S 1653 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-MECHANICAL
ECH RICA(. PLlyp'T NO. 1653
BUILDING DIVISION APPLICATION/PERMIT PINGPRNOCT IDENTIFICATION
l`J
RIIILDiNG PROJECT IDENTIFICA'T'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SERVE TEA DATE
aaL1 Rai �(
WNER'S NAME: /l'HOiG N'I�I[$S'�ME'. LIC NO
V 1If!'')) NIC CO TROLp
-� ARCH__a NCINGER: LIC NO: �Sti�DgEl
lH JJ
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) PI.DG ELECT' P UMB MI:CH
❑ ❑ ❑
LICENSED ad,,p DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby arum Inn l dm licensed anon provi,dnns tr chapter v a�nmtmeneing JOB DESCRIPTION
Woo'z with Sermon 700101of])isdin 3 tame laimermal Pmoes,mr,Code,wdmy licenm is RESIDENTIAL,
F•
Woo, full force and elfin PERMIT ISSUANCE
Xl F 5I ❑SFUWL ITCNF.N REMODEL
aUU Licenu Cuss Lic.p APPLIANCES-RESIDENTIAL. ❑ADDITION I MBING RF.-PIPE
F L Bum—C4���4 Contractor�TI{ aL n�
ARCHITECTS DECLARATION E3 MULTI-UNIT STRUCTURAL
(..,❑m PANELS MODIFICA'T'ION
Z O 1 underswnd my [.,,,,hall be used us public records
oy�o UI'T02I1UAMPS E3 INTERIOR [-]CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
J OWNER-BUILDER DECLARATION ❑BATH REMODEUREPAIR [IDEMOLITION
a 04 Q 1 hereby affirm that I am exempt from tine Contractor's License Law for the OVER IpM)AMPS
Q.X 3 LL F following reason.(Section 703 L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
F.�.a.y
� which reamers a Permit use construct,deet,improve,demolish,or repair any structure
pnormits issuance,al.sures,doo the applicant forsveh m file le unignedsmm
ment SPECIAL CIRCUITIMISC.
� that he is licensed pursuant to the provisions ofhe Commnm's license Law l Chuprr9
ly �� (Ionmencing with Scetlon 7000)of Division 9 nfthe Business and Profasnieas Code)or 'I EMP METER OR POIX INST. COMMERCIAL:
Ps o y that he is exempt meml'rnm unit the basis fnr me alleged exemp0on.Any vintinion nI ❑NI:W BLDG/ADDIH[ON ❑DEM01.19'[ON
�^},m Section 7031.5 by anyapplicam for a permit.bjaztshe applicant to a civil penaltynf POWER DEVICES / ❑TENANT ❑FOOD SERVICE
t more than five hundred dollen($500).
F•Z i IMPROVEMENT
< ❑1,azowner of the pmpcny.or my emNnyces win wage,az Meir role wtmpenserion, SWIMMING POOL ELECTRIC
will dothe work.and the amaure is not intended orofered for sale(Sec.71X4.Business ❑OTHER
63 m and Professions Code:The Contmcinh License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such Impmventents are not intended or offered for NEW RESIDENTIAL FLECK SQ FF.
sale.If,however the buddingor improvement is sold within one year of contpletinn,the SQ.FT.FLOssifftA A $SQ.FT.
owner-builder will havo the harden of proving that hedld nm build or improve fnr par- ss.
pow of,ale.)' TOTAL: AY 1
El I,as owner of the pmpeny,am exclusively contracting with licensed contmemrs to 3 /IIf(1r
entertain me project(Sec.7044,Business dad Professions code:)The Commcmr's Li-
,euva, d
Law msnolapplym an owner of poapmt,who builds or improvesCl/
thereon,and QTY, PLUMBING PERMIT FEE V y (Jf-
who License Laws for such Projects with a contracmKs)licen d pursuant to the Contractors Iourlrl
Lil HSV
❑ Inn exempt under Sec .R&to C lin his reason PERMIT ISSUANCE.
