S 0159 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIIBAING-ELECTRICAL ,.i t. PHRMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 0159
BUILDING PROJECT IDENIIFICYRON
DOILUING ADDRESS: SANI'T'ARY NO. APPLICATION NURSE TIAI,DATE
OWNS 'S AME: J I'NONIi:� QS�O COM UOR'�A E� r�p�'L� yI
NIC CONTROL#
WCHITECl/EN (NEER: I.IC NO: ADDRESS: ❑
NTACT: PHONE: BUILDINGPERMITINFO
I' �/ �-�� ❑ Consultant Fees Paid by Applicant(Initial) m,D -ELVig, PLUMB M17CCH
I.ICF.NSI!DCONTRACTOR:SDI:CLARATION QTY. ELECTRIC PERMIT FEE
I hereby alfrm that I am licensed under provisions of Chapter 9(commencing JO DESCRIPTION
{Q{yyaZ with Seciion7fMM))..t Divisien3ufthe Businesaand Pro psi p Code,and mylicenuis RESIDENTIAL:
I-�- in full force and effect. C PERMIT ISSUANCE ❑SFDWL ❑KITCHEN RHMODEI.
e-Zu License Clals� �Lic.x pppL1ANCLS-RESIDENTIAL ❑ADDITION 0PLUMBING RE-PIPE
F Q nal Dulc f e f I �4�J Cnmractm
m a —ter ❑MUCI'6UNIT El STRUCTURAL
ARCHITECTS DECLARATION
Z p�Z I understand my plans shall he used as public records
pZ , PANF.IS MODIFICATION
GP1O200A PS
❑INTERIOR 0 CHIMNEY REPAIR
F�(;W Licensed Prefeormill 2OI-IDIp AMI'. - IMPROVEMENT �SWIMMINGPOOLS
-� OWNER-BUILDER DECLARATION
1 hereby ufirm that 1 am exempt from the Cutthroat's License Low lin the OVEN IIMIBAMPS' [I BATH REMODETIRFTPAIR DF:MOLRION
°xx' a following mason.(Section 70313,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
Isl'3 t4 F' which requires a permit un construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such pemtiuo file asigned statement SPECIALCI .UI
f y} that he is licensed pursuant o the provisions of Ne Communes Licenu Inw(Cha n"9
f C�0
(commencingwith Section 7orm)(d Division 3 ofthe Business and Professions Cod0or TEMP.ME R OLii NST. COMMENCIAL:
a y M fE that he is evempt therefrom and the basis for the o11L exemption.Any viol.......of ❑NEW BLDG/AU ❑DEMOLI'T'ION
6411 LLy Section 7031.5 by any applicant for apemtit subjects the applicant o a civil penalty of POWER DEVI S T ❑FOOD SERVICE
FZy not more than five hundred dollars($50% IMPROVEMENT
6O DLas uwneruf the mopeny.or mycmpioyceswiN wages es theirsole cnmpensminn, SWIMMING POOL ELECTRIC
f� will do the work,and the structure is not intended ondaned(orale lSec.70YL Business ❑OTHER
Y7 and Professions Code:The Contractors License law does
not apply In on owner of OVfLHI'S-$WITCHIT$-19X'NNITM
a'3 property who builds or improves thereon,anJ who does such work himulf or through
his own employees,provided Ohe such improvements ora not intended or offf m l for NEW RESIDENTIAL ELECT SQ fT.
