S 0360 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDCITY OF CUPERTINO LUMBING-MECH NICU PE 111MITNo OJ�O
BUILDING DIVISION APPLICATION/PERMIT PING pROG.MECHANICAL CJ
RI111.pING PROJECT IDEN'1'IF'ICKr10N
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BUILOINGADDRE!SS: x SANITARY NO. APPLICATION SUBMITTAL DATE
JVJIqJ6U/L-c '/ - /'�Ja
OWNER'S NAME • PHONE;:
CONTRACTOR'S NAME!: LIC NO:
O { NIC CON'IROLX
ARCHITCCf/ENGINEHR: LICNO: AI RHES: //I Q (/ ❑
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ONTACT: PHONE: NN1141 6UILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) RLD HI.LCT PLUMB MUCH
LICCNSED CONTRACTORS DECLARATION QTy ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under previsions of chapter 9(commencing _ JOB DESCRIPTION
Matzth section 7")of Division 3 one Badness and Profession%Cade.and my license is RESIDENTIAL.: -
Fo� full force an dI c. 09 YIiRMIT ISSUANCC
��-/� ❑SPDWL ❑KITCHENRF.MODEL
UU ervv Class L ' APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLl1MBING RE-PIPE.ante�-.— —r�—cammctm
ARCHITECT'S DECLARATION ❑MULTIUNIT ❑STRIICT'l1RAL
F.,p y PANII S II'ICA'I'ION
y p+�l unZ I deranod ny plans shall he used as public record.
OZ-�p UPT0200AMP5 ❑INTERIOR CHIMNIiY REPAIR
1-4 U4 Licensed Dot i...I 201-1000AMPS IMPROVEMENT El SWIMMING POOLS
ag Se:w= nsOWNER BUILDER DECLARATION OV12R I0110Asi [IBATH REMODFIAEPAIR ❑DEMOI(TION
W tY W 6 I hereby affirm that 1 am exempt from the Contractors License Law for the
p U following reason.(Section]0315.Business and Professions Code:Any city or county SIGNS ELECTRICAL. [I OTHER
YJ 3 LL which requires a permit to mr,trveL alter,improv,demolish,or repair any structure
Fq"�p prim m its issuance,also requires the applicant Fusion porion lileuxigned statement SPECIAL CIRCl11T'IMISC.
y�G y tient he is licensed Emn,mirto the previsiorsaf the Commove,Licer,c Law(Chapter 9
W ad (commencing with Sect ion]000)of Division 3 of the Business and Professions Code)or 'TEMP.METER Olt POLO INS . COMMERCIAL:
0. c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of a ❑NEW BLDG/ADDITION ❑DHMOLITION
n"I
lin Sectio031 S by any applicant for a Permit subjects the applicant us a civil penalty of POWER DEVICES ❑TENANT ❑1'001)SERVICE
FZa• no,tem than five hundred dollars($50t IMPROVEMIiNT
p6 Las owner oOhe pmpenY,or my employees with wages as their solr mrrom,tim, SWIMMING POOL ELECWIC
W C will do the work,and the structure is not intended mothered for sale(Sec.70FL Business ❑OTHER
ad3 and Professions Code:The Contractor's License Law does not apply ro an owner of mOUTLETS-SWITCHES-FIXTUk..
�' .. ppmty who builds or intpmves thm, lf
erunit who does such work himseor through
his awn employees,provided that such mprovenrena are not intended or offered for NEW RESIDENTIAL ELIiC'f S IT.
sale.If. the building orimprovement is sold within one year ofcompleion,the SQ.FT.FLOOR AREA 4/SU.yr
wner-builder will have the burden of proving that he did not build or improve for par- /
post of sale.).
❑L as owner of the property,am exchoovely contracting with licensed contractors to
construct the project(S .70,W,Business and Professions Cade:)The Commnors Li-
cense ecenseLawdoesnotapplytoanownerofpmperywhobuiidsorimprovesdereon,and QTY: PLUMBING PERMIT FEE
who contracts forsu h projects with a comracmr(s)licensed pummmrm the Grmmerors
License Law, PHRMIT ISSUANCE!
