B 0491 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECI RICA]. PERMIT NO.
BUILDING DIVISION APPLICATIONMER P UMBING-MECHANICAL
G PROJECT IDYMINICA'TION, SOOOI 49
BUILDING ADDRESS' ( e_ SANITARY NO. API'LICAI'IDN SUBMITTAL DATE
Ll Iq
OWNIiN:S yq Pf1)NE: CONTRACTOR'S NAMIR LIC NO.
l/I/1 N/C CONI'Roll.-NK
CHITECUENC� r LIC NO: ADDRESS: ❑ q /
CONTACT: PHONE: BUILDING PERMIT INFO
/` — _O ❑ Consultant Fees Paid by Applicant(Initial) Bi ELECT PLUMB MECH%
VtAW
L SED CO ACTOR'S DECLARATION TY. ELECTRIC PERMIT FEE 'IL�JI IrJ/ TI LrJ✓
I hereby anion Ih l I am licensed under pnvlsimns or chapter 9 mnmmemhlg .. JOB DESCRIPTION
OCy with Smtimn 0 of Jofdle liusincssn (. i McE nJ my license is R - 10
W ae n PERMIT ISSUANCE
F�y�� in full Eacea effec rcmn /a ❑$FOWL. El KITCHEN RGh10Dlil.
6UV Licensc Lich pppLIANCEs-RESIDENTIAL. El ADDITION [-I PLUMBING RE-PIPE
F-Q W urate Commcm
ARCHITECTS DEC E3 MULTI-UNIT ❑STRUCTURAL
z ON' lundersmnd my plansshall heused as public records
PANELS MODIFICATION
oy4 UPT02110AMPS ❑INTERIOR El CHIMNEY REPAIR
W Licensed Professional 201-109RAMPS IMPROVEMENT E]SWIMMING POOLS
Y � OWNER-BUILDER DECLARATION pyF.R❑NIIIAMPS BATH REMODIiI/REPAIR [I DEMOLITION
C' I wish,off rtn(hot I am exempt from the Comoctor',License Lea,for the
%It1V following n.Seetical7031.5,Insinessand Prnfas.tinns CWe:An I t ❑OTHER
LLLL1l F g reaw y ci y or county SIGNS ELECTRICAL
4 N which requires a Permit to construct,alter,improve,demolish,or mpair aay structure
p,I.,to its issuance,also rv,mocstheupplicam termch permit refile a sigaedsmtemenl SPECIALCIRCUIT/MISC.
�y Iba,heislicensed pursmail,,bepro, mmidits Conbtmmt,LicenseLow(Chapter 1)
W IyQ0 (commencing with Section 7000)of Division 3 ofthe Business and Professions Care)or 'TEMP.METER OR POLE INST. COMMERCIAL:
6 q o IY that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�raN Section 90315 by any ii,twato for a permit.subject,thunPpliwnl to a civil penalty of POWER DEVICES ❑TENANT El FOOD SI?RVICE
not more than five hundred dollars ISSue).
!E P - � " IMPROVEMIiN'I'
=�Q ❑Lo the voroflhe property,ormy enlpi with wages asale( ea vole 7044pensmien, SWIMMING POOL ELECT IC
will doth¢work,and the svvemreator,Liceedornlw does art lay to an Business ❑OTHIiR
W and property
whuas Code:The Conlmcte Licensc Lew does nm apply s if owner of OUTLISIS-SWITCH UltliS
a 3 pmpcny who builds or improves t such i,and who docs such wnrk himself or Nrdugh
his own employees,provided that such improvements arc not intended or.offered for NEW RESIDENTIAL F.LIiCTR SQ FT.
,ale.IL hmwevot.Ihe building orimpmvement is sold wllLln one you of sroinplmion,the Sp.FO.FLOOR ARRA EISA.PI'.
owner builder will have the burden of proving that he did not build or improve for pur-
osemfssleJ.
