S 0862 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO xun.mlar. ELi!CI'RICA1, rr�mflT NO. 0862
BUILDING DIVISION APPLICAT'ION/PERMIT 1'LUh1RING�AtEC11ANiCAL J
BUILDING PROJECT IDENTIFICATION
31LDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
0 0 � � u �6 � Till
`FRONT?: )MI' ORS NqM� LIC NO:
CCT_ �IN/C CO UDI.#
kRC ITECT/ENGINEER: LIC NO: C7FM CONTACT. PHONE: DING PERMIT INFOConsultant Feu Paid by ApplicaELECT PLUMB is❑ ❑LICENSED CONT'RACTOR'S DECLARATION QTY. ELECTRICPERMIT1 hereby atfum thin Inm licensed under provisionsof Chapter 9(commencing B DESCRIPTION0z'L with Section 7000)efDlvlaln 3 ofthe Business and Professions Code.and my license is ,00 _ PERMIT ISSUANCE'n full frce and effect. ❑KI'1'CI IfiN tiliMODliI.V_ License Class Lie.# APPLIANCES—RF_SIDENTIAL ❑PLUMBING REd9PE
F Z til Date Comment,
IiiiQy ❑MULTI-UNIT El STRUCTURAL
ARCHITECTS DECLARATION
p.01n PANF.IS MODIFICATION
ZOV�Z londersmnd my plans shall be used azpublic retards UPT020DAMPS
02,1-0 El INTERIOR El CHIMNEY REPAIR[-.�E-W Licensed Profesxinnel 201-I01)(DAMPS IMPROVEMENT []SWIMMING POOLS
GR4 .J] OWNER-BUILDER DECLARATION OVIiN IW(IAMPS ❑BATH REMODEIAEPAIR 0DEMOLITION
yfy Q 1 hereby,(firm thin 1 um exempt from the Cssions o I:Anne Law for the
y(06V lidlnwing reason(Section]031.5.Business and Professiom GNc:Any city or county SIGNS ELECTRICAL. [I OTHER
W O which requires a permit m construct,ulmr,improve,demolish or repair uny suucmre
prinrm its issuaoce,uls,require,theid,lanna mister permit no file u signed statement SPECIALCIRCUI"PMISC. a
} that har,liceased,uismnlm,heprnvisiontofthe Camommr's Licensel.aw(Chapter9
CO (commencing with Sec,ion700(fo,Division3ofthe Sminessund Professions CMe)ur TEMP.METER OR POLE INST. COMMERCIAL:
d C did he is exempt therefmm and the basis for Ne alleged exemption.Any violation of C1 NEW BLDG/ADDITION ❑DEMOLITION
1i• Seafion 7031.5 by any applicant for a Permit subjects Ne applicant to a civil penalty of POWER DEVICES ❑TENANT FOOD SERVICE
I-2Ynot more than five mndreddollars(S500). IMPROVEMENT
=C ❑I,asawnerofthepropeny,or myemployees with wages ss,heirrole comprnxmion, SWIMMING POOL ELECTRIC
will do the work,and the structure is not ine nde lorolfned far sole(Sec.7041,Businell ❑OTHER
and Promotions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
n' property who builds or imporox ue.mi and who does such work himself or through
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL ELEC'I'N .Q let.
sale.It,however,the hitildogor impowetnent is sold widurioneyearof completion.Om SQ.1"R 1'LOGR AREA 81SV.1'I'.
owner-builder will have the hander oT proving that he did not build or improve for par
post of sale).
