B 0619APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CONTACDv - PHONE: r
CITY OF CUPERTINO BUILDING . ELECTRICAI.
BUILDING DIVISION AFPLICATION/PERMIT PLUMBING MF.CHANICAI.
nOILnING PROIECP IDENTIFICATION
PERMIT NO.
SOOO 1 - I I-
1/t
OFFICE
FEE
risme
BUILDING PERMIT INFO
BLDG . ELECT PLUMB MECII
JOB DESCRIPTION
RF.SIDENTIALDEFNTIAL'� I❑6L
SFDWL RITCHEN REMODEL
❑ADDITION ❑ PLUMBING RF. -PIPE
❑MULFLUNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑ RAI If REMODIiUREPAIR [I DEMOLITION
NEW BLDG/ADDITION El DEMOLITION
❑TENANT ❑ FOOD SERVICE
Him
' FEE
201
Iti
V
I BUILDING DIVISION PEES
ENERGY FEE
GRADING
SOILS FISC
PAID
I'Y is R¢ciplX
r BUILDING JEE 2
FEE SEISMIC FF.
MECHANICAL FIJII (X 0
CONS' I'IIUCTIONCONS N IAX
HOUSING MITIGATION FEE
PAID--
Dam Reccipi p
f
1t _3 9 p
ISSUED BY: `!
CONTACDv - PHONE: r
V
- - �{7 ^I � � 1
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❑ Consultant Fees Paid by Applicant (Initial) .
LICENSEDCONTRACfOR'SDECVA�FRTION
1 herchy uf0nn thm I um tic roW undo provision of Chupler 9 (commeneing_aOZ'pwithSeuhm`700nlafDivision 3nflhaBllMlmNs an rn'c.aons Ct Jc�lnd mylicense is
in full force and effect -�7/ULicense Cl�/--RESIDENTIAL<� Dale�C.mmctourT]CHITE'CF,,DECL(i�R/sTION
IunJecwxnJ mYd i.s shall heusedas pubse recnrrsPSF4CW
ZOZN.Z.
l,ECFRICPERMIT
ZTyM201-HYMAMPS
NCI:6,W�
pCC
�y(U y U
licensed Pmfessinnal
OWNER -BUILDER DECLARATION
1 hereby u1Brm that 1 ata exctnpl from the Cnn nnen:r. License Law Pim the
following reason. (Section ]1131.5, Business and Professions Code: Any city nr county
S+�'2-tr
PS
SIGNS ELECTRICAL
SPEC IAL CIRCU IT/MISC.
413 C) vFi
F�Da
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tl6 p C
1,
i.4
5C❑Lasowno,
Fmwill
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which requires a Permit In consumer,alter, improve, demolish, or repair any structure
poor o its issuance, also requires the applicant forsuch permit In file a signed statement
he is lieutsni,a...om In th..... Wor,criffiriCi ansche" License Low Chance
(commencing with Section 9000) of Division 3 ofthc Business and Professions Cade) or
that be is exempt therefrom and the basis for the a11egW exemption. Any violation of
Semion]03L5 by anyapplicare frrapormil subjeclslheapplamamncivil pcnahyof
more than live hundred dollars (55110).
of the propertyor my anpinyees will' wage"ficirsole compcnsmi.m,
do the wad, and the swcture is not Intended or offered for sale (Sm. ]014, Business
aril Professions Code: The Cement License, Law does not apply m an owner of
pmpenY who builds or improves demon, and who drcc such wmk himsdfor Ihmugh
his own employees, pnNWcd that w01 improvements are nm In coo nr nRcrcJ for
sale. If, however. the building err improvemem is sold within one year of completion, the
TEMPI METER OR POLE INST..
POWER DEVICES
SWIM MI NO POOL LLEC'I RIC
OUTLETS-SWITCIIFS-PIX'1'URFS
NEW RIESIDENTI Al, ELECfl2 SQ Pf.
owner holder will have the barren of a,,Ang that he did not W iId.r improve for Pur-
'f0
pose of sale.).
❑ L as owner of the pm,,,Y, rant exclnsivdy emanneur, with limned atmruetnre to
amstruct the project (Sec. 7(M4. Business and Professions Cole) i he ContruetorN Li-
censelawdoesnotapplytoanowner of property who builds or improves thereon, and
QTY. PLUMBING PERMIT
who un n ,acts for such pmje[ts with a conlrador(s) licensed pursuant m the Contra cors
License Low.
I in. exempt under Sec. , B or P C for the emoor
UANCI?
