PLUMBING - MECHAI
Soy-
BUILDING PROJECT IDEM'
BUILDING ADDRESS
2o6cio
wain Isfne,-
BUILDING FEE
OWNEfTINAME: 1.
1 _.
- 1, PHONE: _
CONTRACTOR'S NAME:_
LIC NO:
COMV1 qqq . p�3� ❑ Consultant Fees Paid by Applicant (Initial)
I hmrany arrinn n,m 1 am Banwed amaer rmvidnn, wrcnapinr 9 n.�tnmareing
WOZOwi(M1 Scctinn700)nf Divisionlnf lLc flusinens mW l'nRevsiovG e, ane my Lanz i,
F in full force and effect,
QV U License Class Lic. M
Z h Date Curren
ARCHI I17CT'S DECLARNFION
ZFO-Z I undentanemy plan%Shall be used a, imbuerecords
OZ=O
1 4 t w Licensee Prove ...... I
W OWNER-IIUILIIER DECLARATION
fY W d 1 M1erchy aflinn (bar 1 ran exmnpl (ram the Contractor's Live— Law for the
O 1 V Iullowing rcloom (Section 7031,5, 13nonesc and Profession, Code: Any city nr county
W 3 L n which requires a permit to mmaun, alter, mignon, droadsh, or repair any straclare
FLLOQ prior us in issuance, also requires the applicanl for. such permit to rile a signal statement
that he is licensee pursuant o the previsions of the Contractor's License Law (Chapter 9
xw'd (coninmore ng with Section7000)ofDivisie.3ol(he Business and Processions Code) or
L y o K that he is cscmpt theneliom and the buses for the adegut exmngtinn. Any Oolume of
W m Section 7031.5 by any agplie.t for a permit subjects he applicant to a civil penalty of
or more than five hundred dollars CS500).
FZQ D Lato, net of the property, or my employees with wages as their sole compensation.
d do ria wnrk. Code:
The Contractor's
tots License La lc does
it(,[ apply to an, Business
pre 1'ny who
Omlor The CommeLicense w Luo s such
mol work
hi m an owner h
L 3 - property who hues, or improves tsuchthereon, and who ansa mne wnrk himself or through
his . H. anrver, the
building that such mentm'emenw are net intended or completion,
for
----
sale. weever, II have tthe bonng or ,,, of lnrm is rat a within one ycan, improve
the
arvbuiWcr will have the burden of living (M1m hu did not buil) or improve fnrguo
�mwne
r of Inc See 704, ran exclusively cnntracung with i The
mment'ss e
use a the es jot apply
o an Business and property
who In, Code:)The ConTmcmi, rid
cense law aces not apply to an wither of progeny who builds or ant to the thereon, and Q1 Y.
whocw [.a.. [wrmeh pro'eas with aenmmmuq,l licensed pursuant to the Contractor
License how.
❑lam exempt ana yh_.B&PCfor�tlis tram
I hereby allium under pcn:Jly of perjury one el the following declarminn.v:
I nave and will maintain s Cerilicme of Cnnsenun,elf-insure for Workers Compen-
saion, us pmvidW for by Section 3710 of the Ichor Code, for the performance of the
work for which this permit is issued.
D 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700of the Labor Coda for the perhaturnee wf Lha wnrk for which rims permit is ,,umd,
My Worker s Compenamion Insurance timer and Policy number am:
Cartier: Policy No.:
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
1'1his,mli need out heounpWed d(Lapermit Ls rnrona bendeddolars61010
it, le,,.)
I certify that in The performance ofthe work for which this permit is issued, (,ball
not employ my person in any manner set as to become subject to the Workers Compcn-
C)Z safon L... of Ciddonam Date
Z Applic:uI
NOTICE TO APPLICANT: If, arm, making This Cenifcae of Exemption, you should
a ; become mba mjctpe
he Waukee, Cwmns...a provisions of The Ichoru Code, yomust
Lt1 forthwith comply with such provisions or Nis pencil shall be deemed revoked.
d Q
CONSTRUCTION LENDING AGENCY
V 0 I hereby aflinn t hat there is a conswdion lending agency for the performance of
the work fill which this pemtil is issued (Sol. 3097. Civ. C.)
f-'
OLender's Name
U
GJ Lender', Address
I ...Idy thus I have read nim, up,hr moI, and won that tha oboe infnrnnnion is
I"' hcorrect. l agree to comply with all city and county ordinances and%Tate lawsrelaung to QTY.
