31228 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUamNG-ELECTRICAL PERMITNO. /] /�(�O
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL. J L C o
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI'1
aIVYN f
OWNI? 'SNAMR:.a PHONE: CONTACI'UR'S NAME: LIC NO:
/.4F_X e_ffala�if� ALL 21` [/ IC CON ROL#
�4RCHMECf GI,E,RLIC NO: ADDRESS:
CONTACT, PHONE: BUILDING PERMIT INFO
A/11�� /� ^ ��C �// ❑ Consultant Fees Paid by Applicant(Initial) BI G F:LFC[ PLUMB MECH
C LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEF, I�u{`, '�C�jJ(�1 /Ir�'r[
1 hereby union that 1 am licensed under pmvixions of Chapter 9 moraniencing JOB DESCRIPTION
woZ with Section 7")of Division 3 ofthe Business and Professions Code.ands license is pERMH'ISSUANCC
D O y RESIDENTIAL:
an full force and eRe<I /,
�FVV
License Class Loup ❑SFDWL ❑KITCHEN REMODEL
N�� Dae—� Contour GAPPLIANCES-RESIDENTIAL
❑ADDITION C PLUMBING R&PIPE
Z poen ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
t�Z 1 understand my plans shot[be used as Public retards MODIFICATION
O Z—�CI UPTO 200 AMPS
Licensed Professional El INTERIOR 0CHIMNEY REPAIR
[-�1=
l-pd OWNER-BUILDER201-HXIOAMPS ROVEMENT
�j CC a DECLARATION OVER USOAMPS T
yyH REMODEUREPAIR El DEMOLITION
1 herebyuM I.that I ant eIonll from the Contmclor's License Law Iisr the
pc 6 V fallowing reason.(Section 2031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Wit:I.LLO{'2 which requires a Pool,to w ,rearm then improve,demolish,ar repair any swcturc
.x'71 prior to its issuance.also examines the applicant for such Permit to rite u signed statement SPECIAL CIRCUFRMISC,
ydust he is licensed pnrwsm to the Provisions of the Counselors License Law(Couple,9
GAO (oommencing with Section TIDO)of Division 3 ofthe Business and Professions Code)0, TEMP.METER OR POLE INST. COMMERCIAL•
tst e C that he is exempt Ihcrefmm and the hands for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
-,lay Section 70715 M1yn1Yapp[icam for o permit whjecta Ne eppiisnt 10 a civil pe 111 of POWER DEVICES []TENANT ❑FOOD SERVICE
not mma,laa Eve hundred dollars MOM. IMPROVEMENT
C] � EJrap
Los owner ofthe pery or my employees with wages as their sole compensation, SWIMMING POOL CLI _
YiYi will Jn Ne work.and thcaweture in nm imm�eed aruffered for rule(See.]M4,Business ❑OTHER
W and Professions Calc:The Contractor's License law does not apply to an owner of OUTLET$-S W ITCHES-FI H
0,3 property who builds or improves thereon,and who does such work himself or through
his own enployecs.provided that such improvements am not imended or offeml far NEW RRSIDENTIAL El.
sole.Ii however.the huilding or improvement in sold within ane yearate. leninn.the SQ.FT. AREA $ISQ.FT.
owner-huilder will have the burden of proving that he did not build or improve Iia pur- rs„�
Pott saleJ. IJ
❑I,as owner of the property,am exclusively contracting with licenxd commuters to T
IWGV
minister the pmjmt(Sec.7044,Business and Professions Codc:)'I.,Comm 1-1
cense Luwdaes nmaggdymanuwm,ar,o,woy whomilds mimpraves daree,nnd QTY. PLUMBING PERMIT y(Jj- LUY
who contracts for such projects with a contractors)licensed pursuant the Contractor's �Un,r,11
License Law. PERMIT ISSUANCE I' O
0 l oro exempt under Sec. ,R&P C for this reason
ALTER-DRAIN&VENT-WATER(EA)
Owner Dane VALUATION
WORKER'S COMPENSATION DFCLARA'rRTN BACK FLOW PROTECT.DEVICE dr Y_
I hereby affirn under penalty of perjury one of the following declarations:
❑I haveand will maintains CeniEcaraofConum In self-insure for Wofke ,Camara- DRAINS-FLOOR,ROOR AREA,CONE. STORKS TYPE CONSTRUCTIONsadon,sea provided far by Section 37M of the LuMm Cale,fur the performance of the
work for which this panni,is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3.
