29486_ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEL HUCAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PHRMIT NO. 2 ^ 4
L s4J l}J( lhJ
BUILDINGADDRESS:�O i•s (sz� Irgl'n� ,/'(Lr�
•//IDVX /�/'
Vf
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWNER'S NAM PHONE (j•Vp
' J(AII r\s ^`A)&— Log 2S - /1�
CONTRACTOR) NAME: LIC NO
(ii!/ler l�ltb k *
WC
CONTROL# .
RCIII };CT �L+R: e. f ���/ LIC CO: 09
1I`` ��(w�aRK
ADDRESS:
CONTACT. L�
7�S/yHHt�T /-/�8
S(•QL ( K� 1V Cr ,1 OW e uO / ^ M_�,�
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑
' LICENSED CONNTRA`CTOR'SIDECLAR•ATTION
1 hereby affirm that 1 am licensed trader provisions of Chapter 9 (commencing
with Section 7") of Division 3o fine Business and Professions Cole, said license is
j y
in full processor] anti effect.
j License Class Lic.p
1 Dula Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION/
RESIDENTIAL:
_Q. K//
�$FDWL t ITCNEN REMODEI.
[]ADDITION - ❑ PLUMBING RE -PIPE
[]STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IPFEOVEMENT
ATH REMODEUREPAIR [ I DEMOLITION
❑OTHER
PERMIT ISSUANCE SJ
APPLIANCES -RESIDENTIAL
j ARCHITECTS DECLARATIONPANELS❑MULTI-UNIT•
1 understand my plem shell he used as public mo fix '
IO 200AMPS
Licensed ProfessionalProfessionalUP
- -
DECLARATION Cona ON'
Oat I am exempt
I hereby affirm Secl [hat 11. exempt faro he CssionsoA : Any c Law for the
Prove, he iol h, or many city or county
1 followwhich requires
emitto 703 1.5. t, alter,
andimprove,
i which requires n permit re construct, alter, improve, demolish, are a sig any structure
I prior to its issuance, also requires the applicant for such pemiu. filenvigned ammmem
that he is licensed pursuant to he provisions ofhe Contractor's License law (Chapter!)
(commencing with Section TIM) of Division 3 ofhnBtime JPrafesslons Cole)or
Ilett he is exempt therefrom and the he fiw. alleged ryl�y tion. An violation of
Section 7031.5 by any applicant for a. it so' she pplieant to a civil penalty of
.I. than five hundred do mf, 51X1
❑I, en owner.! he pro..In amp wi s as thein.]. compensation.
t willdothework,im 'iH 1 t t erect fona]e(Sec.1fN4, Business
and Profcsm I • n for .ic'e law docs not apply m an owner of
propene µit6rti digit �h n, coed who does such work himself or tluough
his own ya.ploy v '• m s h improvements are nm impeded .1.Rered for
sale. It,, bgvFse,, dog �ri anovemeat is sold within one year of compl.Imm,he
owner-hufrRlcr will hE the burden of proving that he did nm build nr improve for per-
pusc of sale.).
❑ i, as ownerof the pmpeny, am exclusively contracting with licensed rontractors to
onshct the projm (Sec.'/M4, Business end Pmfictokim, Cole;) The Corauclors Li-
cense Low doei not apply to an owner of property who builds or improves thereon and
who contracts for such pmyccre with a cotnmetor(s) licensed pursuant n the Coulmctols
License Lew.
0 tem exempt un Sec .B&P C farhis reaun
owner 'rZFDate
201d(Nq AMPS
OVER Must AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.'
THMR!"Hi THRORPOLEMST, a
COMMERCIAL .r
[]NENANT BLDG/ADDITION [I DEMOLITION
[]TENANT ❑FOODSERVICE
IMPROVEMENT
OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWTfCHEs-FIXTURP_S 1
NEW RESIDENTIAL ELECTR
SQ. FT. FLOOR AREA
$/SQ. P..
'TOTAL.
QTY. PLUMBING PERMIT FEE
PERMIT' ISSUANCE
ALTER -DRAIN & VENT- WATER (EA)
VALUATION
C�C� (%
s U
ORKER'S COMPE ON DECLARATION
I hereby affirm under penalty ofperjury one of he following declarations:
I have and will tvainam a Certificate of Consent to self-inaate for Workers Compen-
satin., see provided for by Section 37M of the Labor Code. for the perf ..race of the
w.fkforwhichffib,simitisissued I
-I 1 have and will maintain Worker's Compcnemion Insurance, as rcyulasl by Section
3901 of he labor Code, for the perfortnnnceof the work for which his permit is issued.
