S0001B0302 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ^( //�
CITY OF CUPERTINO BUILDING-F.LECI'RICAI. PERMIT NO. O J O 2
APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJEC'P IDEN'I IF11CA'1'ION S0001
BUILDINGADDRES
S: I CI �� SANI'IAItY NO. AI'I'LICAl10N SI111MI1-1'Ah UA"fli
OW R'S NAME: PHONES: C RACfOy'S Al .IC NO.
/ NIC CONTHULM
•ARCH1'rECAPENGINEER: LIC N11 ADryi�ti/ f C ❑
CONTACT: / PHONE: /1// BUILDING PERMIT INTO
/ ` ❑ Cnnsultanl Feu Paid by Applicant(Initial) BLDG ELECT PLUM MECH
VX JJ4dJJ7_5 3_✓ ❑ 1:1 11
LICENSED CON']RACI'OR5 DECLARATION Q'rY. ELECTRIC PERMIT 117F JOB DF;SCRIPTION
I neeeny animh mm 1 ant licensed ander prnvixmnn..r cnaptm 9 a"ords'mg
M�Z with Semina llN0l of OivisionJol the Business ani l'mfcssions CrWe,and my license is RESIDENTIAL:
WO, PFRMI"I'ISSUANCE
�,0 in full force and eIF ❑SFDWL ❑KITCHEN RFMOD12L
QUU Licenxc CL, Lica APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
y_u Dad Confrere--�� ❑MULTI-UNIT ❑STRUC'I URAL
ARCHITE DECI.ARAfWNN PANELS F y Z i undenwed my plum shall bd used m public neem[. MOUIIICA'I'ION
C,Z=o UP'102(MIAMPS El INTERIOR El CHIMNEY REPAIR
1:.vi Fey Licensed Professional 201-IB(OAMPS IMPROVEMENT E]SW MM INC,POOLS
0:S: OWNER-BUILDER DECLARATION OVER IgII)AMPS ❑BATH RErODEVREPAIR ODEMOLITION
acOVER
6 1 hereby of era that I am ewmpt fear the Contmaors License Law for the
1 O fowing neon.... SIGNS ELECTRICAL(Smtion]ENI S,Bnsinens ani Prnleesinnx CnJe:AnY city err county ❑DTHF.R
3tL U llo
W y which requac a Isermit ha cnnximut,alter,Irprova demolish,m'repair mry sduetnec
(..,WOa prior to its issuance,also requires the applicant for such permitto file a.signed swmmanl SPECIAL Cl RCUIT/MISC.
that he is licensed punueouo the provlaons of the Contactors License Law(Chapter 9 COMMERCIAL:
u9I�0�0 (commencing wire Sation]IXXII of Dirizion3of the Business ani lYnfesxions CoJcprt TEMP.METER OR POLE INST.
L o mat he is exempt therefrom and the h dis fur the alleged exemption.Any violation of ❑NEW Ii1.DG/ADUI'I'ION El DEMOLITIONa
Xms Section ADLS hY any applicant furaperil xunjects the applicant lou civil penalty of POWIiR DEVIc6S ❑'H?NANT El Fool)SERVICE
nm enure than live hundred dollars(95000. IMPROVEMENT
SG ❑L nsawnerof the property,in nryctnploycC with wa,c,.s lhairsod compensation. SWIMMING POOL ELECT 111C
F. ❑Q'FLIER
will do the work.and the sbucwrc ffn
is manderdvd,a. ed foesale Ned.7044,Business
m
W atm Pmfewions Code:The C.raticum's License Low docs not appy m an owner of OUTLETS-SWITCHES-FIXTURES
pmpcny who builds or improves thereon and who does such work himself or through
his own employees,provided that such impmvcments are at intended or offered for NEW RESIDENTIAL P.:CTR SQ FE
sale.it.however.the building or improvement is sold within one year or completion.the SQ.IT.FLOOR ARBA b/SQ.II'.
Los nerbuilder will have the burden al proving that he did not hui Id or improve For pur-
paw of sale.). TOTAL:
❑ I.a owner of the property,am exclusively contracting with licensed conductor,to
consumer me projes,(Sec.7044,Business and Profession,Csie:i*Me Commerce'UP-.
