S 0472 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUDDING.MEC'ITRICAI, PFgMI l NG O
BUILDING DIVISION APPLICATION/PERMIT rLumnwr,-MF:atnrvlcnL CV
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS t_/YI` SANITARY NO, APPLICATION SUBMITTAL DAPI
AI3 !9
OWNER'SN L: PHONE: PRACI'OR'S NAME: LIC NO'.
NIC COMIROLp
Cb.
'L RCHITF,CGGNGINHER: LIL O: ADDRESS'. ❑
2-C21,41i
CONTAC'11 PHONE: t BUILDING PFRMITINPO
❑ Consultanl Fees Paid by Applicant(Initial) LD .LF F,(Z PLUMB MI'.
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB�BDE$CRIPTION
1 hereby affirm tha I unr licenced under previsions or Chapter 9(commencing _
mfullf
1- LicenuC , rsinn3ofm°IlusrDEC1.A ATlp unix Gsdc,anday is RESIDENTIAL'
won ion7W))nf Div' PIIRMI'I'ISSUANCB
Fo sand effect. 'f ❑SFDWI, ❑KITCHEN REMODEL
Lica 4 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPIi
Z7M Ont c` Conlmc�� .II�—
ARCHITIiC'1"S N ❑MULTI-UNIT ❑S ODIFTURN.
z p Vn Z [understand my plans shell be used as public records PANELS MOUIFICA'I'ION
OZr4O UPT0200AMPS ❑INERIOR El CHIMNEY REPAIR
�a4qFq p,] Licensed PrafeWoral 20kIP0AMPS fIROVEMENT E]SWIMMING POOLS
K2 OWNER-BUILDER DECLARATION QVIiR I11fX)AMPS fIIt RMODHLJREPAIR ❑DEMOIATION
tY Wst 1 hereby affirm that 1 am exempt from the Comraclers License taw fill the(i15O F U following reason.(Section 7031.5,Buiness and Professi.ns Code:Any cityor county SIGNS ELECTRICAL. ER
m a n.vFi which requires a permit m construct.alter,improve,demolish,or repair any stm.mre
O� prior to its issuance.also requires the applicant forsuch permit t.file a signed.mmment SPECIAL CIRCUIT/MISC.
F y that he is licensed pursuant the Provrcions of the Contucters License Law(Chapter 9
C d'E (comnenei ng with Section 7000)of Di vision J of l he Baninexs and Pnrlcsninm C:xle)or TEMP.MCI'BR OR POLE I NST. COMMERCIAL:
W a o ffy� that he is exempt therefrom and the basis for the alleged exmnptinn.Any vinlminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
X^N Section 7031.5 by any applicant for a panto,schjw,the aPPlivart m a civil penalty or POWER DEVICES ❑TL'NAN'1' Cl TOLD SERVICE
l. ern or.then five hundred dollars($500). SW IMMINO Ir001.CLr:CfRIC
Z Y IMPROVEMENT
��< Las owner of the pmpeny,or my cnmloyces with wages Its their vole mmpmrswion,
W fz-0 will do the work.and the structure is not intended conferred for sale(Sec.]044,Business [1 OTHER
143 and Professions Code:The Cont actors License Law does not apply to an owner of OUTLETS
Property who builds or improves thereon,and who does such work himself or through
his own employees,provided that.uch improvements arc not immmdcd or oR'med for NEW RESIDENTIAL 1?LEC'I'R SQ FT.
tale.ILhowever.theboddingnrimprovement iswld within one year ofmmpletino the SQ.Pr.FLOOR AREA $ISQ.PI'.
owner will have the burden of proving that he did not build or improve Tim per-
_ pose of sale.).
