S0015 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
Is.. cii'r OFCUPF,RTINO BUILDING-ELECTRICAL PERMIT NO.�
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL ®� ��
BUILDING PROJECT IDENTIFICATION
BUIL DEI AT SANITARY NO. APPLICATION S/�U1B1,{M.I(1ITAL DA'I'F
07
WNIFR'S NAME: 1L PHONE: CONT# :SN B: liiitl LIC NO: ��L "
- N/C �CONfROL#
ROUTEh ERR: LIC NO'. ADORES: ❑
'ONTACT PHONE: BUILDING PERMIT INTO
X14'2- ❑ Consultant Fees Paid by Applicant(Initial) p ELECT PL IMB MEPH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm tial l am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Section 7040)of Division 3 of Ne Business and Professions Code,end my license is RESIDENTIAL
00 wt PERMIT ISSUANCE.
CWF in full toter send effect.
I ❑SFDWL ❑KITCHEN REMODEL
aFUU License Class Lick APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
RAL
N<G Date Cn..ms.r
F a y ARCH TECPS DECLARATION PANELS ❑MULTId1Nl'f ❑MODIFISTRUCTCATION
z ZZ lindcrssnd myplansshall bemvad.iTublicreconcs MODIPICA'TION
OZ- UP TO 200 AMPS I C3 INTERIOR [I CHIMNEY REPAIR
E on E-I� Licamed Professional 201-10(H)AMP5 IMPROVEMENT 0 SWIMMING POOLS
OWNER-BUILDER DECIARxrlON OVER Iq0 AMP5 [IBATH REMODEURJi AIR [IDEMOLITION
yyx C W Q I hereby oftimt that 1 am exempt from the Current.",
m rent.",License Law for the + A
W O L U following reser. ss.(Section 7031.5,Busineand Pmficoome,Cale:Any city oun
r county SIGNS ELIiMICAL [3 OTHER G nn
[a]3 q which mquimx a permit to construct,alter,improve,demolish,or repair any structure
,F.LLOg primmimis.....c.also requires the applicant fursuch permitto file a signed comment SPECIAL CIR IS OM .
y�y that be is licensed pursuant to the provisions of the Convm
acrs license Law(Chapter 924
I+1..00 (commencing with Section WOO)ofDivision3nfNe Business and lhoaor
fessionsCk) TIiME.METER P C,g1F
a y C that he is exempt therefrom and the basic for the alleged exemption.Any'whaion of ❑NEW B47I$f(fUDITION ❑UEM[)LTTION
iLLCI „LLy Sorban 7031.5 by any applicant fora permit subjects the applicant m a civil penally of POWER DEVICE. xll7p 1Als"1 I Ur VU )SERVE,
FZY not more than five hundred doll..($5W). IM OV
Fl 1.us owner of the properly,or my employees with wages as their sole compression, SWIMMING POO E . IC
H0 will Jo t be work,and t he smsolure is not intended or offered for sale lS.7044.Business UJ OTHER
W on and Professions Cale:The Cmnracmr's License Law docs not apply to an owner of OUTLETS-SWITCHES- T ES
Formerly who builds m improves thereon.and who does such work himself-r a mug
his own employees,provided that such imprmvcnsents ore not intended or offered for ss. NEW RESIDENTIAL ELECTR SQ IT.
sole.IL however N<M1uilding orimpmvemem is old within oney"nof completiogthe SQ.FT.FLOOR AR /`SBFT.
