S 1470 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL EN ONLY
CITY OF CCPFRTINO llsRUILDI 'G-EB.HCTRICAL PE19T NO. O
ItUR.DINC DIVISR)N APPLICATION/PF.RMIT PLUMBING-MECHANICAL. J
BUILDING PR(IJI?(YT IDFN'1'IFICATION
BUR OINPADDRESS: � SANITARY NO. APPLICATION SUBMIITALD T[
1
OW :R'SN MB: PHONIi: CONTRAC'I'IJR'S NAME. LIC NO
NIC Q/�� CONTROhN
'ARCHITECT/f GINFER: C O'. ADDRESS: ❑ Q 7fz6
wel
CO CT: NF BUILDING PERMIT INFO
/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG E .CIS I' �I1Mn MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE IrrrX`/
1 hereby affirm that I am licensed under provisions of Chapmr 9(commencing .LOB DE$ RIPTI '
{QRZ with Scetimn7M06 of Divlxinn3 ofthe Business anA Profssulom'CrW0.mW my llcemeiv N
Fa, in full force and effect. PERMIT ISSUANCE. is. SFDWI ❑KI'I'CHEN REMODEL
U F hieeau Class Tic.p
6 U APPLIANCES-HF_SIDEMI'IAL ❑ADDITION [I PLUMBING RE PIPE
FZW Dam Cantmnor
rnQ0. ❑MUI.TI-UNIT ❑STRUCTURAI.
ARCHITECTS DECLARATION
NyZ 1Oldec,mldm hII be used nv blic.,ad, PANELS MODIFICATION
C)Z4 YPmresu Pu UP 10 2IXIAMPS
OZ-�O ❑INTERIOR [I CHIMNEY REPAIR
F:�E'41 Licensed Professional 201-I00AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IOW AMPS ❑BATH RF.MODEL'REPAIR ❑DEMOLITION
Q I reaso affirm that 1 1. exempt train the Cmsions Coc License Law for the
76 6V following rearms.(Section cmim,Business and improve.
dainm CnJe:Any city or county SIGNS ELECTRICAL ❑(TTHER
1+13 W y which requites Issuance,permit ac char Em,almm improve,demolish or repair any sauaurc
prier mics edpursuant inithe provisions or fin,urthe coM1mncinoicensle e Luis(Chapter
SPIiCIAL CIRCl11T/MISC.
pr that he is liwroed pursuant in provisions of the commences ease LawlChapter9
d� "Ou'doneing with section]BW)of Divieinn3ofthe Business send Professions C-111 of TI:MP.METER OR POLE INS'1'. COMMERCIAL'
a 6 a,yOy that he is exempt flonfrom and the basis for the el legM exempann.Any violation of ❑NIiW BLDG/ADDITION ❑DfiM01,IT10N
Section 7031.5 by any applicant fora permit subjects the applicant macivil penalty of POWER DEVICIS ❑'TIiNANT ❑FOODSERVICE:
re than live hundred dollars($500). IMPROVEMENT
�� a I as owncrof the n SWIMMING P(101.ELECTRIC
G pncpc Y,nnny enq+lnyeea with wages sex 0hulr soleacmpensminn,
f. III Ja the work.and the%fracture is not intended or offered for sole(See.71 W Business ❑OTHER
63 9 and Profession,Code:The Contmemre License Inw does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
peapeny,who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvement,ate nal Intended nr onemd for NIEW RESIDENTIAL EL(CTR SQ FT.
sale,IL however,the building or improvement is sold within one year of completion,the SQ.I'I'.FLOOR ARCA 95Q.FT.
ownecbuilder will have the burden of proving that he did not build or improve for pur-
pose of sale.). ij
❑I,asowner of the Size7G,am exic,Bomasi add connecting with licensedcmmrucds m TOTAL: ( /N
rose a the project(pec.o an owner of
and property
who but ds daJori The es themod,and
/e/J`///� ''� ,0
cause Law does not such ply ower an with
aofpropeny whosedporimpro the Contom e.s QTY PLUMB( O MIT FEC
who contracts for such project,with ucommnnrts)licensed pursuant to the Cnmmnolx 'mak
License Law. IFPERMIT ISSUANCE
i]Iam exam dor,Sec. .Il&P C on this reason '✓ ' G.
