S 0895 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUILDING-ELF.0 I'RICAE PERMIT NO
BUILDING DIVISION APPLICATIONMERMIT PLUMmrvG-Mb:cunNlCAI. 5 0895
BUILDING PROJI:CJ'IUF.MI'IF'ICATIIIN
BUILDING ADDRESS: / SANI'1'ARV NO. APPLICATION SUBMITTAL BAIT
( NER'S A I'HONIi: C ACJ'(lR'S NAME:
ISO,
NIC CON"IROLq
• A HITGCf/ENGINIiIiR: LIC NO: ADDRESS: ED
CONTACT. QPHONE: BUILDING PERMIT INTO.
SJ-,&A-A— ,�-- l ua qg6 +qtc Consultant Fees Paid by Applicant(Initial) BI.I Ii1.1❑'Ar PLUMB _ MECH
LICENSED CONTRACTOR'S DECLARATION QTY I FLECTRIC PERMIT PEE
I Immhy affirm(hut I am Iiccnsui under provisions of Chapter 9(commcmcing JOB DESCRIPTION
OCO wifulfortcevalU)or'Uivisiun}of)hq'IProfevypnSUiN� n E
WO '�,Y Lx PERMIT ISSUANCE
W F m WL ❑KITCHEN RIiM(Illlil.
aVV Liccme Class Li,N
APPLIANCES-RIiSID1iN'I'IAL ❑AUDI T[ON ❑PLUMBING R17 PIPE
I--'ZW Dole Commctnr
rn<a ❑MUUI'I-UNIT ❑STRUCTURAL.
F,Cy HITECTS DT:CLA PANELS MODIFICATION
ZO,�Z IunJ lis m pans shall be usul os public records UPT02OOAMPS cz-p F1 INTERIOR El CHIMNEY REPAIR
W Licensed Prnfessimml 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION EVERi"AMPS ❑HAI TI REMODEL/REPAIR ❑DHMOI-ITON
C w< 1 hereby affimt that 1 am exempt from the Contractors License Law for the
ape,,OEU following umor.(Swtion]031.5.9mim.and Professions Cale:Any city.r county SIGNS ELECTRICAL ❑OTHER
al a W 1Na"' which requhes a permit fo venarum,alter,improve,demolish,or repair any Merclure
FLLO.] priormin issuarece,also requirmthe applicant fursuch pemiiuofileasigned statement SPECIAL CIRCUI'DMISC.
that he is licensed pummnuothe provisions.(the Conmmcme,License Ease(Chalm,9
W pO (commencing with Section 7000)(f Division 3.f Ne Business and Proessimw Code)or TEMP.MCI 17R OR POLE INST, COMMERCIAL'
Wy o that he is exempt Ihenefmm and the basis for Ne alleged exemption.Any violation of ❑NEW BLDGIADDI'FIGS ❑DEMOLITION
WMtib Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES ❑TENANT ❑Fool)SERVICE
F,yq .t more than five hundred dollaa WW). IMPROVEMENT
TQp Las owner of the propea....or employees with wages as theirs.le compensation, SWIMMING POOL ELECTRIC
(.. willdeflcwork,and thesrurt
udis Bol inmlWed nr oRemd l'ollee(See.]03q,Business OTII-R
63� and Professions Cale:The Contactors License law does not apply to an owner of OU 1'LITS-SWITCHES-FIXTURILS
pr.perty who builds or improves thereon,and who does such work himself or through — —$ �
his own employees,provided that such improvements are not intended.,offered far NEW RESIDENTIAL ELEC'I'R SQ IT.
sale.If.however,We building or impmvenmm is sold within one yeurof complminn,We SQ.IT.FLUOR AREA StSQ.IT
,oner-builder will have the burden of proving that he did not build or imprnve for pur-
aa of arae.).
