S 1231APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-:1IECHANICAL
I4UILDING PROJECT IDEVI'IFICA'FION
PIJ I'l'ls()
1231
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WIELDING ADDRESS
SANITARY
SUBMITTAL DAI'li
12C)5�3 jl'EVEt�s ce8g
:711PLICATION
NI♦ff5 NAMIi PHONE:
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OR NAME LIC
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��a(J fiLICENSED
❑ ConaWlRn/Fees Paid by Applicant (initial)
BUILDING PERMIT INFO'
BL_ I>c Itl.l_iC'I' PLUMB MIiCH
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COWRAC'POR'S DECLARATION
I hereby anirm that I am licensed under provisions of Chapter 9 (commencing
with Scaion ra)0)ofnirision3mfthe Business and rrole..iore Coae,andmylicetnci,
in full foreeanJc et.
1.¢cnrc Cles Lic.aniq
Dam Cnmen
ARCHITECTS DECLARATION
1underhand my plans snail beused as Public me I,
QTY. ELECTRIC PERMIT FEE•
_ -
JOB DESCRIPTION
RESIDENTIAL,:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION El PLUMBING RE-I'IPIi
❑MUTAFUNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑SWCHIMNEY
MMINGREPAIR
IMPROVEMENT ❑SWIMMING POOLS
POOL
El PATH REMODEL/WiPAIR [D DEMOLITION
❑OTHfiH
I'IiRA11T iSSf1ANCE
AI'I'LIANCES-RFSIDEM'IAL
1'ANIiLS
UP 10 AMPS
Line ed l'rofcn,ional
OWNER- BUILDER DECLARA'I'[ON
I bemby nation that I am exempt from the Connaetmr's Licenee Law for the
fichowln 6 (Sees a 70315 Be,iri,,und 11 fission, CAny ) cmnty
wb 1 I p tt t It t'1 1 fit i minorY:tncu re
priolut it,'.' y Tom, Ifte up'licianI II it to fl 'g d'encmem
201-I(XN)AMPS
pyliR 11000 AMPS
SIGNS hhhCl'ItICAL
SPI.CIAL CIRCUIT/ SC.
yW,
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la�p..�
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fit I, fi,in,,c],armantt me,survesions ott Cnurvor s License Law IChapmr9
(ct ar,omng with Seeuon 700T.fDv,ron 3 of the Rosiness unit Professions Code)or
that he is exempt therefrom wd the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permitsubjects the applicant in a civil penalty of
amore than live hundred dollars )BSER).
Q l,,, he vork,tard ropeny,or myempbyeeswithwagesa.Uheirsn 704,1, nattiness
will dnthewons andthe sbuaumare, e,License"femdfor male (Sec. ](1W, easiness
and Rnfessiom code: Tne Contrenors License Law drcs not apply to an owner of
properly xbo builds car improves thereon, and who does mob wad himself or though
his own employees, provided Nat such improvements am nut intended or offered for
sale. If,however, thebuilding or improvement is wild within oneyeatofcompletion,the
'HIMIl Mli'ITS, OR PO '
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION
[I TENANT ❑FOOD SERVICH
OTHER I3MIiN'I'
❑OTHER
POWIiR DHVICES
SWIMMING POOL ELL'CI
OUT 'LfTS- SWITCHES -Fl 'U
NEN' RESIDENTIAL ELECTR Ir
SQ. IT. FLOOR AREA
P'
$/SQ. FT.
owner-builder will have the burden of proving that he did not hadit or improve for par-
ped r ),
Los invoca Ili the EcurFori, are exclusively t t k with licensed contractors to
PNI I�
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T(GAI.:
...... tona 0he pro,rcl (Sec. 7044 Bmam, and 1 . Col,)ILTo, Cearrair, Li-
c I in a,p,t f property 1builds-ourprovei thereon, and
con'.
1I'tC/ 1�1Mis
QTY PLUMBING PERMIT PEE
who wnuds Ramith projmu wim.eo muco nOloc ...I ptrmanO he Contractors
License Law.
(tan exempt under Sec. ,& i' C lar this n
[:]Breaso
b L 41�
�f LU�..r
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PERMIT ISSUANCE
Owner Dam
ACFEN- DRAIN&VENT- WATHRGA)
VAIUATI
2 5, GCS
WORKER'S COMPENSATION DECLARATION
HACK FLAW PROIT.CT. DEVICE
I hereby affirm under p mid, of perjuryaneof the following decimeters:
s have and will maimutina CeniOcate ofConsenno mlGinsure for )Yorkers Co.. pen-
dation, av provided for by Section 3700 of the Lobar Cala, audit, performance of the
DRAINS- FLOOR, ROGER AREA, GOND'
510RIIL5
TYPE. CONSTRUCTION
work for wbich this permit is issued.
