S0026 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO /r BUILDING'=ELECTRICAL PERM(Y NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICALe7G
6UILDING PROJECT IDENTIFICATION !ice
BUILDINGADDRESS: Gp� I� I� SANITARY NO, APPI.ICAI]ON SUBMITTAL DATE
NF.R:S NAM1IE: ZQ�b3 MERR�TT DR , CONTRACTORS
S` OL/ • LIC NO:
NIC cum'HOLX
nRCHITECUIZNGINEER; LIC NO: ADDRESS: ❑
CONTACT': PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MFCH
❑ ❑ ❑
LICENSED CONTRACI'Ok'S DECLARATION QTY ELECTRIC Pk.RMI'I' FEE
:::
norm thm I ant licensed order provision.of Chapter 9 JOB DIiSCRIP'fION
9aZHIof Dlsisior 3oflna Busiresaand Professions Cela,11.11 ny license is RESIDENTIAL:
� in PERMIT ISSUANCI:
Iy-ly� fall bore nal effect, ❑SEGAL ❑KITCHEN BE ODH
6UULicense Class Lic.0 APPLIANCES—RESIDENTIAL ❑ADD]TION �At[_GMBING BEPIPE
N'Z W Dam Contractor
w6a0MULTI-UNI'T if ETVOLCTURAL
E.7m ARCHITECTS DECLARATION PANELS
'-Z I understand my plans shall be used as public rec,)rd.x MODIFICATION
ZOZ 0 UP TO 2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Clans)Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
y•l$.d OWNER-BUILDER DECLARATION OVER["AMPS E]BATH REMODEIIREPAIR ❑DEMOLITION
1 tY G I bcrtby M.]hat I am exempt from be Cm carr or's License Law for the ❑OTHER
KOyU following reason,(Section 7031.5.Business and Professions Cada Any city or county SIGNS ELECTRICAL
W 3 a H which"and,amit pervt comance,alcor.improve.d<mdiE.or repair any mmctme
F�OQ prion its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/M ISC.
F,H} that be is licensed prsrac
uuam to the previsions of the Commrs license Law(Chapter 9
Wly�C (atmmencing with Section 7") Division 3 of the Bonnessaad Professions UJetor TEMP METER OR POLE INST. COMMERCIAL:
W E:c y' that he is exempt therefrom and the basis for the alleged exemption Any violation of NEYBLDGIADDTTION ❑DEMOLITION
W rat Section 71131.5 by any applicant for a permit subjects the applicant to acivil penalty of POWER DEVICES ANT ❑FOOD SERVICE
not ate than fi ve hundred dollars($500). IX ROVEMENT
❑ I,as owner al the Poi or my employees with wages as rhei...lecurnam'mioa SWIMMING POOL ELECT RIC
02 will do the work.and lhivou,nmisnot adeadedorofferuJ farads,(Sec.]IWY.Itusincs �OTHCR
w
6'3 and I'ndwhiob Cdr:9'hc Convenor's Cancra Law Joel nm apply m it owner bl' OUTLET'S—SWITCHES-1'I%'TURES �r
hi,own who milds,)r improves thereon.and who doss such work hled o rot throngh
bis'awn ennployecs,provided teal each impmvennenrc um mol in¢nAW or uRemA lo, NFV✓RBSIDENTInI.IILEC'I'12 Sp IT.
sale.It.howe,r,the Buildingm innpnwcmcnt i,,.Id wiihinore year in ournen i.lhc S FTI LOOIt AREA $ISQ.Pf.
cr-nuilder will have the burden of proving that he did not build or improve lar put- A D
rev
"'dM sale.). TOTAL:
❑ 1,as owner ol'the progeny,am exclusively contracting with licensed common rs In �� 292msmct the project(See.]Bb1,Business and Professions Lear:)'Ihe Contmmor.s Li- a41
cense law does not apply manoarntf propcny who builds,),improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a conmacton s)licensed pursuant m the Condaccen's _
License paw. B&P C far this matron PERMIT ISSUANCE jl f LT UUNtHTWp
I am exempt under Sec. .