1,rvs owner of Ibe prnperiy,ran cxclunivulY cmm�sdng with Ikunsed a. TOTAL:
mnswenhe proj Y(Sec.]IW,9uslness and Profestoons Cnde:)'fheComaue(oraLi-
cerise WwducsnutHoPlytoanawnerofPropenywhobuildsorimprovesdromon,and QTY PLUMBING PERMIT FEE CEIVE
who Contracts fursuch projects with a commands)licensed pursuant to the Comracmrs
License law. PERMIT ISSUANCE IEC
Cl+/1 O
❑ I am on exempt under See ,B&1'C for this reason / 3
ACI"ER-DRAIN&VENT-WAq'ER(RA) VALUATION
Owner Date --113y:
WORKER'S COMPENSATION DECLARATION HACK FLOW VROTEC'1'.DEVICE .[
• I herchy affirm ander Penalty ofpepuD one offle following decimations:
❑I have and will maintain a Certificate of Consent to self-insure far Worker's Compel- DRAINS-FLOOR,RO(IR.AREA.CONE' DNS'1'R UCI'loss
satin as provided far by Section d
ion 37M of the Lar Oe,Bonne performance of the STORMS
work for which This permit is i.smi FIX'I'ORES-IT R1'RAP
1 have and will mai main Worker's Compensation Insurance,as required by Section )
J n aMr Cn e,For the Pe mace rL the work for whichthispernnjisissued. GAS-EA.SYSTIiM-I INC.<OUTI.E'Lti OCC.GROUP APN
MyW rkh' M1 ion lnsnr a 's dP.licym (SIIoil
VC
Corrin, idt Nn.: GAS-BA.SVS'1'EM-OVI'Rq(EA)
CERTIFICATE Oit EXE ION I7RO WORKP.RS' GRI3ASEINDUS'1"RI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PERS
This sectionnad n.Ibec.mpleted ifthepermil isforonahundrecidallurs(5100) GREASETRAP nr less.) PLANCHECK FEE
I verify that in the performance all the work for which this Permit is Elrod,I shall SEWER-SANITARY-SI ORM EA,200 FE
not employ any person in any manner so as to become subject to the Workers Compen- ENERGY FEE
O z smiaa Laws of California Date WATER 1117AI ER W/VEM➢ELECL'R G
O Applicant RAVING FEE
NOTICE ID APPLICANT:IL after making(his Certifiene of Exemption,you should WATER SYSTBM/IRHA PING
become subject to the Workers Csnnpensmion provisions of the Labor Cud,you must SOILS]:HE
forthwith comply with such prwisions orou,pewit shall W deented revoked, WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.'LMB. SQ.Ie1L PAID
UZ I herebyaffimuhalthere isacomnmaion lendingagency hrrtheperfuwance.f Date Recc' tp
U O the w Inr which this pewit is issued(Sec.3097.civ.C.) inn
W Lenders NameT AL:
LU Lenders Address TO I'AL:
11....tt fy 1 cmify that 1 have real this application and..ate that the aMwe information is NUILDING FEIe
fir In
comm.Insole to cmnply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U x. bnildingconsuucti.nomdherehy ouNorizs,mpomianu(ivcs offhis city memo upon the SEISMIC FEE
above-nmntioned papery for inspection purposes. [']:JIM] ISSUANCE
(We)agree m save,indemnify and keep bowies,the City of Cupcnina against ELECTRIC IEE
liabilities judgment,costs and expenses which may in any way accrue against said City ATTER OR ADD TO M ECK
in c.nscquence of the journal,or mi
this pert PLUMBINGFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UND'(rO IQ(RECFM)
MECIfANICAI.FE
SOURCE REGULATIrDNS.
/ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sign ure.f Applican omactor Date EXHAUST HOOD(WMUCI) HOUSING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store Or handle hazardous material HEATING UNIT TO 100.00 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Hcallh Imd Safely
Code,Section 25532(x)? HEATING UNIT(OVER If id,00n.ITU)
❑Yes Fl No PAID
VENTILATION FAN(SINGLE RESIU) Dote Receipt#
Will the applicant or fuwrc building occupant can equipmcnl or devices which BOILER-COMP(3HP ON IIX).000 BTU)
emit hmmdous air contaminants as defined by the Buy Arlie Air Quality Management TOTAL-:
I District? BOILER-COMP,(OVER 100,000 BTU)
F-1 Yes El No
AIR CONDITIONER
1 have read the hazurdnus materials rtquiremen(s under Clelpter 6.95.E(he Cali- ISSUANCE DATE
fornia Health&Safety Ctde,Sections 25505,25533 rand 25530.1 mdemmnd that if he NEW RESIDENTIAL MECIL SQ.Fr. /9 _ � /` . 9 7
huildmg d�csn.(currently huvcn mount,thin h is my o"'and"'hy utnlifythc asman" ( F l
of the requirements which must he met prior to closure of Certificate of occupancy. .��)�'''
Ownerarouthurizcd agent Ilam TOTA ISSUED BY: I" gpr� 4 ^ To
OFFICE