cem,c lrw Jots not applym anowncr,of pmpcny who builds m improves thcaon,..a QTY. PLUMBING FEE
who curares fm curb projects with a contrecmds)licensed pmanot to the Contrumor's
License Law, PERMIT ISSUANCE /
I a.c,aipt under Sec ,B X 1'C lite this rcnnon
ALTER-DRAIN&VIiNT-WATER(EAI VALUATION
owner, Data
• Wm hada,P COMPENSATION p,guION DECLARATION BACK FLOW PROTECT.DEVICE
1 horny of0r vada penalty of ofCon one..(me follnwin6 Jcelamtions
Mauve xndwill f..by Seeli 3700 of the LnitoCode.to,cre Worker's Cmnpchr DRAINS-Iq.00R.ROOF,AREA.GOND. STORIES l'YI'ii CONSTRUCTION
,orkf us provided nor rm Section 3](0 of the Limon fide.rem etc Perfnmmnec ul'thc
work have
and ills perit i.x orkee PI%l'URIS-PER TRAP
❑I have ani will maintain bcpau Compensation w Insuakfor wit h required by Salon
' l]OB ofthe(slrhWo56Cot't��tfonn�he)yperfnrwcc the work for which this peritnissucJ. GAS-r:A.SYSTEM-1 INCA OUTLETS OCC GROUP ANN
it MyW 7 (-LLT �Ga WI+-Cdpasy Nlo.: IDY GAS-1iA.SYSTBM-OVER4(EA)
Came
CEkrIFICA'1'EO17EXEM[7]ONiBOMWORKIiRS' GREASEANDUSTRI,WASTE INTEkCEPIOR
COMPENSATION INSURANCE BUILDING DIVISION ITHS
(This section need nut he completed tithe peril is forma hundred dollars 06100) GREASETRAP
PLANCHECK PEE
or less.)
Loy any thatinme an,natpstformanceo me work for which this perthe nit is Wokersual. ,n.shall ,µEk-SANITARY-S'IY)RN EA. IT.
not employ any person in any manner so as m borer subject to the Workers Compcn- ENERGY ItE
Z
n rin.Law,or California.Dale WATER HEATER W/VENTVELECTR D GRADING PEE
z 2 APFlinmnt )
NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you should WATER SYSTEMORCA'1'ING SOILS FEES
become subject to the Worker,Compensation provisions of me Labor Code,you must
lk]�
forthwith comply with such provisions or tris peril shall be deemed revnked. WATER SERVICE
PAID
CONSTRUCTION LENDINGAGENCY NEW RVSIDENTIALPLMB. SQ.FT. Dam R ' 'pta
U Ihereby:nrm,tail[here is a construction lending agency l in the lsafnranec al' .
w F 'he w far wMeh this perit Is issued(See.9097.civ.C.)
ornL:
OLenders Name r0L:
} D.1 Lcndc I Artily BUILDING FEE
A 1 certify mm I ply mai this application ani state mm Ind state iws whiling is
.F. h mrct.l agree mcomply Wim all city and county ordinances and sate laws rclatin6 m QTY. MECHANICAL PERMIT Il;E SEISh11C LLE
U z building construction.and hereby amnon.e representatives oris city meateripon the
above+.ention al property for inspection purposes. PERMITISSUANCE ELECTRIC FEE
(We)agree to save.indemnify and keep bamdes,the City of Cupertino against
liabilities.judgments.costs wd expenses which may inanywayaccrveaphnst saiJCity ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the gaming of this peril.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO L0.00MECH
0CFM) ANICAL FEES
SOURCES REGULATIONS.
AIR HANDLING UNI'I'OVER IILgMI CPM) CONS I'RUCTION TAX its
Signature of ApplicanVContraaor Date EXHAUST HOOD ONMUCI) HOUSING MITIGATION FIE
HAZARDOUS MATERIALS DISCLOSURE
Win Ibeapplicant m fummbuildingoccupant storenrhandle humandm matelot HEATING UNIT TO IOOdXO BTU)
as defncd by the Capistrano Municipal Code.Chapter 9.12,and the Health and Safety HfiATINO UNIT(OVER 100,000 BTU)
Code,Section 25532(u)'! /
❑Yen n VENTILATION FAN(SINGLE RESIU) LAID Date Receipt#
Will the applicant or future building excupant use equipment or devices which
BOILER OHP OR 1(X1.0110 BTU)
r
it hazardous air contaminants az it fipal by the Bay Area Air Quality Management (T
tricfltlr,/„{/ BOILER-COMP(OVER 100.000 BTI)
Yea
1 nave read me hjh.,-�.icansivt.
aterials requirements under Chapter(r.95 of the Cali- AIR CONDITIONER aim ISSUANCE DA91i�
to dt,afdy,Com 25505.25531 and 255}(.1 understand that if me NEW R SIDENTIAL MECH. SQ.FT. ` 2 C(t){dJ7�
b hiding Jnes o ntlthat it is my respoacibiliry to nmify me rseepanl rJ\
n the s Licmetprimlo issuanttofa Cenific wd Ora panty.
Ow ill )sur TOTAL: S ISSUIi)fl Y:
OFFICE