ALTER—DRAIN ffi VENT—WATER(EA) \'AI.UAI'ION
Ox cr s Dae
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTF:Cf.DEVICE
I hereby anon under Penalty of peduy one of the following declaration%:
I have and will maintain aCenifcum ofConcem mself-inmrcfor Worker's Compcn- DRAINS—FLOOR.ROOK AREA,COND. STORIES TYYF.C09STRUCTION
s4rinn,as provided for by Section 3]W of the Labor Cade,for the perfonaanee of the O
work for w'h¢h this permit is ismed. FIXTURES—PER TRAP
I have and will another Worker's Compensation Insurance.as required by Section
37o)al the lahor Cade,for the perhxmanctuf the work for which this permit's isso.d. GAS—EA.SYSTEM-I IN, ,,, TLIi'IS OCQGROUP APT
My Worker'sConnpcnsaJan Insurance carrier and Policy number um: GAS—EA.SYSTEM-OVER 4(L'A)
Currier: Policy Na:
Cj;ffTIFICA'l E OF EXEMPTION FROM WORKERS' GREASEIINUUSTRI,WASTE IM'IiRCIiYI'OR
Co MP12NSATION INSURANCEBUILDING DIVISION FEES
('lhi,sadil shed notbe,napldWif the permit is far are hundred dollars($100) GRFASETRAP
nr less.) naPLANCI{ECK THETHEleerily that in lhcperfnnunofthe work forwwn
hichtnis ldi isissueLf shall SEWER—SANITARY—S'I ORM EA.21X1 IT.
not employ any pcnon int any manner su
so as m become hjem m the Workers'Compcn- ENERGY hlHi
Z anion Laws of California.Dam WATER HEATER WNEN'DE-LECTR GRADING FEE
Z O Apprca l I
NOTICE TO APPLICANT:If,after making this Cenificme of Exemption.you should WATER SYSTEM,`FREATING SOILS FEE
F? bea.ne s.hjal to the Worker's Compensation provisions of the Labor Csde,you must
fonhwi]h comply with such provisions or this pennd shall be deemed revoked ` WATER SERVICE O
a �
5 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLFfB. SQ.FT PAID Date
U l hereby affirm that tconstructiondi
iso construction lending agency for the performance of
the work form
r which]his peit is iaued(See.3W],Civ.C.) ecc
Q TOTN.:
C) F' 1-eMer'a Name `O
r W Lander',Address BUILDING PEE
0.t 1 cerci fy that 1 have read this application and state that the ahs,information is
F" tq rnrrcct.I%gra mconnply wiro all city and county urJlnanccs and sturo rows rdutins t'n QTY. MECHANICAL PERMIT FEE SEISMIC FEr
V Z b,)iWingumsmntion,and hdeby mahsi'cnpresemmi,,dof mixciy to cntermpon the
abasun¢ntioned propery fur umprctinn purpnu:s. PERMIT ISSUANCE ELECTRIC FEE
(We.)ugrea to...r,indemnify and keep hnmJe,s the Ciy of Ci pamin t against
Iiahifimcs,jud,,rmU.voa,andcxpcnses which may in any wnyaccmcngainst saiJCity ALTER OR ADDTO MECH. PLUMBING FEE
' ........ ncx nl'tne gnm]Ing of this permit.
AITI.ICAM,t)NDIiRSTANDg AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(IT)10000 CIN) MECHANICAL IT:
SOURCE REGULA I ONS.
AIR HANDLING UNIT(OVL'R llt.gX)CPM) CONS'1'RUCf10. 'IA%
Si gnemcaIApplicandContmeror Doe EXHAUST HOOD GWDULT) HOUSING MITIGADON IT
HAZARDOUS MATERIALS DISCLOSURE
Will thcapplicamor future building occupant store or handle hamNnux acuu al HEATING UNIT LTD I00d000 BTU)
as define)by the Cupertino Municipal Code.Chapter 9.12,and be Health and Safety HEATING UNIT(OVER 1(X).1100 BTU)
Cala lection 25532(11)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Dam pence, tN
Will the applicant or future building occupant use equipment or devices which BOILER—COMP(311P OR 100.000 BTU)
mit hvut rdous air contaminants as definW by the Ba)'Arca Air Quality Management TOTAL:
District? BOILER—COMP(OVER Iq),WI BTU)
❑Yes 7 N
1 have rend the lamrdaas mmedds avlaircmenu ander Chapter 1195 of the Cali- AIR CONDITIONER ISSUANCE DATE
fitment Ilrxdm ffi Soley Code.Sections 25505.25533 and 25534.1 undectmnl that if the NEW RESIDEN'T'IAL MECH. SQ.ET.
hnllAing Axa ern vurrrntly Howe a tcrnnt,that Ili,ns rc al aC iul m etmy the rwamum
ttnba regoiremema wmeln nntt�n ata too pri,)r to i.x,)ane.arts cemfinme of oecopaney.
Owner or authnrieml agcnl Dam TOTAL: ISSUED I1Y:
OFFICE