S 1387 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOp BUILDING-EL1?C'1'NICAh I'ER 1'I'NO
BUILDING DIVISION ) 1Il APPLICATION/PERMIT PLUMB NG.MECHANICAL
1387
BUILDING PROJECT IDEN'I'IFLCATION
BUILDING ADDRESS: SANITARY No. APPLICA'T'ION SUBMl'(1'AI.DAI'F
OT1r ER'S NAME: PHONE CONTRACTOR'S NAMEI LIC NO
Iif�W �C\1aeLh�'l+1 j ggQb N/C CON'IItUI.N
WiA IIIFCTIF.NGINEER: _J.IC N[? IIUiS5:�a R' 1 S 1t �L L ❑ 7 3
CONTACT: (J1O'1PHON@ ClJ DUIhDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BI DC ELECT - PLUMB MECCH
LICENSED CUNT RACT06YS DECLARATION QI'Y. ELECTRIC PI7RM ITFI?E rl=r 1/ IrhX/
I hereby affirm that I am licensed under provisions of Chapter 9(commencing ( I JOB DESCRIPTION
O IXZ with Section 90X0)of Division 3 of he Business and PtuOassi.me Calc,and my license is RR I�F,E lZNT1A1-:
OO PERMIT ISSUANCE
nrullfoneandeffsy ���� ❑SPDWI, ❑KITCHIiN RIiMODF.h
�UU License Class C-� Cont f �� L�rn APPLIANCES-RESIDENTIAL ❑ADDITION ❑PIATKIMNG REPIPH
tFia6a Dam CSVECr bd5
ARCHITF,CTS ECLARKfION ❑MULT6UNIT ❑5"fRUCfURAh
F.,p y PANP.1,5 MODIPICAf10N
y p m Z 1 understand my plans. , blit cards
OZ4O UP TO 200 AMPS El INTERIOR ❑CHIMN17Y REPAIR
W Licensed Professional 201-1000 AMPS IMPROVEMENT F]SWIMMING POOLS
`I OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH NEMOUEVkIiPAIN ❑DEMOLffION
0.'a a 1 hereby affirm that I am exempt tram the Contractor's License Law for the
311 U following reason(Section]031 5,Business and Peio
mfans Cale:Any city or county SIGNS ELECTRICAL EI OTHER
W y which requires a permit to construct,inner,improve,demolish,or repair any structure
.F.y�; prior to itx issuance,also requires the applicant Rumch permit to file aligned satemcnt SPECIAL C I RCUI'UMISC.
V�is
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
W p0 (commencing with Section 9BaB of Division3 ofthe Business
and Toamasina,ConiferTIiMI'.ME'fP.R OR POLP.INST. COMMERCIAL
1y�e c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDC/ADDITION ❑IJP.MOLITION
W� Section 70315 by any appticnt for ape man subjects the appheamn,a civil penalty of POWER DEVICES Z NAN( ❑FOOD SERVICE
not more Nan five hundred dollars($5IXq.
F>¢} - CH HERVIiMENT
aQ 1,as owner or the n SWIMMING POOL ELECTRIC
Property, or
an I (St le compemmiomm,
FFG
will do the work,and theswcture is not intended or olteredfa mle(Se..]I44,lousiness ❑DINER
W"'se and Professions Cade:The Contractor's License Law does not apP1Y to an owner of OUTLETS—SWI DORIS—FIX'I USES O
6 3^ pr.pery who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended.r offered for NEW RESIDENTIAL ELEC'IR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FTFLOOR AREA $/SQ.ET. ,
owner-builder will have the burden of paving that he did not build or improve for not
pose of sale.).
1,as owner of the property,am exclusively contracting with licensed contractors 10 TO
a
construct the project(Sec.9144.Business and Professions Cade:)The Contmmors Li-
cerise Law does not apply toanawner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who eonvnns for such pmjects with a comracrogs)licenwl pars......the Conrzeme.
