29270APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE SALL'P.OINT PEN ONLY '
COPY OF CUPERPINO - .1JR.urrve-BLh.1 IH Al reamu rvo. ^ ^ O
BUILDING DIVISION APPLICATION/PERMIT PLUM BINC.. MECHANICAL LL
giffli
ADDRESS:
❑ Consultant Fees Pais) by Applicant (Initial)
�`2IS.
aZ
00
RF.VZU
LICENSED CONTRACTORS DECLARATIONQq'y.
I hereby offtnt that 1 out licensed made, provisions of Chapter 9leminnancing
wd y
th Section 70001 of Uivmsion3 al dhc Rosiness and l'rtdessi is0111 dro Ilccmeis
i run fume and effect.
License l.ic.p
Date Cnmraam�Lu.
ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
CSFDWI,ITI C KITCHEPLUMBINREMODEL
[]ADDITION ❑PLUMBING RE -PIPE
r PERMIT ISSUANCE
02
APPLIANCIS-RFSIDIiNT1AL
VIQ�
�'
Fah
Z O - z
- ARCHITECT '9 DECLARATION
I uneermane my plans shall be accedes public tis
,tes
C1 STRUCTURAL
MODIFICATIOO N
MODIFICATION
PANELS❑MULTI-UNIT
-
oz—
DgI
UP TO 200AMPS
INTERIOR El CHIMNEY REPAIR
MPROVEMENT
❑ BATH RF.MODEIJRF.PAIR [I DEMOLITION
C OTHER
1"'
O y U
Licenser Professional
OWNER -BUILDER DECON
1 hereby vfnrm that 1 nm exempt from thee Contrawnr's License law for the
Contractors
fallowing reason (Senion 7031.5, Business and Professions Code: Any city or county
201-1000AMPS
OVER DMAMPS
I
SIGNS ELECT RICA).
'3 4 in
F'u'Oa
P� DO
t1yi5 n a
W^m
[-ZY
p q
y^S)
�' ..
which r,gmims a pemtit to conwoun, alter, improve, demolish, or repair any sticture
poor to Bx issuance. also requires the applicant for such pemtit to file u.smgned statement
that he is licensed peaccal to the provisions ofthe Contractors License Law (Chapter 9
(commending with Sedimn 7000).f Division 3 oldie Busineamiri iddes,imoiCodelor
shad he is exempt therefrom and the hasis for the alleged muni,dinn. Any ,,,Indian of
Station 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not mom than five hundred dollars (t500).
I]Laauwner. the pestood oemyemntended widhwagesutheir soleco4, Bushes,
wdl Jn thnsooda and the far mare ncloonot' skins I.mv rud for e,.,itle (Sea In in, Rosiness
and Pndeseians Code: 'The C.nlrnetur'e License Law does nal apply da un owner of
s t and win dies such tinte himself on through
win builds or sided
SPECIAL CIRCUIT/MISC. '
TEMP. METER OR POLE
COMMERCIAL
❑ NEW BLDG/ADDITION C DEMOLITION
tT&NANT EI FOOD SERVICE
IMPROVEMEI�'T
�`/p'/RT- CA
❑OTfIGR V♦
POWER DEVICES
SWIMMING POOL ELECT!
OUTLETS-SWI1'CI31IS-PI
his own
his own employeese building drat such
t such improvements ere not intended or offered for
NEW RESIDENTIAI. F.LIILTR F
old the
man If, however, lhhavethe burdng or en
n of ithat hddwithin are yemt improve
'wee will have the buNen of proving tiro he did not build arimpnrvoIns bur-
SQ.IT..FLOORYpR�
4+i 1 CN
$/SQ. Fi.
if sole.)
Pmc if
,
TOTAL:
❑'Las owner of the propery, am excessively dm[mrins Cod1 licensed aommresa i-
cense the n, Businesseofand
not (Sas CmkU The Contmaon.
JAN 25
La es o a y who bud
Law does not apply m an owner of progeny who builds or improves lheram. and
rid
Q Ty. PLUMBING PERMIT FEE
1996
W M1II contracts for such projnet4 W ITh a {'AnL2Clor(FJ licersedparationt l.lM1e ConiNelors
License !.use
El I am exempt under Sec. ,B&PCfonhivresum
^I��
G Ur kluf'LFII IND
PERMIT ISSUANCE
ALTER - DR
BACK PLO
_
IN & VESU`- WATER (HA)
PROTECT, DEVICE
Owner Dede
WORKER'S COM PENSATION DECLARATION
I hmeby affirm under penalty of perjury ora ol'[ha following Jeclemdnm:
VALUATION
\
DRAINS -FLO ROOF, AREA. COND.
