S 0139 APPL%CANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
J CITY OF CUPERTINO BUILDING-ELECTRICAL PHRMITNO. /�
BUILDING DIVISION APPIACATION/PERMIT PLUMIHNC-MECHANICAL S 0139
'BUILDING PROJECT IDENTIFICATION lJ .L a/
SANIIARY NO. APPLICATION SUBMITTAL DATE
BUILD GADDRFSS: C
14-1 ^
O I :R' M'. PHONE: COM' ACTON:S NAME: LIC NO:
. CONTp
ROL
Pq
ARCf T /ENGINEER: LIC NO: )1 Wa
a.s ❑
II CONTACT: PHONE: / - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby afbtm mat I.a.licensed anter Insulin, of Chapier 9(commencing JOB DESCRIPTION
00.'Z with Section 71XX0of Division 3.flhe Busimonand Profesxio0 Code,amdm fcenseis
{ 00 It a PERMIT ISSUANCI!
FF,-. t full force and filen O DWI. ❑KITCHIiN NEMOUI?I.
�UEU LicenseC ss� LIc.M APPLIANCES-RESIDENTIAL ❑ADDITION C3 PLUMBING RE-PIPIT
ZW Dom Cnmmcror
C,Qy ❑MULTI-UNIT [I STRUCTURAL
A CH ACTS DECLA ATION
I-,p y PANF.1.5 MODIIOCA'1'ION
`2yz IundcrxtnnA my plans shall be used av public recnds
:1 UP1021N1AMPs [I INTERIOR [I CHIMNEY REPAIR
1Q-•��W Licomod Professional 20i-IWBAMPS IMPROVEMENT 0SWIMMING POOIS
CY ; OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
tY W Q 1 herehy air,.that I am exempt Tann the Camfacon''s License Law for the
ippi55,�O y U following reason.(Section 9031.5,Busin'n and Pofesaions Code:Any airy or county SIGNS ELECPRICAI. ❑OTHP
W y which requires a permit to consumer,aiman
alley,improve,demolish,or repair any s,., . nl
F 0¢ primmitxi....le,01maquireshe.111h ut forsuch gamine file a signed nme.ent SPECIAL CIRCUIT/MISC.
�a a�
that he is licensed pursuant nthe provisions ofineCnmradorsLicense Law(Chapter 9
U DO (commencing wish Section]INNpo1Dlvlslnn 3ofhc Boxin'sstmd Polficsions Code)or TEMP.METES ON IR)1.EHEST. OM AL_
ayx e rG mol he is canal Iherefmnl and the builtfn the alleged exemption.Any violation of / [I NEW BBLDGLDG/ADDITION [I DF.M01.1'I'ION
W^ Section 7031.5 by any applicant for a permit actions the applicanto a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
t z>. not more man five hundred dollars(5500). IMPROVEMENT
1,as owner of the proper&or my cnlployeen with wages as their sole compensation, SWIMMI NG POO(.ELECTRIC
❑OTHIiN
Wi PLO the walk,and the stecmre is nutunaided mm'sued f...III Sco.7IH4,Bananas
LL13 e��o and Profession Cale:The Contractor's Licease 1.aw does not apply to an owner of OWLETS-SWITCHES-FIXTURES
progeny who builds or improves darer,and who does such work himself or through
his own employees.provided that such improvements am not intended or offered for NEW RF,SIDENTIAL ELECTR SQ SU�Flt FLOOR AREA S/gQ.PE
sale,ll',however,the building or imp vecrmnt is sold within one year of completion,the
owner-builder will have the burden of proving that he did not build or improve liar pur-
pose of rel
TOTAL:
I,os..or of the poison,ma exclusively contracting will licensed contractors to
Construe he project(Sec.71Wq Business and Profession,Code;)She Contractor's],I-
move Law does not apply to an owner of P.Perty who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contacts for such projects with a comencions)licensed pursuant to the Commerce, ,
License LOW. PERMIT ISSUANCE
❑ Iumexemplunder Sec. ,B&PCfim Ihi,mm.n
ALTER-TRAIN&VENT-WATER IEA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby,Rum under penalty of perjury one of the following dedaraninnz:
w Fl on,a,preen l far 1, eCion 170mol'Co Ligan,Code,for
Workers cetnpen- DRAINS-FLOOR.ROOP,ARIiA,GOND. STORIED TYPE CONS'TRUCI'ION
union,us provided far mi Section PIX)of the IOhnr Crede,fur Ihu performance of the
work for which this permit is mued.
