S 1722 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT PF181 'No.
BUILDING DIVISION APPLICATIONIPERMPI' PLUMBING.MECHANICAL ``7 r
22
BUILDING PROJECBIDENTIFICATION
BUILDIN s ADDRESS: / SANITARYNO. JAPPLICNIJONSUBMIT'EALRATE
c .
O NP NAb�:. q G HONE,: 'U 'kA R'S NAME LIC NI} SIC C(INIAOLp
• "G/// c
CHIMCI'TiNGINEER: LICNO: ADDR ISS: ❑
CON'I'AC'P: PHONG. GUILDING I'EI2MI'F INFO
❑ Consultant Fces Paid by Applicant(Initial) BLDG cast[❑" PLUMB MECH
❑ ❑
LICENSED that I a CUNTRACnder p oviCons of CON QTY ELECTRIC PERA7IT FEE
1 hereby artmh that 1 am licensed rm,r provisions air Chapter 9 kammeohehhg JO DESCRIPTION
MM, xithSeaian lUXgofDivision 3 of the Business and Prolusions Code.and my license is RESIDENTIAL:
PERMIT ISSUANCIi
F0C
Lfull fortc..dcRccl / ❑SFDWL 0 KITCHEN REMODEL
�U~ icense Class I.he S�""�/�
6 V APPLIANCES-RESIDENTIAL ❑ADDITION OPLUMBING RE PIPE
.<y Date rU[ r ❑MULTI-UNIT ❑STRUCTURAL
AH .HCh'S DECL. A'1 )
Z o un Z I understand my plans shall be uta,as public records PANELS MODIFICATION
UP'f0200AMPS ❑INTERIOR OCHIMNEY REPAIR
W Uce ed Pone"inlml 201-10fN)AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUH.UFR Df:CLARA'1'ION
WCC C G I hereby affiln thin 1 un c.cmd tram she Conuacmr's License Law far the OVER 1000AMPS ❑ISATIi REM QUI'/RQ 131'Allj OJ]ISIk SOON
x L V following reason.(Section 7031.5.Business and Professions Code Any city or county SIGNS ELECTRICAL II `�kC\r'�-'r ![t�Y+
1+13"'h which requires v permit to"amuact,alter,imprint,demolish,or repair any efi ctutc
E a,i� poor o its issuance.also restraints the applicam lin such permit to file a signed unitarian SPECIAL CI RCUYUMISC.
that he is licenmd prommncom prnvisiaold the Conlimear's License Law lChape,9 SRI
uW C (commencing with Section 7")of Division 3 of the pr ice.ss and Professions Cade)of TEMP.METER OR POLEINFE IAL°
C 1 that he is exempt therefrom and the basis for rhe alleged exemption.Any violation of [].NEW BLDG/ADDITION ❑DEMOLITION
X�p- Scninn11111.5 M1y any applicam finapermil whjecu the applicam ma civil penalty of POWER DEVICES
V.
+t more than five hundred dollars(S500). ❑TITRANT ❑I'UOD SERVICE
=60 Las owner of the n SWIMMING POOL MA YI , OTHERVEMENT
props y.nr my employee.with wages as their sole camlenmtiOO' QOTIILR
N wit Paidc....a,Cod.:
he Cont info l Liillo1c at on e,rmle(See.11 in' wliinos
13 m nnA I'rnfcainnr CnJ¢The Contrucnds Li¢nr,Law dies not apply ro nn owner nl' OUThB'f5—SWITCI 'S—Il%'I'UIt ITS
pmpeny who bulli,or in.pawcs tmrvon,all who Joos much work hhnse,Rr mrongh
his own employee,,provided that such In...rovemcms arc not intended.....illicit lar NEW RESIDENTIAL HUTC','li SQ FT.
sail.It.however,the bui,d'ntgof it eancet is,old within oncYcor of completion,the SQ.IT.FLOOR AREA $/SQ.Fr
owner-builder will have the molen of proving that he did not!mild or improve for pur-
qne ol'side).