Ow Data
NTER—DRAIN N'I' AT.R(' ) A ATION
WORKER'S COMPEN TION UHC RATION BACK FLOW PR(TfE .DC E Vt7
Ihereb affirm under penalty nfP lurymm nl the following Jmdurmiona:
❑ I have and will maintain a Cenilicam of Consenfto self-insure for Worker's Campcn- DR INS—FLOOR. .ARE ,CO STORIES YPH CO ON
.Sutton,as provided for by Section 3710 of the L mor CWe,far the performance Of the xx
work for which this permit is issued FIXTURES—PER TRAP
❑I have and will malnmin Worked Compensation Insurance,as required by Section
3700 Aide,Lubber Ctdc,for the performance of the work forwhich this penitis issued. GAS—EA.SYSTEM-1 INC.4 OUTLFTS OCC.CROUP APN
My Worker's Compensation Insurance sumer and Policy number am:
Came, Policy No.: GAS—EA.SYSTEM-OVER 4 EA) / }:
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASVINDUSTRL WAS TE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
pminion
his need not be emmplenedll the scnit is I..ice handled drift.,IS 100) CRBASE TRAP
mless) PLANCHECK PEE Q
I certify that in the arrformunceofthe work(or which this permit is issued,l shell SIiWEH—SANITARY—. H E 2W,
ant employ any person in any manner xn us to Mcnmc subleat ti the Wmars'Campen- ENERGY PEE 0
tion Law s of Califomia.Date WATER HEATER WNEN'OE,LECTR GRADING ITE
z O AN NOTICE TO APPLICANT:If,ager,making this Certificate of Exemption,you should WATER SYSTEM 1
1"1
must SOILS FEE become subject m the Worker's Compensation provisionshal of the Labor Cola,you r
W Q forthwith con
comply with such prnvisins ond
or his permittshall M:deemed rcvmkcJ. WAFER SER ICES. ws
a' CONSTRUCTION LENDING AGENCY NEW RESIDENTIALh.MR.'sn V'uoSt�FE PAIL
D
atatRocap,N
L) I heachy a if.thadsam is a tom ustion lending agency for the performance Of
the work(nr which this permit is issued(Sec.3007.Civ,C.) C( AI
f'" Lenders Name o
0 {U lAM&a Address TOTAL: illb
I codify that 1 have read this application and state that the above information is corect.lagme m cmnply withal)city and coumyordmances and nate laws relating os QTY. MECHANICALPERMIT FEEU z ,
above-memiotmd prnpeny for inspection puI'm'. PERMIT ISSUANCE
(We)agree Pismo,vindemnify and keep hanaless the City of Cupertino again ELECfR 19iF. /7
liahilitics,judgment,n+.as andexpenses which may inany way accme ugnina said City AI TER OR ADDTOMIiCfI. PIAMBI :FEL '�Sr
in consequence of the grunting al this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to,"CFM)
SOURCE REGULATIONS. MIiCHANI'AI.FEE
AIR HANDLING ON]T(OVER 10.1011 CIM) CONSTRUCTION TAX
Signature of ApplicunVCmntmcmr Ilam I.XHAUS IHOOD(W/DUCT) HOUSING MI'I'IGATION ITE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hazardous Mideast IIPATING ON IT(TO 100,000 BTU)
as deposit by the Cupertino Municipal Code,Chapter 9 12 and the Health and Safety
Code,flection 25532(50? HEATING UNIT'(OVER 100,000 HE
Yes No PAID
VENTILATION FAN(SINGLE BESIDE am ReceiptM
Will the applicant or future building occupmn tn use atpoodeor devices whlcM1 IW,g0 it
emit hazardous air cnntamde
inunts as bated by the Bay Area Air Quality MunagenreBOIhP.R—COMP(311P OK nt L: .O
Dome? BOILER—COMP(OVER IUTRIxl 1,11U)
❑Yes i]No
I love read the huznNou.v nme rial.rcqu....dems under Chemaer h 95 of the Can- AIR CONDITIONER I I SUAN/C[y�D
forma Heahh&Safety CIA,.Se tions 25505.8533 and 25534.I undfu mad that d the NEW RESIDENTIAL MECH. SQ.IY'. .^I —[
building does nm currently have a terms,that it ismy responsibility m notify the occupant
of the mm
quireen¢which must be met prior to issuance of a Certificate of Cccup racy. 111-7
Owneroro.thomed.,at Data 'TOTAL ISSUEDB'IV((
OFFICE ""-