sale.It.however,the building or improvement is sold will ncoe yearofcompletion,the SQ.IT.FLOOR AREA SISQ.IeI'. ,
owner-builder will have the burden of proving that he did not build or improve for put- PAI
Anse of sole.). {`1
❑ 1,so owner of the Poland,am exclusively convening with licensed contractors to L'
mstrun the project(Sec.7044,Business and Professions Cade:)The Cnmmcmis Li-
nseLawdoes our apply toanowner ofproperty who buildsm improves thereon,and QTY. PLUMBING PERMIT' 'F.E
who contracts for such projects with a contracmds)Imenud pursuant m the Contrmm's !Y
License Low. PERMIT ISSUANCE µ71N0
I am exemq under See. .R&P C for N "Al
is rea cor U
ALTER-DRAIN&VENT-WATER IEA) ION'
Owner Date ^2.6
i9�w�J
-
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE L.Y
I hereby affirm under penalty ofpctjuny One Ofthe followingdeclarations:
I have and will maintain a Cerlificme Of Consent to self-insure for Worker's Cmnpem DRAINS-FLOOR,ROOF.AREA,GOND, STORIES TYPE CONSTRUCTION
sxtion,as provide)for by Section 37M of the LaWr Code,for the performance of the
work for which this permit is issued.. FIXTURES-PITR TRAP
1 have and will maintain Workers Compensmmin Insurance,as required by Section GAS-
37MoftheLaborCade,forthe petfamonce of the workforwhMhiith En,permit iss ii1tral. EA.$Y$TEM-1 INC. QIITLEI'S OCC.GROUP AIN
Cu a ng t urxnce carie Pol cY NwY�at a ?"'=32 GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OE EXIT I N INN FROM WORKERS' GREASEANDUSTRI.WASTE INTERCEPTOR
COMPENSATION if INSURANCE: Iib' INl 1 VI ON Ig3F.S
(This union Meal nal be complete)iftbe permit is(Drone hundreJ dollen 151001 GREASE,TRAP
It less.) PIANCHECK FETE
Toy any power
int he anymannrw as e work far tbeemewhichthi.the Workers'
ed.I hallConran- SEWER-SANITARY-ST/INM EA.20()IT.
not employ any permn in any manner was m become subjecun the Workers'Campcn- E
NERGY PRO Ili
,Z srIi,m laws of CufRm t D m WATITR HEATER WNENT/ELECI'R
O O Applicant I GRADING
y NOTICE:TO APPLICANT:If,after making this Cimificom of Exemption,you should WATER SYS9EMITREATING FET.
a � became suhjectm the Worker's Onommaathm proviskm,ofthe lahor Code,youmost
W forthwith comply with such pmsi,i.asa,this permit shall M deemed revtked. WATER SERVICE
Q
CONS9'RUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.PI'.
UO Ihereby offintrEad there is a mnsuuNon lending agency for the aformanceof Doe Receipt#
U L•' the work far which this permit Is owed Nec.3097,Civ.C.) -
O U 1<Iders Name TOTAL:
GTa Lender's Address 'I OI'AI.:
g� I certify them I Love read this application Intl store that the above inf..mmion Is NG FEF
(A correct.I agree to comply with all city and county ordinances and some laws arbongm QTY. MECHANICAL PERMIT FEE
U building amstrectinn,and herehy authorize representatives afthis city to enter upon the C FEE
ulawe-mentioned properly for inspection purposes PERMIT ISSUANCII
(We)agree to save,indemnify and keep harmless the City of Cuperti......inst RIC F F.
humilities,judgments,casts and expenses which may in any way accme against said City ALTER OR ADD TO MECH. ING E
in consequence of the granting of this permit APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL".NNO/7'POINT AIR HANDLING UNTI(TO IQoso CPM) NICAL P
SOURC REGULATION 'C �/
A Y�V � AIR IIANDLINGUNITIOVERI(LOf10CFM) RUCIIONTA%
��tluli/e ofApplcarmCommactor Date EXHAUST HOOD OVMUCf) NG MITICATIONIF,.
HAZARDOUS MATERIALS DISCLOSURE
Will theupplicantor future building oecupant store or handle hazardous material HEATING UNIT OU 100,000 BTU)
as defined by the Cup,mato Municipal Code,Chapter 9.12,and the Ileabli and Safely
Cale,Section 25532(a)'1 HEATING UNIT(OVER 100.000 BTU)
❑Yes ONO VENT]LAT ION PA N IS I NGIX RESIT) PAID
Du1c Belli pt#
WII the applicant or future building Occupant use equipment or devices which BOILER-COMP(3HP OR 1110,110)BTU)
emit hazardous air contaminants os defined by the Bay Are,Air Quality Management IOTA[
Is District70Yes ON. BOILER-COME(OVER 100,000 BTU) 1
I have read 0e hvnrdous mmerials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATI3
home th alth At Safety Code,Sections 25505,25533 and 255.1k 1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building docs not curmnfly have u tenant,that it is my responsibility to notify the Occupant
of the requirements which must be met prior to issuance of a Cordillera of Occupancy.
166Q__z__
Owner or amhowed agent Date 'TOTAL: ISSUED BY:
OFFICE