00010021 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY �0 10 El 10 I�y�2. 1
CITY OF CUPERTINO BUILDING-KLKCI'RICAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PFRMIT PLUMBING-MECHANICAL SOOOI
IIUII.DI.NG PROJECTIDENTIF'IC'ATION
BUILDLNGADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE,
sur C7 why GuF�a(lnry , cls _ , bio
OWNER'S(NNAfM�E:1 PIIONI?: 7i ^� CEJ R" AME: L 1 yIGI LIC N¢ N/C CON"IRot,P
A { 1 �, /uVKGINEI: LIC N(: i U R
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I �! 5INE: BUILDING PERMIT INFO
t Fees Paid by Applicant(Initial) BLDG EEL.PM PLUNH MECH
LICENSIED CONTRACTOR'S DECLARATIONQ'TY. ELECTRIC PERMIT FEE JOH DESCRIPTIONI hereby affirm that 1art licensed under provision, f Chapter 9(commencingwith Section 9000))Off Pitman]ofthe 1p-ressand Prid-mon,Cade,and my license a RESIDENTIALp SUANCE��F. it dill for ❑Sh'DWI, ❑KI'CCHIiN ItI?MGUIiI.auu Licence Class Lie of ES-REST UP.N'I'IM. I ❑ADDITION ❑PLUMBING HIbI'IPF
E-4w Dau. Conmaor ❑MULTI-UNH' ❑STRUCIORAL
ARCHITECTS DECLARATION MODII4CA'I'ION
OZHZ I undesand my plansshall he..it m;public rcord., ` )AMPSC ❑INTEk10R ❑CIIIMNI:Y k1iPAIN
(-4F'W Licensed Pmfn,imeal MPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEVREPAIR El DEMOLITION
O C 1 hereby affirm that 1 am exempt from the Contractor's License Law for the ❑OTHER
aQ u following kaon.(Section 7031.5.Bmincse and Profession,Cute:Any city or county I SIGNS ELECTRICAL.
W 3 WE- which m,uire,a perm,of um.anret,almr,Improve.demollah,or repair any structure
sal",,.�+�g prion r alxn y :tl ppl' II hl n II 'g J,fi muv SIECIALCIRCUIUMISC.
� } :hull Jp rsu;in,l Ibcp s fin Cent d ,Li I (Chapter 9 COMMERCIAL:
WLCC (commenemgwnh Secli lop)ofDviFoe3oflhe Bmnesaand lknfvss enc Cafw)or ThMP.MLTF,R OR POLE LNS'I.
a a ey that he is exempt therefrom and the basis for the alleged exentp,on.Any violation of EINE 6LDGIAUDI'1lON ❑DEMOLITION
XMNSection FIJl.5 by any applicant for a permit subjects the applicant)a civil Penalty of POWER DEVICES "ANT ❑Pool)SERVICE
t mom than five hundred dollars(5500). IMPROVEMEM'
SSC ❑Lnowncr of Ne propcnY•nr mycmploycez with wage,as their sole aimpwnsation, SWIMMING POOL ELECT RIC
F. wilt do the work.and the machine is not aradedorofcnal for sale(See 70:1 Business ❑OTHfik
W:i,3 and Professionsno
Carle:The Common,',Licence Law does t upply to an mune,Of OUTLETS-SWITCHES-PI%"I'URIS
d property who build,or improves thereon,and who down such work himself or through
Itis own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECI'R 5
vote.IL however,the buildingor iropnrvement is cold within ore ycarof mmpleion.the SQ FI'FLOOR AREA SSV FP
owner-builder will have dm harden of proving that lie did nor build Or improve lot pur-
is col',ale.). TOTAL of7 Z
1,a,owner of the•pnspcnY,am exclusively contraain6 wilM1 licensed amvanom ni
,enact the project(Sec.9144,Hostess and Profession,Cedeq'Htc Catamount's Li
minu Law de,not apply to an owner of property who builds or improves ihemon.and QTY. PLUMBING PaRMIT FF.
wan contacts for such projects with o commctm(sl licensed Pursuant to the Ci mractofz
License Law. E'IERMIT ISSUANCE
I am exempt under Sec. .B&PC for this reason -
ALTER-DRAIN.F VENT-W .A) VALUATION
Owner Dole
WORK]:N:SCOMPENSAI'ION DECLARATION HACK PLOW PRO"L'EC'I'.D" CE `J✓\
I hereby dB maintain
i under Imnahyofperjuryenc ofthe followingdcdker',' r,.
