S 0021 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-MEC MECHANICAL
PEkMIT NO��
BUILDING DIVISION APPLICATION/PERMIT PLUMBING
OJECT IDENTIFICATION �.wna� 1
BUILDING PROJECT IDENTIFICATtDN
BUILDING ADDRESS: O , SANITARY NO. APPLICATION SUBMITTAL IlA'Pf
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gIyfN i PHO CONTRA 'S N 1 LIC NO'. c �q
Std �A, _ - /�7 NIC CONTROL#
ARCHITECT nPI GINEER: 'tel LIC NO: `•F- DRP?:7 ❑
CONTACU PHONE: BUILDING PERMIT INFO
' ❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of chapter 9(commencing . . _ JOB DESCRIPTION
�04Z with Section'IDW)ofDiemen Sof the Business and Professions Cade,suit my hopmeis pERMI'f ISSUANCE RESIDENTIAL:
.F W r bob fail forceas,a5n,d.��ef�fect. � ❑Slim. ❑KITCHEN REMODEL
UV 4censcC" '/ Lic'N APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
P.ZW Lice Lic.at ter
ARCHITECPSDBCIFARATION ❑MULTI-UNIT ❑STRUCTURAL
E,lD. PANELS - MODIFICATION
1 understand my plans heart housed as public words
OIZ UPTO200AMPS El INTERIOR [I CHIMNEY REPAIR
Licensed Professional 201-IOMAMPS IMPROVEMENT E]SWIMMING POOLS
Pd 1- OWNER-BUILDER DECLARATION OVER IOOOAMPS ❑BATH REMODEUREPAIR (]DEMOLITION
y%W< I hereby affirm that I am exempt from the Contractor's Liceoe Law for the
X O G O following reason.(Section 7031.5,Business and Professions Coda Any city or coma SIGNS ELECTRICAL ❑OTHER
W W m which requires a permit m construct,alter,improve,demolish,or repair any swcmre,
Q prior to lh iaauance,also rcgdires the applicant for sucepermit to fileasigned statement SPECIALCIRCUIT/MISC.
pi"a that he is liwnsed pursuant tome musfiom probe Computers Lie,um Law(Chapter 9
LL' Q (commencing with Section 9000)of Division 3 of the Business and Profesmpo Ceme)orENEW
ER OR POLE INST COMMERCIAL
thin he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Int%7 yWj Section"I03L5 by any applicant for a pcnnitaabjens Ne applrcum to a civil peunity ofPOWERVICE' ❑TENANT ❑FOODSERVICE
not more than five hundred dollars($5(10). - IMPROVEMENT
gFqZd D 1,as
owner of the refinery,or my employees with wasn't,their sal,compenicurou, POO RIC
2�0 wJl do the work vnd the strucwrels nm imm�dedomffereA for sole(Se.9044,Bmidese ❑OTHER
�, m and Professions Code:The Carbonate's License Law does not apply to an near ofSWITCHES-FI RES
property who builds or improves thereon,and who does such work himself or through
his own emplayees,provided that such improvements are not intended of offered forENTIAL R Q UIL
sale.If,however,the hiilding or improvement is sold within one year ofcompletion.the S O R G $/SQ.IT.
pncmer-huilder will have the burden of proving that he did oat build or improve for pur-
.of
[-]I,as owner of the property,am oxelasrvely enameling with licensed contractors to I
TOTAL
MAY 11 REND
co
obstruct the projmt(Sec.9044,Business unit Professions Cale:)The Cmareaunf,Li- -
cwhse Law does not apply to an owner of properly who builds or improves thereon,and QTY,; PLUMBING PERMIT 'FEE
ocontrics forsuch primmus with accouramr(s)licensed pursuant home Gmtraetors - 04 Y(If uurwimc)
License Law. PERMIT ISSUANCE YAI� Y Y41_I _pl✓
❑ 1 am exempt under Sea. ,B&P C for this reason
ALTER-DRAIN& (E
VENT-WATER A) VALUATION
Owner Data
WORKERS COMPENSATION DECLARATION PACK PLOW PROTECT DEVICE
1 hereby affirmm underunder peaky of perjury,one of the following decimations:
•�m,as andwledto,by Sector.3700
of Con senna selfb,in,t fogWmker's Camped- DRAINS-FLOOR,ROOF,AREA,[OND. STORIES TYPE CONSTRUCTION
work f as hick Chi[or by Ss issued.