My Workers Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.:
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF, AREA, GOND,
STORIES
r
OCC. GROUP
TYPECONSTRUCTION
APN
FIXTURES - PER TRAP • r
GAS - PA. SYSTEM -1 INC, 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
CERIMICATE OF IIXHMPHON FROM WORKERS'
COMPENSATION INSURANCE
(This section nod nal he campinal ifhe permitis fnrnnehundrtd Mlles (SIM)
nr to..)GRPASE
Ic<nify psnomfin in any ormrrrnitur.fthe work for whichhis the Workers'
not employ any person in any manner sn as to become subject 1. the Wnrkcrn' G+mpen-
onn'O
of California, Dam
Amino Applicant
um
GRIIASFANDUSI'RL WASTE INTERCEPTOR
BUILDING DIVISION FEES
TRAP -
PLANCHECKFEE
SEWER - SANITARY - STORM EA. 200 PT.'
ENERGY FEE
WATHR HEATER WNENT/ELECTR
GRADING FEB
-
NOTICE Certificate
NOTICETOAPPLICANT:II;C perkingthis nNitie;of of Exemption, dyou should
become suM1jeci to he Workers Compensation provisions of the labor Csde, you most
forthwith comply with such provisions or this pemut shallbe Memed mvoked.
CONSI'RUCTION LENDING AGENCY
I hereby affirm that hem is aconstmction lendingagency for the Performance of
he wok for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
WATER SYSTEMnREATING
SOILS FEE
-
WATER SERVICE
PAID
NEW RESIDENTIAL PLMB. SQ. FT
Date Receipt#
TOTAL:
Larches Address
TOTAL: 'yI
s�
I certify that 1 have read his application and stare that he above informatimt is
comectlagrce In comply with all city and enunly nrdinmmcx and xtum bows reimingm
building construction, and hereby imloucenpresenlatives oflhiscity loaner upon the
imm e-peemianed pmpeny for inspection putpoACs.
(We)agme, to save. indemnify and keep harmless the Cayof C.Parime against
liabilities,judgments, costs and expenses which may in any way accrue against said City
in cnnuque a of he granting of his permit
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE GUL S VMECHANICAL
2
BUILDING FEE
?
JS. S
QTy, MECHANICAL PERMIT FEEt
SEISMICFEE t
`
PERMITISSUANCE
ELECTRIC FEE
/
b a 6
ALTER OR ADD TO MECH: '
PLUMBING FEE 1
AIR HANDLING UNIT TO 10,0011 CPM)
FEE
AIR HANDLING UNIT (OVER 10,(1(111 CFM)
CONSTRUE ONTAX
SignadfuNof ApplicanVConaa tIr Dam
HAZARD S MATERIALS DISCLOSURE
Will the applicant or future building^ccupint Aare orhandle hamrdnuA mamrial
us defined by the Cupertino Municipal Code. Chapter 912, anti the Health and Safety
Code, Section 25532(a)7/
❑Yes gN.
Will the applicant or future building occupanr use equipment or devices which
nn hazardous air contaminants as defined by the Bay Arca Air Quality Management
Dusncs7
(] Yes Qf n
I have mad the hazardous materials requirements under Cho ler b 95 of the Cali-
P
fnmia Heu & Safety Calc, Sections 25505, 25537 and 25514, I nndershnJ that iflhe'
building snot curren0y hovearennnl, that it is mymsponsibilitytanotifythenccap.I
of be to umheaunNiorwisuanceof.Cc ificulcl pancy.
Own r auh.' gent - Dme
EXHAUST HOOD(WMUCT)
HOf151NG MITIGATION FEC
HEATING UNIT TO 100,000) BTI[)
HEATING UNIT (OVER 100,1100 BTU)
_
PAID '� S
Date Receipt
VENTILATION FAN l$INGLE RESID)
- BOILER -COMP (3HP.OR 100.000 BTU)
1.q9-[J0AL:V161,
00
BOILER - COMP (OVER IW000 BTU)
C1I )'IIF r
AIR CONDITIONER
-
-ISSUANCE DATE
%
ISSUED BY: 7G,071F/ /f-ITVCJL
NEW .HIiSIDP.NTIAL #ECH, 'SQ. FT.
TOTAL:
OFFICE