V Z building mnswctinn, and hereby authonx reprcsenmtives of this city to emerupon the
above-mentioned pmppuff
coy for inspection ppoxs.
(We) agree In save, indemnify and keep harmless the City of Cuperino against
liuh'ditlesjudgov n .. cn.Is and expenv,, which may In any way acerae ngzirul slid City
in n.ccquence of The granting (if thin Perini(.
APPLICANT))1NDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RGOULATIONS. / . i
I I1A7ARDOUS MATERIALS DISCLOSURE
Will the unitarian or future Building occupant store or handle hauraons material
as arboreal by the Cupertino Municipal Coda. Chapter 9.12, and the Health and Safety
Coda, Section 25532(a)'I
0 Yen /j��t
Will the applicant 6rfumrt (wilding occupant use equipment or devices which
emit boared is it amt.dium nt, as dclinW by the Bay Arca Air Quality Management
Di.strictl
D Yes
I have real the has Imperials equiemene "I Chaffer 695 of the Cali-
Btmia Beellh fey Cu". Scmions 25505. 25513 and 255N. I understand Ihm if the
bullh doe, ( currently have a ZJyt. that it i, Icy rc.yvnuibility modJify th,ocenpant
oflhL Iruu' mems which must le�f(4*nort issun olaC ',,'f OuyfTaruy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 20t) AMPS
SIGNS IPLEC'I RICAL
SPECIAL CIRCUR/MISC.
'rKmE Mi ER OR POLE INST.
POWER DG"CES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RF_CIDENTIAL FLECK
PLUMBING PERMIT
PERMITISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR. ROOF, AREA, COND.
FIXTURF_S - PER TRAP
GAS -IiA. SYS 'TEM. I INC. q OUTLGI:S
GAS -IiA. SYSTEM OVER q IEA)
GREASUINDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER -SANITARY -STORM EA. 20 FT.
WATER HEATER W/VENT/ELECTR
WATER SYSTEMO-REA'1'ING
WATER SERVICE
NEW RESIDENTIAL PI.MB. SQ, PT.
MECHANICAL PERMIT'
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUSTHOOD (W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100.000 BTU)
VF.NTI -ArION FAN (SINGLE RE.SID)
BOILER - COMP (LHP OR P00.003 BTU)
BOILER-COMP(OVER 100.00(19HJ)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. PT.
OFFICE
MK•�
FEE
SQ. Fr.
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11
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- OCCGROUP�(/aPN
G23 s -o3 9
UILDING DIVISION FEES
PLANCIA)K F : 'z S
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Receipt M
FEE
JOB DESCRIPTION
RESIDENTIAL
O SFDWL D KITCHEN REMODEL
ADDITION D PLUMBING RE PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
D BATH REMODEIJR17PAIR D DEMOLITION
D OTHER
Soy-
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O V
BUILDING FEE
0
COMMERCIAL:
D NEW BLDG/ADDITION D DEMOLITION
❑TENANT OFOOD SERVICE
IMPROVEMENT
D OTHER
SEISMIC02-'Go
FEE
SQ. Fr.
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- OCCGROUP�(/aPN
G23 s -o3 9
UILDING DIVISION FEES
PLANCIA)K F : 'z S
7— z7 -
ISSUED BY:
X 7 1
PAID
Date
Receipt M
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BUILDING FEE
0
FEE
SEISMIC02-'Go
ELEC P
P if 'FEF,
MECH ICALFEF.
CO CTRI ICTTON TAX
ROUND MITIGAJ'ION
ITS
PAID
Da¢
Rcccim x
7— z7 -
ISSUED BY:
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