❑Ihavc sol will maintain eCenifcam of Consennn self -insure far Workers Cmnpen-
sation, as provided for by Section 3000 of the Labor Code, for the perfonn,nce a( the
STORIES
TYPE CONSTRUCTION
TI=RES RAP
work for which Nis permit is issued
have snit Will meirtain Worker's Compensation Intimate, as terminal by Section
011o1'the Labor Code, for the performance ofdhe work for which this Penn![is Issued
My Woryee's Compensation mormaecaniermdPolicy
numbe.,
OAS - EA. SYS'r NC. 4 OUT Li:TS
OCC. GROUT'
APN
Ca,rmcc (•'� Policy No
GAS - EA.SYSTEM-O IR 41FA)
- CERTIFICATE Or 1. EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhieaedionncodno[ be completed it ml pwnnid is for one hundred dollars l$1(Ilps,
or less)
GREASMISDUSTRL WASTE/ TF:RCEPfOR
BUILDING DIV ION FRsS
GREASETRAP,,
PLANCIiIiCK FEE /
SEWER -SANITARY - STORM RA. 211(1
'
Z O
Ioyainy Naanin any manner sin s, tWmk fns subject to themitisiss'Con,aall
not employ any person in any manner m as to become subject m the Workers' Cumpen-
amiolr Lw s of Califomia. Date
icant
a
ENERGY IN
WATER HENIER WNENT/ELECTR
GRADING P
NOTICH TO APPLICANT: If, after making this Certificate of Exnnption, you should
become subject to the Workers Compcvsation provisions of the Labor Cade, you must
fonhwidh comply with such provisions or this permit shall be denoted revoked
_
GONSTRUCLION LENDINGAGENCY
WAFER SYSTEM/PREATING
(A
a;
ow ca
SOBS FEE
WATER SE RVICE
PAID as
NEW RESIDENTIAL PLMIL SQ. FT.
U O
1herebyaffintthanhe.is. m:mdmrinn lenaingogenvy liv ase performance of
Recemptk
P. t•+
O U
the work for which this Permit is marred (Sec. 3097, Civ. C.)
Lenders Name
TOTAL:
Address
TOTAL:
iULender's
Or
BUILDIN( E /�
1 certify that 1 have read this application and stoma that the mare infotvuttimn is
Q'Iry, MECHANICAL PERM 11' FEE
N
U i_:
correct.I mo. 1. comply with all City and a ... lyordinances snit ante laws relming to
building construction, and hereby autumn representatives mod, city to ender u Pm the
SEISMIC INE
,hove-nenrioae l pmpeny for inspection pudposec
(We) agree ns rove, indemnify and keep harmless ry o
tless e Cif Cupertino against
PERMIT ISSUANCE
ELECTRIC PEE
� viry way t¢ctvc egainm snit City
cn o 'g Penni!.
Iiahilidicx,juJgmema, roaOND
g1.TER OR ADU T'O MECfI.in
PLUMBING INE
AIR HANDLING UNIT(TO 1n,(pU CFM)
A LICANT 'D WILL CO 'LY 'H ALL NON -POINT
S 'RCER LAT1
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,000CFM)
GON$TRLILTIDN TAX
Sign r n ontrar0 Data
c HAZARDOUS MATERIALS DISCLOSURE
EXHAUSr'HOOD(W/DUCT)
HOUSING MITIGATION
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant orhandle humorous material
defined by the Cuptoom Municipal Code, Chapter 9.12. and the Health and Safety
ode, Section 25532000
HEATING UNIT (OVER 100,000 BTU))
❑Yes ❑Ns
Vile the applicant or future building occupant use equipntem or devices which
'.hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
PAID
Dam Recei
VENTILATION FAN (SINGLE RESID)
BOILER- COMP QHP OR 100,000 BTU)
TOTAL:
❑Yes C] No
BOILER- COST(OVER 100.000 BTI)
CONDITIONER
1 have des[ the henNoas mater aii,AIR
requ'vements under Chapter 6.95 of the Celi-
forma Heahh & Safety Code, Sections 25505, 35533 unit 25534. 1 undooment that if the
buildingdoeshad munendy have. tern,that it ismycespar,Nlity in notifydie'.r ,at
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
of the requirements which must be met prior to issu: nce of a Cmturwe of Occupancy.
ISSUED BY:
Owner ar euNorized,gend Dare
TOTAL:
OFFICE