S 0482 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO IIUILDNG-ElRCI'RICAL P I'1'NO.
BUILDING DIVISIONAPPLICATIONIPERMIT PLUMB;NG.MECHANICAL 0482
BUILDING PROJECT IIIPMIPICA'TION
BUILDINGADDRESS: SANITARY T
'ARY NO. APPLICAION SUBMITTAL OA'1
ZIP 15,410 !NEIMA) 1 1
OWNER'S AMP: PHONE CON ftACTUR'S NAME: LIC No:
S N/C CON]ROL#
ARCHITECT/ENGINEER' LIC NO ADDRESS: El
I �
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT DLII MECH
LICENSED CONTRACTOR S DECLARATION QTY. ELECTRIC PERM IT - FEE
I hereby affirm that I am licensed ander provisions of Chapter 9(emmnencing JOB DESCRIPTION
MWZ with Sondor7000)ofnivium 3.fthe Baslnesxaod Professions Coax,aad my license is RESIDENTIAL
IAO PERMIT ISSUANCE.
SIA- mfollfizibandeff Q ❑SFDWI. ❑KITCHEN REMODEL
QUU Licens<Cla _ Cab APPLIANCES-RESIDENTIAL DADDTDON 0PLUMBING RE-PIPIT
H W Dam Cummcmc
m 6 D MULTI-UNIT []STRUCTURAL
''
A CHDECTS DECLARA'T'ION
PANELS MODIFICATION
Z O I undemanA my plans obeli M used as public records
Oy�O I1PTO2110AMPS 0INTIiRI(1R DCI{IMNRY REPAIR
C� WC6 Licensed Pm@esiond 2II-1000AMPS IMPROVEMENT E]SWIMMING POOLS
J-J OWNER-BUILDER DECLARN'ION
OVER IINor AMPS El BATH ItIiMODE1IREPAIR DUIi.MO1.ITI0N
6 I hereby,(firm on I am exempt from the CommnCs e:License Law for the
3e.O following reason.(Section 7031.5.Businessandmpr improve,
demolish.
Co de:Any city orcountySIGNS ELECTRICAL DjH�f)IQ e` ,.I
W W u0 which req permit consumer,pine 'repro c d I h rope y p sediment
/ /V b
poo I T man also eN eiv applicant for suchraPermit fleasigned ammemmt S1'ECIAL,CBCUI'1'/MISC.
ce } thenh T sed pu ai ntI they ofheContractors L 1 Is Code) 9
F�<f COMMERCIAL:
W 00 (cot be is(commencing dice ire alit of basis or the
the ex ptio Professions Code) TEMP.METE OR POLE INS'(.
dy ey� that he is 31.5 b Jany cep at applicant
the avers for the alleged exemption Any solution of D NEW IN,DOIADDITION D DEMFOOD LITION
SERV(
iemlA Section 7031 Shy uundredicamfoT5010) suM1jactx tlm.applicanl lnncivil penally,of 1'GWIiR DEVICES
�rN nm mnro Nvn ave hundred dollars(85(X1). ❑TENANT ❑FOOD SERVICE
f-ZY OTHERIMPROIiMENT
G Lu iework,the pestour,oT myeutntended wiNscmd f r alei(m.armpen.itis SWIMMING POOL ELF.C'TRIC
p=., will Jo the work,and Nc utmcwrcis not imendcJomRcrcdfor salel5ec.7(la,raerof OTHER
W and Pmfessionx Cale:The Cantracmr's License Lew does nm apply m an rmme iof OIfILETS-SWITCHES-IT%'1'URI!S
6 3 pmpeny who builds or improves thereon,and who does such work himself nr Onmugh
his own employees,provided Nat such improvements are not intended or offered for NEW RESIDENTIAL ELECT R SQ
IF V
sale,If.however,the building in,improvement resold within one year of completion.the SQ.IFAA A $/SQ.Fr.
