29823 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-,USE BALL POINT PEN ONLY
CITY OF UUPERTINO NIIIIAINO-ELEC'1'RICAI. PERMITNO. ^ w A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING G CT IDENNIFIC L�`lJ l8 L
ItU11.DINf,PRll.11iLT IDRNTIFIC,\PION
SANITARY NO. AYPLICADON SUBMITTAL DA'I'F.
BUILDING ADDRESS:
12,
'
OWNER'S N �/rV//t f/ CON'TRACTOR'S NAME LIC NO:
NIC CONTROLp
.RC IT;C /ENG R: LIC 0: ADURIiSS: ❑
67
Aim
CONTA f: P ONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LDG HEEff PLUM MB
8 lRe9
LICENSED CONTRACTOR'S DECLARATION— TY ELECTRIC PERMIT' FEF: JOB DESCRIPTION '
I hereby affinm that I am licensed under prnvisions of Chapter 9(commencing
C=Z with Senion]t100)af Divi,ionJo(the Ousioess anJ lhofesninnsCodc,end my license is RESIDENTIAL
Ise in full farce tad effect. PERMIT ISSUANCIi
[y..�W 0 s5Rt�E'SI WI, KITCHEN 12[iMODEI.
QUU License Class Lic.p APPLIANCES—RESIDENTIAL X ADDIT10N ED PLUMBING RE-PIPE
�G6 Dute Commctor ❑MULTI-UNIT ❑STRUCTURAL
OZD� ARCHITECES DECLARATION PANELS
I under,rnd my plans shall be used as puhho records MODIFICATION
UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
�1 W Licensed Professional 201-I000AMPS IMPROVEMENT
OWNER-BUII.OERDI'.CLARATION OVER 000AMPS El BATH REMODEL/REPAIR ElDEMOLITION
Q 1 herby affirm that 1 am exempt from the Contractor's License Law for the
�aU following..air (Satlt o7031.5,Business and Professions Cale:Any city a county SIGNS ELECTRICAL. []OTHER
a1 i 4 vF� which requires a permit to cnmwd•shier,improve,dentolidt or o,eir any on cure -
�1"„�Da prior to its issuance,also rcquircs the applicant for such permit o file a signed statement SPECIAL CIRCLE HMISC.
�!!j}•.1 that he is licensed pursuanunthe pmokint,club,Contractors License Law(Chapter 9
OC (commencing with Section 7 MOof Division Sof lire Bounessand Professions Code)nr TEMP.METER OR POLE INST. COMMERCIAL,
d y m e that he Is exempt hand.mn unit the basis for the alleged exemption.Any violation(it [I NEW BLDG/ADDITION E]DEMOLITION
ISX7 4• Station 7031.5 by any applicant for a permit subjects the applicant n u civil pcnalty.f POWER DEVICES OTENANT ❑FOOD SERVICE
F not mom than five hundred dollars($500). IMPROVEMENT
C=Q I.as owner of the r�ert,or'm loecv with ws as their sole competition) SWIMMING POOL I3LECT'RIC
52 Q ❑ P P Y YcmP Y gcs Pa ❑OTHER
Fs
will da the work,unJ the nmdurc is Orn intended ondfered for sale(Sec.]OqG,Easiness
LLI�� and Professions Code:The Contractors License Law does not apply tr an Owner of OUTLETS—SWITCHES—FIXTURES
�• papery who build,of improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or ofRred to NEW RI7S I DENTIAL HILHC Of SQ IT. -
sale.If,however.the building or improvement is sold within one year ofcompletion,the / SQ.FL FLOOR...ARE
/gl�� SQ.FT.