3900 of obp Labor Code,for the performvnee of the
work far which this airanie:.oral. FIXTURES-PER TRAP PA
❑ I have Li will main min Workers mance of thi w rk for.fu eon required by Section
J900 of the Labor Cade,for the performance pfihewark for which this permit is issued. GAS-EA.SYSTEM-I INC.4OUTLETS DCC. � }p APN
My Workers a carrier and Policy Further are:
Came,�t� IF �mnr Policy N.: GAS-EA.SYS'TP.M-0VER4(EA) ,y^.
(�CER�TIFIC�ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASE/INDUSTRLWASTE INTERCEPTOR DIVISION 'S
(Thisscenon deal not hewmelved iDhe permit is Parma hundred dollars($100) GREASETRAP -
me less.) PLANCHECKPEE "ANO
I certify that in(he pcar munoe of the work for which Was permit..issued,l skull SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any manner so as to become subject to the World rs'Comped- ENERGY FEE
Q Z sation Laws of California.Date WATER HEA'1'BE WNENT/ELECTR GRADING PCE
y 0 Applicant 1
7 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
become eobject to the Workers Campeactina provisions of the Lahof Code you must SOILS FEE
Wforthwith comply with such provisions or this permitxhall one deemed revoked. WATER SERVICE
Q
a' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL U PUMP. SQ.FT PAID- Date Receipt p
I hereby vfl7rm thus there is a wnswe0on landing agency Porthe perfomm�cppf
the work for which this permit i.issued(Sec.3097,Civ.C)
�' Lenders Name TOTAL,°
Lenders Address T BUILDING FEE
1 eealfy mat I have read this application and state tem the shove Infommtion is
In correct.I agree to comply with all city and county ordinances and.state laws relining to QTY, MECBA ICAL PERMIT FEE
U Z building ame,mctim.ard hereby authorize reprcaemmives oflhis city to onto,upon the SEISMIC PEE
'--r above-menlional property for notation purposes. PERMIT ISSUANCE
(We)agree to hindemnify and keep hunnlese the ty of CupuNno against
ELECTRIC FEE
ave C
liailifes,judgmems,come and expeme,which may in any way acerae uganmsaid City ALTER OR ADD TO MECH.
mnmmumn,of the gnmting of this proud. PLUMBING FEE
tAPPLICAN'T UNDE STANDS AND WILL COMPLY WITH ALL NON-POINT AIRHANDLING LINIT(TO I0,000CPM)
SOURCE REGUI ONS. MECHANICAL FEF.
AIR HANDLING UNI'P(OVER 10,0100 CFM) CONSTR [:CION TAX
ignorer paha VC for Date EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
IIA DOES MATERIALS DISCLOSURE
Will the applicant pr future building compet store or handle hazmdouh material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Hculth vad Safety
Code Section 25532(x)9 HEATING UNIT(OVER 100,000 BTU)
❑Yes FIN. VENTILATION FIVE(SINGLE RESID) PAID "-
Uma keeeipt p
Will the applicant or future building occupant use equipment or devices which
1 emit hazardous air confirmations as defined by the Bay Area Air Quality Arrangement BOILER-COMP(3HP OR 100,00013'1 U) TOTAL:
Dis¢jet! BOLLER-COME(OVER 100,000 BTU)
❑Yes E:1 No
AIR CONDITIONER
I have feud the h odNeF tions 2 is requiremenn under Chapter,understand
of the Cali- ISSUANCE I
fomiv Health&Safety Code,Section 25505,is,and 25534.1 u hard,the
that if the NEW RESIDENTIAL MECH. SQ,PI'. /��✓/
building does not currently have a tenant,that it is my responsibility m notify the occupant
of the requirements which mum he at Eno,ho issuance of a CmaGeme of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:'
OFFICE