owner-budder will have the burden of proving that he did not build or impnbe for par- NOV
you of sale) TOTA14:
. 7
[:]I,,I owner of the property,em exclusivelyexclusivelymnancling with liecn rd cnnlnminfs m
REC-D
minaret the project(Sec]LAq Business and 1'mErosions C dc:)The Contractor
To 's Li-
meLawdoesnolapplyanownerofpropertywhebuildsorimprovesthereon.and QTY. PLUMBING PHRMPI' FEE Ci
whocontracts farsuch pmleefc wirdacommctnr(s)liccnud pursuant mthe CnnlmctnR - Ur VVrCy i 11yo
License Law. PERgfIT ISSUANCE
❑I am exempt under Sec. .R&P C for this rersnn
AIT'ER-DRAIN&VEX'-WATER(EA) VALUAI[ON
Owner Date
•t WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DE ICE
I nerebyafllnn under formally of perjury onu ofine following decl,mdob,: GQ P", �q
D l have and will maintain a Certificate of Cnnsem m self-insore fur Workers Cooper- DRAINS-FLOOR,ROOV,,AR1iA CO STORIES 'TYPE CONSTRUC'T'ION
uvtio t.os provided for by Section 37M of Ne Labor Code,for the na
omfnnncc,of the
bark far which This permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
37M afthe labor Code,for the performance ofthe work for which this permitkinured. GAS-ITA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Worker Co., rains lr andPolicy no ry':♦
Cartier: AAI,&Z " Policy ^ V12,OY-D GAS-ITA SYSTEM-OVER 4(HA)
CRIT B CATE 0 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRHASIVINDUS'FRI,WANT 1:TNT ERCHVTOR
13UILDIN01lIVISION P(?BS
(This vection need not bocampincd ifnhc permit is fnnme huoNed dollva(SIIN) OREAST.'TRAP
nr
less.) PLANCIII[CK Il?E
T cmify that in its,performance of the work for which Nis Email is issuext.I shall SEWER-SANITARY-S'IDRM ITA.200 FT.
not employ any person in any manner sat as m bemme
c subject Ne Wnrkcri Compen- ENERGY ITE
Z salon LoOof Califaid..Date WR'I'ER BEATER WAVENTMLECTR
Applicata l GRADING PGI?
NOTICE TO APPLICANT:IT,after making this Certificate of Exemption.you should WAFER SYS fEMn REATING
a ; become mhject m the Worker's Compensation unemors of be Labor Code you imp solus Fid?
W forthwith comply wish such provisions or this Timnnit shall be deemed revoked. WATER SERVICE
0. La
CONSTRUCTIONLENDINO AGENCY NEW RESIDENTIAL PLMI3. SQ.FT. PAID
U O Doc Receipt p
1 hereby aNath
ffirm ere construction a cnnsctinn lending agency fnnhe performance of
she work far which this permit is issued(Sec-3097.Civ.C.)
lenders Name TOTAL:
U Lender's Address TOTAL
1 certify that I have read this application and state that the above iol6mwtimn is BUILDING FEE
F: w comet.L agree to comply wilt dI city and mmnly ordinances and state hsvx edu1mg or QTY, MECHANICAL PERMIT FEE
U 4 building conslnnlion,end hereby awborize npreremnllvcx of this city In emerurym the SEISMIL'I'lili
above-menhmned property for inspection Truitt PERMIT ISSUANCE
(We)agree hs save,indemnify and keep harmless the City of Cupeninn against F.LCCTHIC -
Iiabilities,judgments,cops and expenses which may in any way accrue against said City AITIiR OR A UD TO MECH.
in asequence of are granting of this permit. PLUMIIINL -.13
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('TO 1I,000CFM)
SOURCE REGULATIONS. MECHANICAL PEE
AIR II ANDLING UNIT(OVER 10J)d I CFM) CONSTRUC'T'ION TAO
Signature of Applicant/Cnnitnclor Dare EXIlAUSdI IOOD(W/DUCT•) HOUSING MI'T'IGA'T'ION PER
HAZARDOUS MATERIAI.S DISCI.OSURE
Will the applicant orfuthre building occupanlsmre or handlehicanknsmoterial HHATINGUNIT(T0100,(XN)B'1'U)
as defined by the Cupeninn Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532(oft? TREATING UNIT(OVER I T)JIN)13'ru)
❑Yes ON. VENTILATION RAN(SINGLE RESID) PAID -
Dam Rcccipt s
Will The applicant or future Wilding anupant use equipment or devices whleh
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME TRIP OR 100.00N1 BTU) TOTAL.
District'
❑Vex GNoRDILER-GDMP(QYER 100,000B'fU)
I have read the hmaNws materials mquiremena undtt Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
(aria Health&Safety Cale.Sections 25505,25533 and 25531.1 r ndemand and if the NEW RESIDENTIAL MECH. SQ.Er
building does not currently have a mason.that it is my responsibility to notify the oecupom
of the v-airemems wh c map Is,mer prior m issuance of o Cenifimte of Ocenpancy.
Owner or authorized nUu1c TOTAL: ISSUED BY:
gem `
OFFICE