1,an owner of the Noped,an cxclu,ivcly contracting with licensed contractors to
to TOTAL:
consumer the project(Sec.IOIJ,Business and Professions Code:)The Contractor's Li. n_ ^
c se law does not apply to m owncrof property who builds mi,noweslhcmm.and QTY. PLUMBING PERMIT FEE e(YjyOle� V
who contras for such perj,as with a con onus(,)licensed pursuant to the Compactors
License Law, PERMIT ISSUANCE 8
❑ Bum escmpt under See .B&PC 6r this auson
ALTER—DRAINh VENT'—WATER(EA) GHA V, ON
Owner Date,
WORKER'S COMPENSA'T'ION UECLAHAHON BACK IT OW PROfIiCI',DEVICE •e��AA
'• I herchy a,trnh under pendry of sajon,nam of the following Jeclarala : 'I
❑ I have and will romnitin u Ccrtili"arol C..nwoOo,,Ilin,mvba Worker's Cnmputr DRAINS-BOOR.Ii00F,AIt13A,CL ). STORIES 'I'YPIi CONS'rRUC'IION
star...,ns....aided lir by li-I a 311X1 of the Labe Code,fns the perfnmmall of the
work for which this permit is reseed. FIXTURES—PERT RAP
O 1 huvv and will mer mens Worker's Conon, alion Insurance.as required by SecJon
1111Iol the labor Code.In,rhe perhnmence of a he work far whichrhis permit is issued. GAS—EA.SYSTEM-I INC.i OUT LETS OCC GROUP MIN
My Wnrkcrs o ,mjonl uraneeearnallaiJPolicynl bell GAS—EA.SYSTCpLOVIiRa(IiA)
Carriar.'-3 _ `a�—Policy No.:
ERI I (ATL 17 EXEMPHON PHO, 'O K GRF:ASEBNDUSI'RE.WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION PEES
(nissectioanced not becompletedifthepcoin isforuncload ildollatopliND GREASETRAP
or Ino.) !PAID -
CONSTRUCTION
EE
I certify thin int he performance aDhe work for whichthi,pennll isiaued,[shall SEWER—SANITARY—STORM EA.210)Fr.
not mnploy any W,air in any manner en as to become subject n the Worker:Cnaopen- ENERGY
,Z linin i Laws nl'California.Daae WATER HEA'I'VR WIV17N'UELI1CI'If
z O Ap,hvam
NO]WE'10APPLICANT:11,later oinking fill,CcNOcaleof Exemption,you xhoold WATER SYSTEMTKEAI ING
heroine subject to the Wodrers Congenm.ino pnrvi cions of the tabor Code,you mull
�i forthwith comply with such pnrvisiam nr this pcnnir sheath deemed revoked. WATER SERVICE
a' CONSTRUCTION LENDING AGEE, NEN'RFSIUT:NTIAL PCMB. SQ.PIL e roV(] l hereby affirm that there isa conswaion lending agency far the perfonnvee of
UFthe end for which this pctmn is issued(See.3091,Civ.C.)ULender's Name '1 OTAL:W bender's AJdros TOTAL:'>q WI certify that 1 have read this rpplieatian and state that the above infanhation isF,
aF".a 5e) . ...I,I upon,m"amply with all city and county oramences and state laws reining to (Yry.. MECIIANICAL PERMIT FE-F SHISMIC FEE
Uz building mnsmtalion.and herebynalliniec representative,o,'this city'ovara "m the
H uI v-,,v cal p11,voy for inspcctiun purposes, PERMIT ISSUANCE ELECTRIC FEE
(WO ngrec to save, mit, filyand keep hmnmxu the City of'Cupeninu against
Iininfiiu.)ndgmmpt..a,atx and...enmxwhich naay in any way.c,m,aguin"suit Clay ACI ER OR ADD'IU MITCH PLUMBING FEE
amgocnm of tic grunting ol'do,Per 1.
APVLICAN'I'UNDERS'ITNDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNI'p 00111,10X1 CFM) ME CHANICAL IIB
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAS
SignammofApplicanVComracmr Dv¢ EXHAUST HOOD DV/DUCT) HOUSING MITIGATION FEE
HAY.ARI()US MAHiRIALS DISCLOSURE
Wall the app,it,ormfumre building occupant store cahartic Introduce,material HEATING UNIT(TO 100.100 BTU)
m defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25512(u)1 HEATING UNIT(OVER Htooso BTU)
p acs ❑No VENTILATION IAN(SINGLE RES ID) PAID Date RccciptM
Will ah,applicant or tumra building occupant use equipment ordevice,which NOIIJiH—COMB'(3111'OR HN).000 BTU)
'nait kwon on,air andiumnant,as defined by she lily Arca Air Quality Manugmncul 'IOI'AL:
Uisancft BOILER—COMP(OVER HXLINO[it U)
❑yes E]No
I have readth hacmdaus heart un Chapter A95 of rhe Cxli- AIR CONDITIONER ISSUANCE DATE
Gonia f Safety C ,carom 25, .23533 mad .1 nod, .rd that if the NEW RESIDENT IAL AfECII. SQ.Fr.
hail "n, hos current, hevevtena nr it' sdai' -- Purl
I mqui aims whi h! aCcrtiO roof Qtupovcy.
cot oriseJu mos m f. 41 1 TOTAL: ISSUEDBt':
/ OFFICE