RAIN Ar VENT- WATER CA)
Owner Dntc
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty ofpoUne, onoof Tho following Jealarre as:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Camper-LOOR,
sation. as provided for by Section 37W of the IsMr CWe, far the Performance of the
w rk for which this permit is issued,
1 have and will maintain Worker's Compensation Insurance, as required by Sxti.n
37 of the lahn Cude. fnnhe performance uDhe work forwhich this permit is issued.SYS'I'EM-IINC.4OUTI.FTS
My WalkC['i Ccr re a�In tier wP icYnu 7SY5YTEM-OVER4GA)
Carrier: 1./)i- 1-6-
CERTIFICN'LOFEXEMPTIONFROM O R.
COMPENSATION INSURANCE
W PROTECT. DEVICE
ROOF, AREA. COND.
FHA.
-PER TRAP
GRHASILINDUS'l RL WAS 113 INTERCEPPUZ
GREASETRAP
This section need not becompiml ifthepermitisforonehundreddallnrs(SIW)
.r less")
Ice a any per in the any rancher becons which this thepermit ,kers'red, Ishall
not cnoploy any Pelson in any manner so as to Wcontc subject m the Workers' Compere
SEWI3R- SAN f1'A 12Y -STORM F.A. 2011 PI'.
WATER HEATER WNENTBi1.ECTR
z
scion Laws of Culifomia. Dmc
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aM1cco..c
(1d
Q
Applicant
NOTICE TO AP'P'LICANT. IL after making this Con ificme of Bumptian, you should
ml,d to the Worker, Componsat inn provisions of the L.har Cute, Ina mal
form. ilh comply with such provisions (ir this permit shall be deemed revoked.
WA'I'BE SYSTEM/OFEATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ, FT.
�'T
Qthe
CONSTRUCTION LENDING AGENCY
Ihereby nlT n that them is a cenametion lending agency for the pedurnanro of
work to, which this pmmit is issued(See3097, Civ. C.)
Atif
F'
C) L)
W
(ai)
Ll z
Lenders Name
Lender's Address
1 crony Ilett I have rend die appli[ulion and some That the those Information is
correct. I ngrx m comply with all city and comil,onlinuxns and smtc Iowa mlnting or
building construction. and hereby amhndze representatives ifthis city to enterupom the
ahmcmemioncd propeny for inspection purposes.
(We) agree msvve, indemnify end keep hamdess the City of Cupertino against
Ilnhilines,judyments, costs and expenses which may in any way accrue against said C'IY
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE. A
-71
ALT17R OR ADD TO MECII.
in [smsegmnce of the grating i f this permit.
APPLICANT UNDERSTA AND WILL PLY WITH ALL NON -POINT
AIR HANDLING UNIT (TO 10,000 CFM)
SOURCEREGUI2T
ifANDLING UNIT (OV1311 I[1,00[I CPM)
—A-1 HOOD(W/DUCI)
Signature I/Contmctur, ,are
HA DO A'IERIALS DISCLOSURE
the applicant or lmnre huilding xcupunt score or hunAle lmzarrnws nmoerial
reed by the Cusen'mn Municipal Code, Chapter 9,12, and the Health and Sunny
Code. Section 25532(v))
-4,
If EATING UNIT (IT) 110,000 BTIJ)
HEATING UNIT (OVER 100,0N) BTU)
VENTILATION PAN(SINGLE RESID)
❑Yes No
will the uPplie.a or fm building occupant ase egmipmcm or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
Dwrict?
BOILER- COMP(3HP OR 100,100 BTU)
BOILER - COMP (OVER 100,000 BTU)
C] Yes No
AIR CONDITIONIiR
I have mad the hazardous materials requirements mes unite, Output, 6,95 of the Cali-
NEN' RESIDENTIAL MECH. SQ. FI'.
fond. Health ar Safety Cade. Sections 8505. 25533 and 25534.1 understand that if the
bmIdingJcecmrri'VryjyWves,a tis my um,msihililymnyy__fff,. tthnhe'-;IojSuw�pa-nt
of lha rommomamy�piyFh mull bt. ao ori , visitant. of CenifioQClyy"IT�
I /)
OFFICE
FEE
risme
BUILDING PERMIT INFO
BLDG . ELECT PLUMB MECII
JOB DESCRIPTION
RF.SIDENTIALDEFNTIAL'� I❑6L
SFDWL RITCHEN REMODEL
❑ADDITION ❑ PLUMBING RF. -PIPE
❑MULFLUNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑ RAI If REMODIiUREPAIR [I DEMOLITION
NEW BLDG/ADDITION El DEMOLITION
❑TENANT ❑ FOOD SERVICE
Him
' FEE
201
Iti
V
I BUILDING DIVISION PEES
ENERGY FEE
GRADING
SOILS FISC
PAID
I'Y is R¢ciplX
r BUILDING JEE 2
FEE SEISMIC FF.
MECHANICAL FIJII (X 0
CONS' I'IIUCTIONCONS N IAX
HOUSING MITIGATION FEE
PAID--
Dam Reccipi p
f
1t _3 9 p
ISSUED BY: `!