❑ I am exempt under Sea. .k&1'C for this mason
Owner Dem ALTHR-DRAIN&VENT-WATER(CA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTI C'L DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-imum for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND, ISIORIES TYPE?CONSTRUCTION
ration,ss provided for by Section 37M of the Lubar Code,for the ped nature of the
work for which this permit is i"soo. FIXTURES-PUR'1'RAP
V
I have and will maintain Workers Compensation Insurance.us required by Section
�Ii00 of the Labor Code,for the performance of the work for which this permit is issued GAS-EA.SYS'HzM-I INC.40UTLH1S OCC.GROUP AI'N
My we lisciani'ati 1 umomenta.er and Policynum r
Currier Q>L n� Policy No.: S�� GAS-EA.SYS'IAAhOVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INDUSTRI.WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe permit is focone hundred dollarsD s10) GREASHTkAP
or lesa.E PLANCHECK ITE,
Loy anytbetln the an,onmanc is,
becorkome subjecch t
In permuteers'm.I deadCmpi SEWER-SANI'T'ARY-STORM EA.200 IT rat employ any pvtxnn in any manner.en a"ro hecnmc bject m @e Workers'Compete 1!NIRGY FP,E
Z smion Law"of Calif ia.Date 4-3 -.V7 WATER HEATHR WNHIST/ILECTR
Z Applicant r _ GRADING PI[P.
'T..' y NOTICE TO APPLICAIf. ftterma�g�'eri&am of Exemption,you should WATER SYSTEM?RHxI INC,
a hrrnme subject m the Workers Compensation proo kions of the Later Coate,you most
SOILS PEE
I]a forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE!
aQ
Z CONSnce is. 10th LENDING AGENCY NEW RESIUEN'1'IA1.('LMH SU.Fr, dFH
PAID I t Romipq
U p (hereby al0nn thmthere iso conmmainn lending agency l'nr the perlbmtance of
the wads for which this permit Is issued(Sec.3099.Civ.C)
p UI-enders Name T(11'AL: TOTAL G
Lenders Address
BUIL G Plili
[.. 1 certify thin 1 have read this application and stain thnt the ahswe information is
h correct.l agree tocnmply with all city and county ordinances and state law.iodaing1. QTY MBCHANICAIj PERMIT
U building construction,and hereby authorize representatives of this city to enterupon the SEISMIC 'EF;
above-mentioned property for inspection purposes. P17RMIT ISSUANCE
(Wo)ngrer ,,save,indemnify trod keep harmless the City"I Cnmcnino against 1!hIC'1'RIC Eli
Imbilitics,pil,menfs,cast,and espouses vehichniq in any way accrue against said City A LFHR OR ADD'10 MEC 11.
in unsequence M the granting of this permit PLUMBING lite
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON.POINT AIR HANDLING UNIT(TO 10,000 CFM(
SOURCE REGULATIONS. - MECHANICA ITE
AIR HANDLING ONE'1'(OVER IBM)CFM) CONSTRUCTION TAX
Signature of Apphcunt/Commctm (late EXHAUST HOOD IW/DUCT) HOUSING ME FIGS]]ON FEE
IIA4ARDOUS MATERIALS DISCLOSURE?
Will the applicant or future builJlngom.Enctstomor handle ha,i i..sm+terial HEATING ON[FEE 0100,001 BTU)
as defined by the Cupertino Municipal Gide,Chapter 9,12,and the Health and Safety
Coda Section 25532009 / 14 EATING UNIT(OVER 100,0011 BTU)
LJ Yes T/N�
VENTILATION FAN(SINGLE RESIDE PAID
Date ReceiptM
.Will the ur con m or furore building y the a use equipment err devices which BOILER-COMP OHP OR 1000000 BTU(
emit rtzarduux air nnnuminanm as defined by the Bay Area Air Quality Matwgdmem TOTAL:
Dletriet9
E]Yes MOILER-COME)(OVER 100,000 ETU)
I have mail the hanadous materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE.DATE
fomia Health&Safety Cede.Sections 25505,25533 and 255Y1.1 undcrmandthat if the NEW RESIDENTIAL MICH. SQ.IT.
building docs not currently have a tenant,the it is my respomilohly m manly the meaning 7 ^3
of theaqui ms hnich be met rior us issuance of s Cenifieate
° .aiv-(L a wl .V
Owner nr authmiceJ agent Date Tarn1: ISSUED BY:
OFFICE