TOTAL'
[] 1.Its owner of ny,the pnspcam exclusively centracti ng with licensed contractors to
construct the project(Sec.7(AL Business and Prob sinus Code:)The Convnrmfs I- -
causeLawdoesnotapplytoanownerofpropertywhohuildsorimprovesthereon.and QTY, PI,UMBINGPERMIT FEE ^� O
who contracts for.such projects with a contmchn(s)licensed pursuant the Comment's I '`/JS
License law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&P C for this reason
Dale
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK 19-OW PPROTECTPROTECTDEVICE 4-1 3j
1 hereby alarm under penalty of perjury one of the following dlalamdons:
wont
have and willfor by ection 37M of Glenns sdhlnsur the
W11manta Comper- DRAINS-FLOOR.ROOT,AREA,GOND. STORIES 'TYPECONS'fRUCI'[ON
mores,as provided for by Section 39 W of the labor Ci for the perl'ormunce of Lha
work as and e].this permit is issuFIXTURES-PIN3 TRAP
❑Ihave and will maintain Worker's Compensation Insurance,as required by Sermon
32W of the Lahnr Cole,for the erl'nrmence of the work rot which this puyth is issued, GAS-EA.SYS'1'1?M-I INC.60U'TLETS OCC GROUP ANN
My Wnr pennorm Ins r„�'Tarierand Policy all
Cartier:�om 1 � w.O��,tlM / A.e.'..� GAS-IIA.SYSTEM-OVIiR9(EA)
�CT'KTI A F I, Illsrys ons.iv,WO .RS
COMPENSATION INSURANCE. GRF.ASI%INDIISTRL WASTE IN'I'IiRCEI'IOR
I1IJILDINO DIVISION LEES
(This nnitnjnrype�Jrlyyle9iflge)I�GtyN�7 r�Jl mdxdallcJ reel all GREASETRAI' :`2,.
or toxo) W11Y/ 7lUL y�77/LNp/1^�/ta[I/i Cfl[CK II /a0
Ice if I at in the perfmmunce el the wnrk fo hsht SEWER-SANITARY_St ORM 13A.200 PI�
not employ any permn in any meaner so as to become subject n the Workers'Compete Ii ERGY FEE-)- `� 'yp 14 \
zz sation Laws of California.Date WATER HEATER WNENFUT LECTR
0 Applicant \ - - GR LNG FEE ,
.Ni NOTICE TO APPLICANT If,not,making this Cenificum of Exemption,you should WATER SYSTEM/FREA'I'[NO SOILS IEE
a In become subject n the Workers Compensation provisions of the Labor Cold,you must
ftarm ilhwmply with such provisions nnhis perard,hull bedeon1cdoevoked. WATI7R SERVICE
0. �
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT PAID
rF1 z
L) 0 Du1c kcceiptN11� IM1erehy nffom ohm there lnnamswction lending agency rot the perfnnnance of
Ne work for which this permit is issued(Seo.3097,Civ,C.)
0 F” lender's Name TOTAL:
L) Lender's Address TOTAL:
BUILDING FEE
F.I 1 eegree o c 1 have read Thi city
and coup and sono Nm the shove laws
re aling iv
N milling agree to comply with allotyandn and enteriatingm QTY.' MECHANICAL PERMIT FEE 't /
U z hurtling construction,and hereby authodu representmives oDhis city menter upon the � SEISMIC IEE
"t
Massa.lnenfiora i pmpcny fill lnspes:tlm pultroles.
(We)agree to save,indemnity and keep hamlless the City of Cupcdim against PERMIT ISSUANCE FI.ECTRIC FEE
Imbilities,judgmenrs.costs and exllsmes which may in any way accrue against said City AIXER OR ADD TO MECH.
e61sranting nr this permitPLUMNING FE[
APPnsC' ti'f ANDS DWH.I,COMPLY WrIII All NON-PHNT AIRIIANDI.INGUNIFI'1OIIl,Ix111CFM1in IRC IEGMECHANICAL I11iE
` AIR HANDLING UNIT(OVER 10,1Xp CIM) CONSTRUCTION TAX O
Signature of Applicant/ me EXHAUST HOOD(W/DUCT) I ;yon^r,nN rl:e
HAZARDOUS MATERIALS DISCLOSUR s
Will morpplinmt or future building occupantsture or handle hazardous material HEATI NO UNIT(TO 100,100 B'1IH
as def tied by the Cupeni no Municipal Code,Chapter 9,12,and the Health and Surety
Code,Section 255320)'( HEAT]NO UNIT(OVER IOg011 BTU)
❑Yes PAID
VENTILATION FAN(SINGLE RESID) Date Beretta#
Will the applicant ur Tum huifined by the B use equipment or devices which
nit hazallous air contaminants ns defined h the Ba Arca Air Quality Management BOILER-COMP(3HP OR IOO.glfl BTU)
Y Y Y g T(YI'AL:
District'!
E3 yes Nn BOILCR-COMP(OVEk 100,000 BTU) On /
r (/ 15
I have loud the nuardous nimerisls rtquiremcntsunder Chapterfi95ofdse Cali AIR CONDITIONER ISSUANCE DATE
fon Safely Code,Sections 25505,25533 and 255311 and sm1 1 it the NEW RESIDENTIAL MECH. SQ,FT.
huild gra s 111 currcms Ily have�ten al it is mY rcspums,bili lY e'd'rY the pant
of tit ,AI„o t to issuoncc ofa Ce (/"e✓' �c�
OO neon. mgt !JN Didee TOTAL:
ISSUED HY:
OFFICE '
tr .
lb
A
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