own,thoulder will have the Ounces ofIF..m,flshedidn,bmidarlmprovc for Fur- A1 L
prat nl'sale,l. .t �{/J�[_�_J
❑h as owner of the pmpery,em allusively commcting with licensed contractors do t
oosome,the pr-jos(Sea 7044,Business and Professions Caie:)The Conmacmrs m m there-n. Li-
curer
i- y'$ `
srLove does napply an nori,id property who builds or improves ere-n.and QVIM
TY. .UMBING PERMIT FEE
who contracts for such preajeets with a commons)licensed pursuant to the Contractors OE —tts
License Law. PERM SSUAN
E] I ten exempt tinder Sec. ,B A P C far this reason
Owner Dale ALTER-DRA ENT-WATER(EA) �— ` VALL`1T
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury otic of t e following declamations:
I have and will maintain a Ceni fiction ofConsc.Do self-insure for Worker's Cmnpen- 17 DRAINS-FLOOR,ROUP,AREA,CONI STORIES TYPE CONSIRUCTION
'Serio.,ns provided for by Section 3700 of the Labor Cale,for the performance of the
work for which this permit is issued. 5 FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Incomes'm required by Scotian q
3700 ofthe Lubar Cale,for the performance-f the work fear which this permit is issued. 1Z GAS-EA.SYS'I'EM-IINC40UTLHTS (KOC O APN
My Workers Cnmpensntion Insurance artier and Policy number ere:
c Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I GREASFIINDUSTRL WASTE INTERCEPTOR IIJIL IN s FEES
(This somion n-cJ not hacntnpkmA if the permit ix Torose hundreA Jnlltirs($I W) GREASE'I'RAP PL 'C FEI ^�
or less.)
I certify that in the Performance of the work for which this permit is issteral,l shall 7 SEWER-SANITARY-STORM IIA.204 FT.
nmenrploy.nyFemo.inanymn in or sa as mmm
beeoe suhlcerthc Wnrkes'Campton- N .E
z soden Lows of California.Date2. WATER HEATER W/VENT/ELEC R
R IN
Q Applicant I G
list NOTICIi TO AI'PI,ICANT:If,tiller making this Celifaue of Exemption,you slmuld 2 WATER SYSTEM,TREATING
' became subject to Ne Workers Compensation provisions of One Labor Code.you mated SOILS FE
� ,..I forthwith wmFly with such provisions-obis permit>hall Oe dcerned revoked. WATERSERVICE
� z CONSTRUCTION is ac0mucimm LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. PAID pare Receipt#
1 hereby affirm the there is a ronstmnion lending.gency for the performance of
V the work for which this rymmlt is issued(Sec.NAD.Co,C.)
QU Lenders Name TOTAL:
LkI Lenders Address
y certify that I have read this application ad stale that the above imormllirn is BUILDING FEE ^�
V) .1 '2,
with in,ityand wunry ordinances andstate laws echoing to QTY. MECHANICAL PERMIT FEE
building construction, th
etion,and hereby anadze representatives of this city to enter upon the SEISMIC 193E
above-Inenriuned Property for inspection purposes. PERMIT ISSUANCE S
(We)agree rosave,indemnify and keep harmless he City o(Cupccorm against ELECTRIC EE
liahilitics,judgmenrs,costs and expenses which may in any way accrue against said City LTER OR ADD TO MECH. �w 1 1 0
in consequence of the grartir,ol is permit. PIAM INC vl
APPLICANT'UNDERST NDS ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0(111 CFM)
nB:L A I
SOURCE J T ) �.
TilrA7 (40 Lad
/Q Z R I AIR HANDLING UNIT(OVER IO.0od CFM CI)N,ST 'l NTAX
J
l- - Apple'... .r nomor Dam EXHAUSTHOOD(W/DUCT) HOUSING ITIOATION 'iLs
H RDOUS MATERIALS DISCLOSURE
Will lheapplicant mfsurcbuildingtccupant smmorha&In arsousmamrisl HEATING UNIT(TO 100,(011 BTU)
as der call by the Cupertino Mouncipal Code,Chapter 9.12,and Ore Health and Safety
Sol 25532(a)^ HEATING UNIT(OVER Iffy"BTU)
Yes ❑No VItN'('ILATION PAN ISINOLG RIiSID) PAID
YYYJJ Dare Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER (JHP OR IW,IKID BTU)
azardous air contaminants as defined by the Bay Area Air Quality Management IITTA
ct I BOILER-COMP(OVER 1110,000 It HU
❑Yes E)No
IDove read the hazardous materials reyuirculena under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE,
fir Health k Safety Code,Sections 25505,25533 and 23511.l nndemmnd east if the NEW RESIDENTIAL MECIL SQ.FT.
building does not currently have.tenant,that it is my onpnmihility to notify the oceumant
of the requirements which must Ix nor prior to issuance of a Cedifrcute of Occupancy.
Owner nr amrhorizetl ager. Dote TOTAL I ISSUED BY:
OFFICE