S 0593 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-MECHA ICA PERMIT NU.
BUILDING DIVISION APPLICATION/PERMIT hLIA+Bml:.ntECU1ANICAL S 0593
IIIl11,DING PROJECTIDENTIFICATION
BUILDING ADDRESS: SANI'T'ARYNO. APPLICALONSUBMITTALDATE
OWNER'S NAME: CnNTRARNAMEb
� NIC CONI'ROLbS� H _ 0L
ARCUITEC'UHNGINEER: LIC NO: ADDRESS: O ❑
CONTACT. PHONE; BUILDING PERMIT INPO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECTO
LICENSED CONTRACTORS DECLARATION QTY. - ELECTRIC PERMIT' FEE
I hereby mfirtn that I am liouxed under provi.dons of Chapter 9(conmenNng JOB DESCRIPTION
Ma'Z with Senion]DXB nfUivision3nf@e Business send Pmfessinns Code,and my license is RESIDENTIAL•
WO Nz�� 'I PERMIT ISSUANCE
I- 'a
in full force and effect Nd2/�'t ❑SFEAVL KITCHEN REMODEL
�UF License Cl t LiaM
Q Z(Ua( Bete Co.
APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RI'.PIPE
/riQy ❑MULTFUNIT ❑STRUCTUNAI.
ARCIII'1'F.CT:S DECLARATION
Z O�i Z 1 and extend my plans shell he used¢s public records PANELS MODIFICATION
OZ , UP TO NNIAMPS ❑INTF:HIOR [I CHIMNEY REPAIR
t Licensed Professional 201-11100AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER UCOAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
1 herehy abGrnt Net 1 ten 2sempm from the Contractor's License Low ter the
3aU following reason.(Section 7031.5,Business and l'ntfesslonx Cadet Any city ur county SIGNS ELECTRICAL ❑OTHER
LL which requires a permit to construct,alter,improve,demolish,or repair any stmcwre
Prior it)its issuance,also requires the applicant for such permit to file o signed statement SPECIAL CIRCUITIMISC.
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but he is licensed part to the provisions of the Comracmrs license Law(Chapter 9
W a�pO [commencing withficclnn]BNB nI'Oivifur3ot'the Boure"'tPulPmfosslom Code)or 'b1?MP M EI'ER OR POLE INST. COMMERCIAL:
a q C
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NIiW BLDG/ADDITION ❑DEMOLITION
4X1 tz• Section 7031.5 by any applicant for a permit subjects Ne applicannn n civil penalty of POWER DEVICES []TENANT ❑FWD SERVICE
y t more teas five hundred dollars($500).=zq ❑ I,us owner uffle property,or my employees with wages as their comrynsalme, SWIMMING POOL ELECTRIC OTHERIMPRO
CCCiCGG GLGL`` willdnthewotk,and mesweturc is not intenAW nr nlYared for sole l5ce.]I144.Iluxinex, ❑OTHIiR
a 3$ send Professions Code:The Contractor's License Law does mot apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds m improves thereon,snit who dres such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELFCl3i SQ Ff.
sale.IM however,the building or bnpmvement issold within one yearofcompletium the SQ.FT,MOOR AREA S/SQ.FT.
ovancobsuilder will have the burden of proving thin he did not build or improve far pm-
se of sale.).
❑1,as owner of the propeny,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sce.704/.Business and Pmfessinns CMcU The Cmntmxtnrs Lt.