orme FIXTURES-PER TRAP
❑ Ihave and will ode,fon Wormer Cance of tionflue
Insurance, h his acqper by Section
J]W of Labor Code,Tonic performance of me work for which this germit is issued. GAS-IiA.SYSTEM-I INC.4OUTLETS *� OCC GROUP AI'N
My Wnrker'. mum 0 on curler and Policy na r yz(7 GAS
-[A.SYSTGM OVER 4If:A7
Curtiec �(_Policy Na:
:RTIFI ATE OF EXEMPTION FROM WORSE S' GREASPANDUSTRLWASTF.INTERCEPTOR 7C
COMPENSATION INSURANCE BUILDING DIVISION FEES
alle
(This section nod nal he completed l face perial for one hundred dollars l Rah GREAS17TRAPF:
1
or los.) Q. PLANCHECK FE
I certify that in he pertnrmanceofthe week for which this permit is issued,l shall SEWER-SANITARY-STORM FA.AIO FIL
not employ any flown in any manner so us ns become subject to the Worke%Compen- \11E
z notion laws of Cdcooio.Dam WATER IIIiATER W/VENT/ELIiCI'R
z Applicant RAKING PF.F. ,
NOTICE TO APPLICANT.If,after..king his CeniOcare of Ecom tion, a should \\
ti g re Yo WATER SYSTEMIfRLATING :SOILS I'
h haomch comply
the Workers Compensation previsions of the"fare Code,you must y
forthwith comply with such provisions or this permit shall FO deemed invoked. WATER SIiRVICIi ! C13U
z QP 'O
Q CONSTRUCDON LENDING AGENCY NEW RPSIDENTIARESIDENTIALPLMB. SQ,FE P at xReceipt N Iheinbyaffrm mat)here u nconaweion lending agency for the performsnce.f
LLL the work far Which'his permit is issued(Sec.3097,Civ.C.)
Q U Lender's Name
TOTAL:
Lender's Address
1t I certify that I have mml'his applicaion enJ slam ha'he eMve informminn is BUILD �
N correct.l agree to comply with all city and County ordinances and slam laws rela'ingm QTY. MECHANICAL PERMIT FEE SEI
(,) buildingeonstrvction,and hereby amhnrim repmwrtaive.v ofhis city toenteruptm the ff
above mentioned property for inspection purposes. PERM("T ISSUANCE CIRIt;PEE
(We)agree to cave,indemnify and kap hamdess the City of Cupertino against
liabilides,judgmems,costs and expenses which may in any wayaecmeagaiosl laid City ALTERORADDTOMECH. LUMBING FEE
in consequence of the gmming of this permit.
APPLICANTUNDERSTANDS AND WILL COMPLY WITHALL NON-POINT AIR HANDLING ONE-[(TO 10,(NX)CFM) MF.CHANICALFEE
SOURCE REGULATIONS.
AIR HANDLWG UNIT(OVER 111,000CFM7 CONSTRUCTION TAX
;Signature Of Applicant/Contmctor Dam EXHAUST HOOD(W/DUCD HOUSING MITIGATION WE
HAZARDOUS MATERIALS DISCLOSURE
3YIlheapplNmd or furore building mcapacitanre arhandle inundates material HEATING UNIT(TO ifinoW BTU)
as defined by the Contemn.Municipal Code,Chapter 9.12,and the Health ad Safety
Code,Section 25532(¢)^ HEATING UNIT(OVER 100.000 BTU)
[I Yes ❑Na VENTILATION FAN ISI NGLE RESIDE PAID Date RemitsN
Will the applicant or future building necupaml use equipment lar devices which. BOILER-COMP(311P OR 1100#10 BTU)emit hazardous air contaminants as defined by the Buy Area Air Quality Manugemenl TOT' L:
Dis'rleR _ MOILER-COMP(OVER 1(10,(011 If ME
E]Yet No
I have read he amadous mrleardsrequire.enm under Chapter h 95 of the Cali- AIR CONDITIONER ISSUANCE IT13
loon'He❑h&Snfery Gds,Sections 255(15,25 enJ 25534.1 undersmnd that it the NEW RIiSIDENTIAI.MfiCli. SQ.IT.
huilAi vnmcmmnlly have a tenant,Iia ' y ne,crsibilhy to entity me occupant lfC 1
of th firemen c 'Tp. uammufa Cerlficam of GC parry. r
w cr ora re t m TOTAL: ISSUEDBY; 2
pit
OFFICE