rl 1,as owner of the property,am exclusively contracting with licensed cnmracmrs to TOTAL: p�
construct the project(Sec.7041,Business and Professions Code:)The Comment Li- {{�� r
se law dresom applymon owner ofpropeny who build.or improves thereon,and QTY. PLUMBING PERMIT FBF' - •
who commas for such projects with a contracmr(s)licensed pension mine Contractors /RJ]�
License law. PERMIT ISSUANCE '•®b�
C]1 um exempt under Site .B&P C far this reason
OwnerData ALTER—GRAIN&VENT—WATER HDO wil rVALUATIO
I hereby affirm unddr penalty of perjury onePENSATION Dfthle fn mwmg declarations: BACK FLOW PROTECT'.UI?VICE Uh`LrCy�
E]I have and will maintain aCertifictne of Cousento self-inmrc fou Worker's Compor DRAINS—FLOOR,ROOF,AREA,GOND, STORIBS TYI`TrCONS1RUCTlOiT
sonon,as provided for by Section 37011 of me labor Code,for Nc pefforromme of the
work for which this permit is issued. FIXTURES'—PER TRAP
1 have and will maimin Wnrkert Comperadoo Insurance,as rtquired by Section GAS—EA.SYSTEM 1INC.J OUTLETS
3700 of the labor pC�ode,for
the performance of the work for which this permit is issued. OCC.GROUP APN
CMy am�r:. JPE' T9) nsy,al yperand Policy um rasa:./?'1tlf�OD
(O Y Policy Nortic / �C Ja GAS—F.A.SYSTEM-OVER J(IiA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIASEANDUSTRL.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEIS
(This section need not he amtpleted d urpermit is Forane hundred dollars(SIM) GREASRI RAP
nr PLANCHECK FEBless.)
Icenify that in the performance ofthe work forwhich this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner sr as to become subject In the Workers'Compen- ENERGY FEE
O Z stair.Laws of California.Dam WAT'1?R HEATER WNIiMPHLELTR GRADING FEE
z Applicant {
H NOTICE TO APPLICANT.If,after making this Cendicam of Exemption,you should WATER SYSTENUTREATING
a ; become subject to the Worker's Compensation previsions of the Lata.Code,you must SOILS ME
l51 forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCYNEW RESIDENTIAL PLMIi. SQ.PI'. PAID
Ll Ihereby affirm lhtn them isocnmtruction lending ugcomy for 0r performance of ()are Rceeipt#
Hthe work for which This permit in issued(Sec.309],Civ,C.) TOTAL:
U.
U Limakes Name
TOTAL
Lenders Address
1.. y 1 cenify that 1 have read this application and state that the above information is BUILDING PEI?
Ly correct.i agree to comply with all city a„d county ordinances and state laws relutingm QTY. MECHANICAL PERMIT FEE
U 4 building construction,and hereby audience representatives of this city to enter upon the SEISMIC PIiF,
alewe-mentioned property for inspection Purposes I PERMIT ISSUANCE.
(We)agree to save,indemnify and keep Winters the City of Cupertino aainm gELECTRIC FE[
hah'dities,judgmenrs,costs and expenses which may in any way uacme against said City ALT ER OR ADD TO MECII,
PLUMBING PEE
in nmseyuethe Sending this Permit.
T
APP T UNDERSTANDS
A D WILL COMPLY WITH ALL NON-POINT' A1µHANDLING UNIT 1111 111,000 CFM)
MECHANICALPI?li
Y tEGULRTI
LI AIR IIANDLINGUNI'PUVER I(L"CFM) CONSTRUCTION 'AX
Signature ofApplicant/Controcntr Tom EXHAUST HOOD(WMUCT) HOUSING MIT 'ATION FEE
HAY.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accupartstore or handle hazardous materiel BEATING UNIT OU H10.1100 RTU)
us defined by the Capetian,Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532.)? HEATING UNIT(OVER I00J000 BTU)
E)yin; [:1 No VFWILATION FAN(SINGI.II RESID) PAID
Date Receipt#
Will the applicant(ir foo6b,building occupant sew equipment or devices which +
•coni,hurardeas air copes imnts to refund by the Buy Are,,Air Quality Management BOILER—COMP 0HP OR H0.000 BTU) TOTAL:
District? BOILER—COMP OVER 100j)(g)13'TU)
❑Yes ❑No
I have mad the huaardousmaterials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
him.HwIN&Safety Cod,Sections 25505.25533 and 25574.I umbmand that if the NEW RESIDENTIAL MECH. SQ.R.
building does nm serenity have a mmmt,that it is on,responsibility nt notify the occupant
of the m{uirements which as,be man prior to issuance-to Cenifirme of Occupancy.
Owner or milbnzed agent Date TOTAL ISSUED BY:
OFFICE