License Lw, PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for this reason
Owner Do. ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I mrabyri iren unda,,rsrltyafpepurymmmfthe f.11nwingdeelomti.rs: O 0 0 0
. I have and will maintain a Certificate ofConsenno self-insure for Worker's Campeau. DRAINS-FLOOR.ROOF.AREA,COND. STORKS TYPE?CONSTRUCTION
,.tion,as providefor d by Senior 390X1 of the Labor Cash,for the performance of the
work for which this permit is issued FIXTURE$-PER TRAP
❑I have and will maintain Wurkers Compemati.n Insurance,as required by Section
37W of the Labor Coal,for the performance of the work for whichthis permit is issued GAS-EA.SYSTEM-I INC.40UTL (ICC.GROUP APN
My Warkd,Cnmpens.mion lnsumncGC[[ and P.licynumb$epycn /_ d9A
Ca' 1110�s IWV.e Policy No.ZrM!'OTJIY GAS—EA.SYSTEM OVER 4(HA)
CERHFICA'1'E OF EXEMPTION FROM WORKERS' GREASEANDUSTRL WASTE IRI 17 RCEPTOR
COMPENSATION INSURANCE BUIL DING DIVISION_FEES
PLANCfiF.CK IgiE V
�N
(ThissecGon need not Ec completed iOhcpunmit is foronehundred dollars($100) GREASHTRAP
or less) T
I certify that in Ne perfnrimwe of the weak for which this permit is issued,Ishall SEWER—SANITARY—STORM F.A.21X1 IT,
not employ any person in any manner so as to become subjectII.the Worker'Compen- F:NF.RGY FEF
..tion laws of Cali fatale.Data WATER HEATER WNF.NTTLECIR
z Applicant GRADING FF.'
ti NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
a , become subject to the Worker's Compensation provisions of the Labor Cale,you mum SOILS
FER ix AA
LSl r4 forthwith comply with such provisions or this permit shall M deemed revoked WATER SERVICE
5Z CONSTRUCTIONLENDINGlending agency
NEW RISIDENI'IALPINT. SQ.FT P ❑
4. 0 mark
rwhich rtn;Permits isx.ad(sea.30lending agency forth,performaneeof Hecciptp
F the work for which this;permit is issumJ(Sec.J099.Civ.CJ
{L Lenders Name
TOTAL:
CUSI Leadee,AddressTOI'A1.:
y 1 certify that I have read this application and nate that the eMve information is MALIN1,I.
rn cormet.lagree t.comply with all city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT ITE
U Z building commaction,and hereby authorizerepresentatives of this city to enter upon the SEISM .FEE
above-menfinned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELE RIC FEE f J
Iiabilititaijudgmrmeric,cost,and expenses which may irony way starve again.said City pt TER UR ADD TO M[CH.
in consequence of the granPermit.ting ofthis peit. PLU LNG FEE
APPLICANT UNDERSTANDS A' '`L COMP.Y LTH ALL NON-POINT AIR HANDLING UNIT(fO 10,(XX)CFM) S
SOUR F.GULATI p ()Xy
MECH ICAL FEE
37170 AIR HANDLING UNIT(OVER I0,000 CFM7 CONSTRUCIION'TA%
Sign of ApplitmVC.r car Date ]� M14AUST IIOUD(W/DUCq
HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will the apPlicam or future building occupant store or handle hazardous material HEATING UNIT(TO I on,0g0 B'ru)
as defined by the Cupertino Munica 1 e.Chapter 9.12,end the Health mad Safety
Code.Section 255320)? HEATING UNIT(OVER 100,000 BTU)
❑Yes VENTILATION FAN(SINGLE RESID) WAID
Date Nacipt M
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPORIDT,11fi BT0) eyfl
Dis.ice (,
❑Yes KN. BOILER—COMP(OVER IIXkIKKI BTU)
I have read the hazardous madmials mr,imantrob under Chapter 6.95of the Cali- AIR CONDITIONER QISSUE DATE
fomia Heald&Safety Cade.Satins 25505,25531 and 255]4.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET. (,
ofthbruilde gdoeamolcurrently have am met l.prior to
ismyce ofab0iryrate of
Nusancy. n
of the tryuirements which run be met prior to issuance of a Cenifiwte of tXcupatmcy.
OwmnerorrifivrizNaTOTAL: ^
gent Dam e �/ ISSUED OY:
OFFICE