El 1.as owner nom the propery,aexclusively connecting with licensed contemn it)
'rOrnL: /
construct the project(Sec.WW,Business and Professions Co,Ina,Conedson.Li-
seLawdoesnotapplymanownerofpr.party who builds or improves thereon,and QTY. PLUMBING PERMIT FCC
who convects for such projects with u asmmorm(O licensed personal to the Connector's
License law. PERMIT ISSUANCE
Iran exempt under Sea. .B&P C for this reason
Owner Date—
AE1'17R-TRAIN&YEN I'-WA'I'17RCA) LUATON �.J
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTF.C.DEVICE �1Y Jr 4Urt �DV
I hereby affirm under penalty of perjury one of the following decimations:
❑ I have and will maintfiin a Certificate of Consent to selflname for Workers Compel+ 1)ItAINS-FI.WR,I200F,ARI:A.CONU. STORIES 'TYPE CONS'1RUC'I ION
cation,as penvided for by Section 37W of the Labor Cade,for the performance of the
far which this permit is issued, IT STORES-PER TRAP
w have clad will melunln Worker's Compensation Lnsnnmce,os required by Section
1Wof the LaMar Code.for the Performance of the work for which this permit is ismed. GAS-EA.SYSTEM-I INC.4 Oil ITHTS OCC.GROUP AI'N
My Workers Canownsma asumn cnoerand Policy number a : q
Carrier. ib"04�Policy No: "I GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE.OFC .MPTION FROM OkK di5' frREASE/INDIJSTRh WASTEINTCRCEI'I'OR
COMPENSATION INSURANCE: BUILDING LIIVISION FEES
('this section neWnnt lel completed iflbe permit is Enron,hundred dollers($IW) GRBASEI'RAP
nr less.) PLANCHECK FEE.
I rerify that in the psaferramsecof me work forwhichthi,permit is i...ed.Isnall SEWER-SANITARY-STORM EA.200 Fr.
not employ any person in any manner sen as fin become subject to the Warkeri Crmpen- ENERGY FRE
Oz action Laws of Calirorait, Date WNIFR H17ATER WNIiNTMIECTR -
Z Applicant ) GRADING FEE
rA NM ICH TO APPLICANT:If.afar making this Certifisae of Exemption,you should WATER SYSTENETRENTING
a ; become subject 1.the Worker's Compensation provisions of the labor Code,you must SOILS W11?
forthwith cnnrply with such provisienn onhis Nrmit.hull bcdeenedrev.ked. WATER SERVICE
a0
CONS'fRUCT10N LCNOINGAGI?NCY NEW RESIDFJJTIAE,PLMB. SQ.FR I'AIU
L) 0 l hereby affirm that there is a coaamction lending agency for the perrunmen of are tN
the work for which this permit is issued(Sec.3097.Civ.C)
Lender's Name TOTAL:
{I]ULender's Address TOTAL:
�I
E.y certiry mat 1 motored this npnlicutlnn and.floc thvt he above information is BUILDING FEL
V) correct.l agree to comply with all city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT FEE M
V Z building contention,and hereby remain representatives ofmis city to enter upon the SEISMIC FE' V
ahnve-mentioned pmpeny for inspection purp.xes. I
PERMIT ISSUANCE
(We)agree m save,indmnnil'y and keep modes,the City of Cupertino ngainl ELECTRIC F5. it r OEM_
Iiabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MITCH.
in nnsequence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COM WITH ALL NON-POINT AIR HANDLING UNII'(TO 10,000 CPM)
SOURCE RE AT S. MECHANICAL Pii
—� AIR HANDLING UNIT(OVER I0,IK0CFM) CONSTRUCTION AX
Sr turcofAplicion- truaar Dote -( [EXHAUST 1 IOOD(W/DUCT) HOUSINGMOIG 71ili
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future buildingoccupant stnreorhandle harurdous material HEATING UNIT(TO 100,000 B TO
as defined by the Cupertino Municied Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? HEATING UNIT(OVER 100,0010 BTU)
❑Yes ❑Nn
VGNTILA'I'ION FAN(SINGLE kFSIDI PAID
Dote Receipta
-� WIII the air contaminants
or ants a building by the B use Area
Air Qu or Maas which BOILER-COMP(31111 OR 100,000 BTUI
emit hnaard.vs oil conmminnnts us defined by the Ray Arco Air Quality Management T09'
❑Yes L]No Olson", BOILER-COME(OVER 100,000000 BTU)
- .
Ihave rcad,hc hmcookes materials requirement,umier Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCBDTC
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that lithe NEW RESIDENTIAL MECH. SQ.ET.
building doe,mn currently have.tru nl,that it is my re,orobility,,notify the occopam
of the n;eirements which must be met prior to issuance of a Certificate of 0scipaucy.
Owncrrrr m,1m6eed vgom Dan TOTAL: ISSUED BY:
OFFICE