verse Law does not apply to an owner of property w Lot builds or reproves thereon,and QTY, PLUMBING PERMIT FF.F, pp��
whocontraets for such projects withn Imunw a s)licenced pursuant mthe ConweSor's p� A Y ID
License law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,H&P C for this reason
Owner Date ALTER-BRAIN&VENT-WATEN(EA) 1I1�PE�[�T�p�/DON
WORKER'SCOMPENSATION UI?Cl.ARAFION HACK FLOW PROJECT DEVICE -fn'�� 1eS—p—
Ihereby a0irmundermmilty,if perjuryone of the billowing declaaionx:
I have and will maintain aCenifcme ofconsent to self-insure for Worker's Compen- DRAINS-FLOOR ROOF.AREA,COND. ST TYPE CONSTRUCfION
sation,as provided for by Section 37M of the labor Code,for the performance of 0a
wt k for which this permit is issued x FIXTURES-PER'I'RAP
I lave one will maintain Worker's Cnmpensatinn Insunence,as requlrod by Section
3700ofthe LaMn Code,forthe performunceofmc work forwhich this permit is issued, GAS-EA.SYSTEM-I INC.4 OU 11.17 1'S OCC.GROUP APN
My Work e's Compensation Insurance carter and Policy n�ttlI I
Cartier 0 C Policy Nn:b+ Lei cl GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRLASIJINDUSTRI.WASTE INTERCHM11
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This sectinnneel Pat oeenmpleted ifthe perant is Lorna hundred dollars(E1W) GREASETRAP
or less,) PLANCIIECK PEE
1 I certify that in the performance ofthe work forwhich this permit is issued,lxhall SEWER-SANITARY-STORM EA.201 FT
not employ any Lamont in any manner so as m beesmc suhject m the Worker.'Compete- ENERGY PEE
sation laws of Culifnan, Dole WATER IIIiAmOt WNI?N'fIELECTR GRADING FEE
z O Applicant
In NOTICE TO APPLICANT:If,after making this Certificate of Esempticn,you should WATER SYSIFM/TR I?A'I'ING SOILS ITiE
' heconte subject to the Worker's Compensation previsions of the labra Cole,you man
4kI forthwith comply withmeh provisions or this permit shall her dereed revoked. WATER SERVICE
Q
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL Pl.MB. SQ,FT. PAID Date Receipt if
V O Iherebyaffirm thauhere ixaconsbmth.lendingagcncy for the performance of
Hthe work for which this permit is issaed(Sec.3(1'17,Ci,C.)
Lender's Name TOTAL:
LUiI Lender's Addresn TOTAL:
fL 1 certify that 1 have read this application sad nate Nat the above inhnmarion is BUILDING FEE O /'
L4) comet.I agree menmply wlh all city and county ordlmanen and state laws relating to QTY, MECHANICAL PERMIT FEF. O
U ,z building construction,and hereby authonee representatives of this city m enter upon the SEISMIC FEE
ahoveanentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep bannle.the City of Cupertino against ELECTNIC FEE
Trial ilies.judgments,costs and expenses which may in any way same against said City ALTER OR ADD TO MECIL
PLUMBING FEF,
I.consequence of the gro ming of this permit.
APPLIl UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITGO O lotalo CFM) MECHANICAL FEE
SO CE RE'ULATIONS.
k--= &0 /f50AIR HANDLING LIN IT(OVER 11,000 CPM) CONSI'RUCTION TAX
SiorlsobartirApplicandContracum m EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA7ARDOUS MATERIALS DISCLOSURE -L I
Will the applicant or furore building occupant store or handle hazardous material HEATING UNIT(TO 100,01)BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,anti the Health:ted Safety
Code Section 25532(2)1 HEA'1'INC,UNIT(OVER 00,000 li'1'W
❑Yes No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt N
Will the applicant or future building occupant use equipment or all which BOILER-CUMPI3HP OR IW,INMI RTU)
emit huzurdmus air cmo m urns ns defined by rhe Bay Aren Air Quality Mnnagemenl' TOTAL;
District! BOILER-COMP(OVER l(X),(XX)B"TU)
E]Yes FNo
I have mad rhe hazardous ma¢rials requirements under Chapter 6.95 nfine Cali- AIR CONDITIONER ISSUANCE DATE
Matin Health&Safety Code.Seuions 25505,2.5 33 and 25534.1 understand than if the NEW RESIDI?NTIAL MECH. SQ.rt
building does not currently have a tenant,that it is my responsibility m notify the occupant
of the tequiremcn4 which run he met poo to issuance of a Cerb icme of Orl.te icy.
Owner nr unthornW agent Dam TOTAL: ISSUED BY:
OFFICE
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