(]an,as andwill f..by Sect n37(XIof Cansentmscltdnsure]ir Workcr'e0ompcn- DRAINS-FLOOR.RO(I,A ?A,GOND. STORIES 'I'YPIi CONS'fI1UCfIUN
.iron,as hick Ohio
(or itis I'm d91N1 of the Iabm Cide,lin the perhmnance n(the
work for which this pcmtii is lured FIXTURES-PER TRAP
Iheroand willome,for
nhe erha Compensation Irsurancek mr%h,as hrequited by Section GAS-EA.SYSTEM-IINCAU
39011 afore Labor Come,fnnhc perfnrmanm advise work for which this permit is ismed. r (XC.GROUP yr, 1'N
My Worker's Compensation Insurance carrier and Policy number are: _ GAS EA.SYSTEM-OVER 4(EA) ��
Cariee Policy No.: 0 I L1
CERTIFICATE OP EXEMPTION FROM WORKERS' r GREASFJINDUSTRI.WA5T'li INTERCEPTOR
COMI'13NSATION INSURANCE BUILDING DIVISION Ell
('Dtiapwclioa need rat be con,doal dar,,umollx fanmelnndred Jnllars(EIINB GREASE TRAP
PLANCI11iCK 14Ji
less.)
]certify thein the any instance sum,
beemoe subjecch hlx pt'rnitike".Colshad $IiWER-SANITARY-S'CORM HA 200 Ff,
not employ any pennn in any mmtner.m usmbecome mhjmlmthe Wnrkerd Compere � ENERGY PIiF.
Z ,ation Laws of Califomin Dae WATER HEATER W/VENTIOLEM R GRADING FELE
Z Applicant t
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/fRIiATING SOILS FEE
a ; pm onto abject m the Worker'.Compcnsaaon pmvi,lons of the Labor Cade,You must
fnnhwith comply witusuch pmvidom,m this pernnahull be deemed revoked. WATER SERVICE
(� PAID
MEW
n' CONS'IRIICTION LENDING AGENCY RESIDENTIAL PI,SIR SQ,FT. Dam Remipl x
hereby affirm that there is a commotion]ending agency for the performance of
DU.r FO~" rhe work for which thin porn,i,:,rural(See 9097,Civ.Cd IOTA I.
O Lend,Name TOTAL:
} {U larder's Address BUILDING]IEE
y 1 cendy Lha L have mail this upplicaion and state that thw aNmc information is
F H c rrect I ugrwc to ready with all city and county ordinances and state laws relating ht QTY. MECHANICAL PERMIT FEE SEISMIC FEE
L) Z building eonstrvetion.and hereby uniform mpremitatives ofthis city to enter upontue
abovemenommod pmpeny for Inspection purpoma PERMIT ISSUANCE ELECTRIC FEE
(gild agree to save,indemnify and keep harmless the City Of Cupertino against
I iahilities.judgments.cons and expenses which may in any way acerae against said City ALTER OR ADD TO MECH. PLUMBING FEE..
In ea....once of the grunting of thin Irromit.
APPLICANT UNDERSTANDS AND WILL COMPLY WIDE ALL NON-POINT' AIR HANDLING UNITHO 10.000CPM) MECHANICALII!IE
SOORCI:REGULATIONS.
/ AIRlIANDLINO 11N1'f(UVliIi IILINNI CFM) CONSTHUC'IIUN'I'A%
Signmurc Of App]icanl/Contmnor Date i EXHAUST HOOD(W/DUCD HOUSING MITIGATION Fri
IIAY.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hvallous lmtterial / HEAI"ING UNIT 1001gN)BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health ad Safety IIEATING UNIT(OVER Il .0d)BTU)
12
Calc,Section 25532(a)'f
Yes No VENTILATION FAN(SINGLE:RESID) PAID
[)am Reaipik
Will the applicant or future building occupant um equipment or devices which BOILER-COMP(3HPOR Po,INN)BTU)
aril Imenrdon air conmrak a lx ax defined by ibe Bury Arca Air Quality Management TOPAI.
Di4rin9 BUII.BR-COMP(UV ER 1111 lbfl BTU)
❑Ycs 0N /
AIR CONDITLONT:R ISSUANCE DATE
1 have th mad the ha menus is r,255 5.l 533 ad u25!Bode,Croton 6.95 of the i The
fumia gdoes&Safety Qde.eatiim,25505.2553)and 25514.1 a notify r that if NEW RFSIDENTIAI.MEGl1. SQ.M'.
building does act currently have a tewn6 that it is my mspsmsihil'ny m notify tuc Occupant
Of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or uutM1orimJ agent
Uma TOTAL: ISSUED BY:
OFFICE