ALTER-DRAIN&V HNT-WATER O A) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
1 hereby affirm under penalty of perjury One of me following dedi mtinns:
❑(have and will maintain aCenificme of Conserv mself-in.rtfor Workers Cnmpen- DRAINS-FLOOR.ROORAREA,GOND. STORIES TYPE CONSTRUCTION
.tion,as provided for by Section 3700 of In,Labor Cade,for the Ferfonnance of the
work for which this permit is issued. r%TURFS-PER TRAP I
I] 1 have and will Liman In Worker's Cam petndfirm Insurance,as rerouted by Section
3700ofthe Labor Coda for the poodmaancc oflho work for which his pennit islssued. GAS-EA.SYSTEM-I INC.40VI'LETS OCC GROUP ANN
My Wnr 'r'n CnntpLasulion lnsumnw carricnmdpolicy mG 'r•:
V ru
Carries Policy No: 'e 7 1,T L'(a LIQ HAS-EA.SYSTEM OV17R 4(EA)
CIiRTIEIC TE Or LXIzmll ION FROM WORKERS' GREASFANDUSTRL WASTE,INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION F E-S
('(Tis union need nm becomplacJ if the permit is fmane hunJmlJoll:vs l$IW) GREASETRAP
or less.) PIANCHECK FEE
I certify that in he perfornerve ofhe work for which this permit in issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as In become subject to the Workers Compen- ENERGY FEE
z •� .tion Laws of California.Lane WR'I'ER HEATER WIVRN'MLECTR
Q Applicant GRADING FEE
f, ? NOTICE TO APPLICANT:If,after making mix Certificate of Excmplion,you should WATER SYSTExto BEATING
become subject rot Ota Worker's Compensation provisions of me Loon Cade,you must SOILS FEE
lorawih comply with such Provisions or this permit shallbe drained revoked. WA'FI7R SERVICE
0
7Z CONSTRUCTION Ltion lending agency
NEW RESIDF.NTIALI'LMB. SQ.FT. PAID Hate Rmei
V Qthere by amnn that them issued(Sec.30 len ding agency fnr the perhsrmance of
the wok for which this permit is issued(Sea.3Ul].Civ,C.)
0 F" Loaders Name T4TAiaw
L
V Lender's Address T[
W� Ii1111.D1NG FEE
i unify that have rend this dppllcutlnn and smm(het the uhnve Inlonnation ix
y correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL-PERMIT FEE
(,) Z FEE
building construction.and hereby sutnonze representatives ofthisciny to enerupon am SEISMIC construction.
imnve-mentioned property for inspection Purpose'. PERMIT ISSUANCE
(We)agar ut.ve,indemnify snit keep harmless me City of Cationnno against RLECTRIG FRE
liabilities,judgments,cwtsund expenses which may in any wayaccrueugaimt.id City AUIER OR ADD TO MF.CH.
PLUMBING FEE
in asequence of the granting of this permit.
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALL NON-POINT Ant HANDLING UNIT UTO 10,000 CFM)
SOURCT Rf?CULAI'I11.V5. MECHANICAL PBH
%/1 r n.. (A II a/vp �/p 0S AIR HANDLING UNI'I'[OVIiR 10,000 CPM) CONSTRUCTION TAX
SigTem fAAppl(i/�c�un�J mmac lo/r AU/w' ) J Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FI
HAZARDOUS MATERIALS DISCLOSURE.
Will he applicant or boom buildirneccupant stare or handle hazardous material HEATING UNIT(TO I01.0I)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(0)! �,� HEATING UNIT(OVER 100,000 BTU)
❑Yee' , A'n V HN'HLATION FANS I NGLE RESID) PAIR
_ Dam Re,:eiFl a
Will thedous air connotations
mommas building by the Brt yse Area
Air
mor lity evices which
Management
BOILER-COME L3HPOR 100,000 BTU)
emit hamNous air nmtmninants as definnl by the Nay Area Air Quality Management TOTAL:
District? BOILER-COME(OVER 100,Om)BTU)
❑Yes _i!!0o
I have madthe hasrdous rwtmais reruirentems under Chapmrfi95of me Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Axle,Sections 25505,25533 and 25534.1 understand that if he NEW RESIDENTIAL.MECH. SQ.Irl'.
M1nilding aced nnl currently have a Icnnnl,tout iI ix my rcaponsibilily da nntily the axcupanl
of the memernients which must be met prior Ito issuance of a Ceniliwto of Oa upaney.
qPP
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE