B 0270 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING.MECHANICAL
ECH NICA PERMIT NCy O ^ O
BUILDING DIVISION APPLICATION/PERMIT PINGPROJECT IDENTIFICATION
SOOOI ��.'L�}/ L
BUILDING PROJECT IUENfIF'ICATION '
HUILDINGADDRISS: SANI'I'AItY N(I. APPLICATION SUBMITTAL DATI
1210 kUPPEL` Pi-ACE CuPEO AJO
q NT I AC OWNIiR'S NAME: I'I{ONE: p lM R ., .L LICNO,
lF r NIC CONTI20L p
ARCIU ECDENGINEER: LIC NO'. ADDRESS, ��• (1 ^ a ❑
/KL7 S•
CONTACT; PHONE: BUILDING PFRMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT ' FEE
I hereby infirm that 1 am licensed under provisions of chapter v(commencing JOB DESCRIPTION
DC) with Sect ion T(MM11 ofDivision3oDhe Business and PmfessitnsCode,and mylicen-i.s RESIDENTIAL:
W O p PERMIT ISSUANCE
in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
�VV License Class Un.Y APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F 61]1 Dalc Cmumclor
D i ARCHITECTS DFCLARA'I'ION LANE S [IMUIdbUNIT [2 STRUCTURAL
� z 1 understand my plans shall be used as public records MODIFICATION
Oz'4O UPT0200AMPS E]INTERIOR ❑CHIMNEY RI?PAIR
tW Lim...itPmfessinnnl 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
2H OWNER-BUILDER DECLARATIONOVER piano
BATH REMODHIJREPAIR CDEMOL.I'I'LON
%Q 1 hereby aRom that I am exempt from the Contractor's License Law for the
q U following reason.(Seclmn]031.5,Business and Professinns CNe:Any city or county SIGNS ELECTRICAL ❑OTHEk
W W WO y which requires a permit to construct,after,improve,demmish,m repair any structure
priorto its isxusum,alsorequirestheappliamt l^rsuch perminn file x signedslalment SPECIAL CIRCUI'1'7MISC, 'Agde ill
y thal be is Kn
eeed pumurnt to me provisions ofthe Cruise....Liora,r l.aw(Chopicr9
9M lati
(commencing with Section 70)(buf Division 3 ofthe Rosiness and Professions Code)nr TEMPMEITROR POLE INST. L
L p,a that he is exempt therefrom and the basis for the alleged exemption.Any vioon of [I NEW
BLDGIADDOHON ElDEMOLIT(ON
❑TENNT ❑FOOD SERVICE
w Section 7031.5 by any applicant for a peoub subjects the applicant to a civil Penalty of POWER DEVICES
nolo v than live hnndred dollam($500). A
TSC ❑I,an owner of the properly.nr my employees wird wages es theirsolc cnmin_nsatinn, SWIMMING POOL ELECTRIC IMI'ROVEMEN'I'
F will it,,the work.Inundate stmcma is not intended or refined fm code(See 7(/W,Business C1 OTHER
a 3'-° and Professions Code:The Contractors License taw does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpery who builds or improve,tlerern,and who does such wad himself o,oli gh
his wn empinyeea,providul tMn such ImprovamenN amour intend If or offered In
on NI:W RESIDI?N'I'IAL ELCG'I'R SQ FC
salc.IL hnweveq the buildins mrimprovemcm is sold within oneywr of SQ.PC FLOOR AREA $ISQ.IT.
completiogthc
owner-builder will have the burden cleansing that he did not build or improve for pur-
p,soof sale.).
11Y I,as owner of the property,am exclusively contracting with licensed contractors it TOTAL:
con emn the pmjat Res.7094,Btsinean and Pmfession,Code:)The Conweme,I.i. P A 6 D
cepa Law does not apply man owner ofpn,,Ay who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
,recreations fe such projects with a oo plan(,)licensed pursuant m the Conlracmrs
Limnsc Law. PERMIT ISSUANCE. JUL 07 AT
1 um exemu
pl mer Sm. .B&P C fill reareasonthis uw
ALTER-DRAIN&VENT-WATER(H VALUATION
w rIPIA-1Dae
KF.R'SCOMPENSATION DECLARATION BACK FLOW PROTECT DEVICEV�IT V( VVf LnIIIVI�
1 hereby affinlm under pen^ity or perjury one of the billowing declarations:
I have and will maintain it Cerlidicum at Consent to wll'-insure for Wmrkcrs Crmpum DRAINS-FILOOR,ROOP,AItEA, O STORIES "1'YPP,CON$'FRUCTIOp
sation,as provided burry Section 3700 of ilia Labor Cods,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,in required by Sectinn
3700 ofthe Laurer Code,for the performance ofthe,work for which this pemin is issued. CAS-EA.SYSTEM-I INC.4OUTLBTS OCC.GROUP ANN
My Writer's Compensation Insurance comic,atd Policy number arc:
Cortico Polley No: GAS-EA.SVSTIiMAVI?H A[EA7
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASFIINDUS'IHL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PERS
rrhispectionneednni he,ormleted if'he permit is fnrrne hmmdrcd dolbns l$IINry GREASETRAP nr Ices) PLANCHECK FER
I rectify that in to performance ofthe work forwhich this permit is issued.I shall SEWER-SANITARY-S FORM EA.200 FT.
not employ any person in any manner so as to become subject to me Workers'Camper. ENERGY FEE
Z smitn Laws of Cali fomia.Dore WATER HEATER WNENTdFLECTR
O Applicant I GRADING LEE
V) NOTICE TO APPLICANT..If,after making this Cenificam of Exemption,you should WATER SYSTI:MfFREATING SOILS FEE
F bemnne subject wife Warkce,Compensaitn previsions of the Later Cale,you muse
Wti GmthwiN comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
Q
'IA
� Z CONSl1LTION LENDING AGENCY NEW RESIDENTIAL PLMO. SQ.FI'. PAID Date Receipt#
affirm V I hereby arm thatthem is a construction Encingasency for the pmodustramof
the work for which this Nitrol is issued(Sec.3097,Civ.C)
Lenders Name '1OTAL:
lenders Address TOTAL:
Cy 1 codify that I have .it this application and tire'hat the above information is BUILDING FEE e 0
y come'.l agreemcamply wi'hall city and county ordinances and state laws coloring ,, QTY. MECHANICAL P13RMIT FEE
V Z building convection,and hereby arborize representatives of this city to enter upon the SEISMIC PEE -
nbnve-meminned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and onto broods,, he City of Cm1x:nlmo against ELECTRIC FEE
Iiabilities,judsmenrc.cos's and expenscswhich may in any wayaccrueogninsl said City ALTER OR ADD TO MECH.
PLUMBING FEE
in consequence of'he flooding of this permit.
APPLICANT UNDERSTANDS AND WI LL COM PLV WITH ALL NON-POINT AIR HANDLING UNIT(TO 10."CFM) MECHANICAL FEE
SOURCE REGULATIONS.
7, AIR HANDLING UNIT(OVER 10,0(10 CI'M) CONS'I'RUCTION'I'AX
Sig tum ofApplica Cntraerm Date HXIIAUST HOOD WIDGET) ROUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicaut or furore building occupant sorm is handle btmrdouS macrial I IEA'FING UNIT(TO 100,000 BTU)
us defined by the Cupenino Municipal Cade,Chapter 9.12,and the Health and Safety
CMe,Section 25532(e)? HI3ATING UNIT(OVER IIMI,(NX)BTL)
C]Yes No VENTILATION PAN(SINGLI?RESID) PAID -
Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100.000 BTU)
emit humorous air commitment,as defined by the Bay Area Air Quality Management TOTAL. �a7/
Dixtnat? BOILER-COMP(OVER 100,000 BTU)
❑Yes
AIR CONUI710NF.R
I have mad the hdous materials requirements under Chapter 0,95 of me Cali-
azeISSUANCE DATE
fomia Health&Safely Code.Sections 25505.25533 and 8534.1 understand'ha if the NEW RESIDENTIAL MECH. SQ.PT.
building does na currently have a mment,that it is my responsibility to notify the ex cup in
of the requirements whichmust Ire met poor to is mance of a Ceniticme tf tXcuparmy.
Owout tore a nt Uem TOTAL: ISSUED fly:
OFFICE