FIXTURES - PER "FLAP
x
0 1 have and will maintain Worker's Compensation Itnurarm, as required by Section
37N)ofthe 1.ulna Code, for the performance of the work for which this permt is issued.
O C. GROUP
APN
GAS -PA. SYSTPhil INC. 4 OUTLETS
My Came,^� /�On s''1'�Imumncecartierolicy Nnd o, tytgt� :2pao
FI�y Policy Nn:_1ri if
GAS -13A.SV5'rCM-OVF.R4fEA)
�7l6p� ClilijjFICAIT OF E%EMY I' ION I ROME WORKERS'
WMr COMPENSATION INSURANCIi ,'�'
GRhASI➢INDUSTRL WAS "T131N'I'RI<CI3PIUIt
lit I ILOINGDIVISION FRES
(Ibiesca inn nein nal be co.nplemd if hi,ennit is for one ITT dreddolte,01100)
orlces.J
GHI?AYIJ'HNP
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PLANCHECK 1403 RL
SII\VER-SANITARY-STORMI?A.2001'r.
I rorlf, that intheperformanecnf the w... ko"Inchu,penniO,rsed.Ishall
not employ any person in any mmmner so as m secane subject to the Workers' Crimper-
ENERGY PRE i
WATER IIRAIER W/VENTMLECTR
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Wforthwith
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dotinn Laws of Calibomio. Dam
Applicant
GRADINGFEI3
NO1'LCH TO APPLICANT. If, after making this Certificate of Exemption, you .Mould
hecnme subject to the Workers Compensation provisions of the Labor Cale, you must
comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance ofU.
the work far which this pert is issued (See. 31X)7, Civ. C.)
ermi
Lend's Nome
WATIIR SYSTEMRREA'1'ING
WATER SERVICE
SOILS FISH
A
on
PATO Date Receipt a
Ri t
P
NEW RISIDI3NTIA1. PLMB. SQ. PE
TOTAL:
I.cader's Address
TGIAL:
BUILDING FI113
I cent), he 1 have read this applicutina and sone Our the above Intellection is
con,ca, I ogre. m comply with all it, and coamy ordinanum, and into law, relating to
building consumer n, and omhy aomerimm,mann idvesol Otis city toca,,t,antho
-
Q'PY. MECHANICAL PERMIT' FEE
SEISMIC FEE
PERMIT ISSUANCE 4
ELECTNIC ISP.:
chosenncndoned Property fmTimpemion porpom,.
(We) agree to save, indemnify and keep harndces the City of Cupertino agalnxt
AI.TI:R OR ADD TO MECH.
PLUMRINGI iE
Infliditics,jidgtnents.minOted expenses whichatay funny way accmeagainvwid City
.in consequence of the granting of this pemtit.
HANDLING UNIT (TO 10.000 CITAD
h1ECHANICA1, Fc '
APPLICAN11 UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAIR
$OUHC[%1!�LAGONS.
AIR I(ANGLING UNIT 10.000 CFM)
CONSTRUCTION TA'
Is,KK �'
U 4 J
.�
Si,ruftmof AP I Date
H ZAkDOUS MATERIALS DISCLOSURE
RKIIAUST HOOD(W)DUM)
HOUSING MI'f1GATio FEE
I ITAING LINE 'LOO I OQWO BTU)
Will the applicam or fuore hullding occupant dom or handle hawNous material
ue delined by the Cupertino Municipal Code, Chnpmr 9,12, and the Health and Safety
Cade. Section 25532(x)']
IIRA'i'INC, UNIT (OVHR 100,000 BTU)
F'1 Ye, El No
Wit The uppliOnt or future humb ing oecupmu use equipment ordcvice, which
tricolors at, contaminants as defined by the tiny Area Air Quolhy Management
PAID
Doc ks cipl8
VIiN'I'ILAI 'ION FAN (SINGLE ItESID)
BOILER -COSJ I' (THP OR IfIg000 BLUE
BOILER -COMP (()VERB IIX),IXX) BTU)
District?
❑Yes ❑Nn
it
AIR CONOI'HONER
I have mad the ltazvdons materials requirements under Chapter 6,95 ofthe Cali-
ISSUANCE, DATE
NEW RP_SINiWIAL MECH. SQ. IT.
Leath Heath & Safety Code, Sector V305, 25533 atW 25VO 1 understand that if the
building Joos not currently have a tenant, Nat it i, my mspmsihility m notify the o er,com
of the triplication, which must be it prior m aster a of a Cenifcme of Occupancy.
'TOTAL:
ISSUED Ii Y:
Owner or autborieed agent Dam
OFFICE