awteOmilder will have the burden of Proving that he did tat build or improve fia,mi- /1 A" ti
Im,xafode.). r (� !.J
❑1,as owner of the property am exclusively contracting with licensed commetors to
construct the pmjecu Ekwc 70,E4,Business and Professions Code:)The Contractor's Li- ( Q D
cerse Law does not apply n.wo owner al'propeny who builds or improves themon,and QTY. PLUMBING PERMIT FEE
who contracts for sac projects withaamtractor(s)licensed puuo
rsnuoithe Contractor's
'i..Lew. PERMI'I'ISSUANCB MAY 20 19
1 m exempt on 'Seo. ,B mthis re: o
thave
ALTER—DRAIN&VENT—WATER(EA) VALIJAT10N
Date (J+R' B ATI ECLARATION BACK Ff.OW PRO'I ECT.DEVICE.hereby affirm um err penalty aneoRhelullnwingJecarmiunand will rotation n aCenifcam of Comenuo self-insure for Worker s Compeer- DRAINS—FLOOR,RUDE,AREA,COND. STORIES TYPE CONSTRUCTION
,alien,as Provided far by Section 3700 of the LuMrr Code,for the performance of the
work for which this petit is issned, FIXTUR17S—PER TRAP
1 have and will maintain Worker's Compensation hommce•os required by Section
3]00o(nbe laborCode.for the perfntance of the wad Rsr which this permitTs issueJ. GAS—EA.SYSTEM-IINC.4OUTI.MS UCC.GROUP AM
My Worker's Compensation Inmmnce currier and policy number an:
Carrier: Pon,No.: ❑A9—PA.SYS'I'BM-OVER 4(FA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINW.STRL WAS'TF.INTERCEPTOR COMPENSATION INSURANCE IL G IVISION ITF_S
(This section nceJ Orn hemmpkterl if Nepe... is!Drone hundrr4dollurs($I W) GO EASETRAP
orless) PLANCH[C
Iccnify that in the Performance of the work far which this permit isissued,I'hall SEWER—.SANITARY—STORM EA.2W FT.
actemploy nay person in any nmmnermus m became object the Workers;Cnmpmt- JVFr
ROYTHE
Z sationlawsof Califlarnm Dmc NATER HGTER WNENT/ELECTR
O Q Applicant DE I '
EEEf•�...ttt V) NOTICE.TO APPLICANT.IL after ranking this Certificate of Faempbon,you should WATER SYSTEMCUREATING become subject to the Worker's Compensation provisions of the Labor Code,you must
WATER SERVICE
CONSTRUCTION LENDING AOF.NCY NEWNI?SIDENTIALPLMIt. SQ.FTU 0 I hereby grim thatthem is a construction lending agency for the perfomance of ate Receiptat
he work far which this petit is issued(Su.309],Civ.CJInndeLs NunnTOlA1"'
ULendersAddressI certify Nat 1 have read this application and suite that the above information i.s LDIN r FEEcomet.1 agree to comply wiOtall city and county ordinances and state laws refining to QTY. MECHANICAL.PERMIT UZbuilding conswction,and hereby subsume repowturbves ofthi 11,enter upon the MI FEE
above-mentioned papery far inspection Purposes. PERMITRSSUANCC(We)agree to save,indemnify andkeepharmless the City ofCupertino againstCT IC ITE
iabilities,judgments•costs and expenses which may in anyway accrue against said City ALTER OR ADDTOMECH. M LNG FEE
in consequence of the greeting ofthis Petit.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,000 CFM)SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) STRUCTION TAXSigamurc cfAppliwnt/Cumartur Orae RXHAUSTHOOD(W/DUCT) USING MITIGATION FB
HAZARDOUS MATERIALS DISCLOSURE
Willthe np,licanmr future building occupant store or handle hauNous mated.] HEATING UNIT(TO 100,0(1(1 BTU)
on defined by the Collection Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x0] HEATING UNIT(OVER 1110.000 BTU)
❑Yes ON. VENTILATION PAN(SINGLE RESIU) PAID
Dote Receipt
Will the applicant or future building membpa ul use equipment or devices which
:mit haurdaus air conmmirmts as defined by the Bay Arta Air Quality M...gement BOILER—COME OHPOR on"TUD
TOTAL:
Dismal BOILER—COMP(OVER]()()."BTU)
❑Yes 0N
I have mad the mount materials requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
humin Health&Safety Code,Sections 25505,25573 and 25531 I undersand thin if the NEW R17SIDENrI'IAL MECH, SQ PI'.
building does noit currently have a lemant,that it is my responsibility to notify Ne necupant
of Ne mquimnumto which must he met pmr,to issuance of a Certificate of Occupancy.
Owner or mummircd a gent Dnm TAM ISSUED BY:
OFFICE —