37M of the Labor Code,for the performance fine work for which this permit is issue. GAS-FA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compcnsmion lnnumnm turner and Policy annular ere:
arrim: Policy No.: GAS-1?A.SYSTEM.OVER 4 MA)
CERTIFICATE 017 EXEMPTION I7ROM WORKERS'
COMPENSATION INSURANCE GREASE NDUSTRL WASTE BITFRCF.PTOR BUILDING DIVISION FEES
(This section need not he complete ifthe general is form ahundred dollars(S l eon GRRASP.TRAP
or lens.) PLANCHECK PCE
It,my that in the any ma mace of the work tie which lM1is pe Wike",CLlshall SEWER-SANITARY-STORM EA,200 PT.
net Lmis any person in any mauncr an rs to heem h�e�gy1�l P1oeate Wnrkern'Cnmpnt- ENP.SGY NEE
zZ salon ant of C (omit.Dam �{�} n 7:fes
O Applicant Q- WATER HEATER W/VENT/ELECTR GRADING FEE
fq NOTICE TO APPLICANT:If,i ficr-*kVg this Cenificete of Exemption.you should WATER SYSTEM?RF.ATING
abecome sbject to the Worker's Compensation now kions of the Lubar Cale,you must SOILS FEE
LSl forthwith comply with such Footmana.nhis Fermin shall be dented revoked. WAFER SERVICE
Q
7z CONSTRUCTION LENDING AGENCY NEW RISIDENIIAL PLMB. SQ.FT. VMECHAAL
L)O I hereby eRmt aha them is a mnsbunian lending agency fonhe performance.! Raeipe M
UL � the work for which this permit is outed(Sm.309'1,Cie.C)
O V Lender's Name TOTAL:
Lenders Address TOTAL:
4 1 certify that 1 have read this application mol state Nm the above information is E
rA correct.l agree tocamply with all city and county ordinances and state laws rclaingto QTY. MECHANICAL PERMIT
U ,7Z. building constmminn,and hereby nuthariu representatives ofehis city to wum.pamlhc 'E
above mentioned)properly for inspection puryoses. PERMIT ISSUANCI?
(We)time m save,indemnify tad keep heatless the City of Cupertino against FEE
liabilitin,judgmenta.costs end expenses which may in eny wey octet against wiJ City ALTERORADDTOMECH.
in consequence of the grunting of this Permit. ME
APPLICANT NDERSTANDS A D WILL COMPLY WITH ALL NON-POINT pIR HANDLING UNIT LTO Iq(gMl CPM)
SOURCE LATIONS, AL FEF.AIR HANDLING UNIT(OVER IO,IXp Cirh) ITAXSign re ofApplicarnAmirecurDane EXHAUST FOOD(WIDUCY) ITIGA ON NEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 1W.000 BTU)
as derined by are Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade.Section 25532bu? HEATING UNIT(OVER 1M."BTU) s
"I Yes CI No VENTILATION FAN(SINGLE RI?SIU1 PAID
P
Will the applicant or furore defused by be B use equipment Id Marta Which BOILER-COMP OHP OR[00,000 BTU) Dme R ei t p
1 ems hmardous air contaminants as Jefne by the Bay Arca Air Quality Management (
Dixeria? TAE:
❑Yes Fl No BOILER-COMP(OVf:R 1110.000 NTD)
I have read the htembars maedals req.1nonems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fame Health&Safely Cade,Sections 25505.25533 and 25534.1 understand east if the NEW RESIDENTIAL ME CH. SQ.ET.building does not comedy have a tenant,that it is my responsibility to rally the«euparal O
of the reyuiremems which most he met prior to issunnee of a Ceni Beam of Occuptnly,
Owner or so honmd near Date A�
ISSUED BY:
OFFICE