S 0909 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOF CUPERTINO IOMBING-ELEUI Ill I, PERMIT NO.
BUIL NG DIVISION APPLICATIONOTERM IT PLUMBING-MECHANICAL S 0909
m BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION Sl1HMITIAI.DATE
i
so HUILDINGADDRESS:
2v SZ? S S c L �rL -q'
OWNER NAMIi: HONE: CONTRACT OR'S N/�A/ME ���� LIC NO:
OQ 9 1 INS NIC ONTROLN
RCHITECDENGINMEE TICNO: ADDRE'�, �AAq 1 ST ❑
CONTACT: PHONE: I,YT4X.XV l BUILDING PERMIT INFO
/N ❑ Consultant Fees Paid by Applicant(Initial) HLDG LF.CI' PLUMB MUCH
N jo X 89 I ems❑ ❑ ❑
LICENSED CONTRACT ORS DECLARATION QTY FLECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter 9(comm.ncing
0342 with Section of Division 3o Fine Businessman Professions Cade.andtoy licence is RFSIDENTIAI;
Wpp w' PERMIT ISSUANCE
F�Wp in inicenl force PSnd eRemC-y! IrvX 6b ❑SPDWL ❑PLUMBKITCHING EST
rnQS Date b J--'&unutar_ API'LIANCCS-RESIUIiNT1Al. El ADDITION ❑PLUMHING RIiPII'E
ARCHITECTS DECLARATION PANIi1S ❑MUhTI-UNIT' ❑STRUCTURAL
F 7 Z I andershmd my plans shall he..ed as public me d, MODIFICATION
Oz-o UP 10200 AMPS ❑IN'fl?RIOR ❑CHIMNEYRIiI'AIR
Licensed Pool..ianal 201.1000AMPS IMPROVEMhNT C]SWIMMING POOLS
dN�d OWNER-BUILDER DECLARATION OVER IMODAMPS El HSI REMODEL/REPAIR [I DEMOLITION
o C I hereby.(ditto that I not exempt(Into the Contraclnr's License[,me for the
d b W V ❑OTIIIiR
xx 6 following reaam.(Section]Onstr Business and Professions Cale:Any city or county SIGNS ELECTNICAI.
W 3 0 fya- which requires o permit it)re conetmc6 alma improve,demolish,or repair any strned ucture
en,
xot,Ldo pnonnslicenodpurnmm to the lhcuppnsoarn v"mi. toicense de a aw(Chapter9 SPECIAL CIRCl1ITIMISC.
'�wy that he islicenacJpotsuam,othepmvisinnsafNeCnnvacmhLicensel.aw(Chupmr9
Sit:x (commencing with Section7")of Division 3 ofine Businessund Professions Code)nr TEMP.METIiR OR POLE INST. COMMERCIAL,
6 p�M ev
that he is exempt merefmm and mm
e basis Lor the alleged e: nption.Any violation of El NEW RLDG/ADDITION ❑DEMOLITION
W^m Section 7031.5 by any applicant far.ps,art l subject,the applicant t.a civil penalty o1 POWER DEVICES ❑TIiNANT C1 FOOD SERVICE
t mare Nan five hundred dollars(SSW). IMPROVEMENT
REM 01,asowneraftheprol ny.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended(it opered Facile(Sec.7044.Ba,inem - ❑OTIi I?R
W t: and Pvdessinns Code:The Commnorx License haw does root apply m an owner of DU'1'LETS-SWITCHIi' 'Tint
6 3•- property who builds or improves thereon,and who diva such work himself or through
his own employees,provided that such improvements ore nn(intended u,offered for' NEW RESIDENTIAL E SQ FP.
sale.If,however.the building or impmventent is sold within one yearafmntpletion.the SQ.IrI'.I FLOOR AREA 5/SQ.IT
ncnbuilder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
E] 1.as owner of the propcny,am exclusively cormcdng won licenun nmmaetom m —(.;Alai
construct the project(Sea 7 0..Business and Professions CodeU The Cntnrecmls Li-
censeLaw does not apply 10 an owner of propcny who builds or immaves mereo.,and QTY, PLUMBING PERMIT FEE
who contracts for such pmnmts with u eonunetnrfs)licensed pursuant m the Conevewr's
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,H&P C for this reason
Owner Dam
AMFR-DRAIN&VENOT-WAT `/3�
ER(EA) YALU TION
^ ../
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT.PROTECT.DEVICECE .`J
- ,crandyvlfmnumneCinulry onojuryone of the following dc�lWomm.a ns
Cm
Inave and will for 1,naCion I'teaf the Law,ade.forthe Workers Congwh- DRAINS-I'LOOR,It00P,AItIiA,GOND' SgOIt1E5 TYPE CUNS'I'HGCI'SON
smirk, r provided for by Section 3]00 of the Lobar Cade.for the perfnmmnec of the
work for whish this permit is iswcJ, FIXTURES-PER TRAP
jq�hove and will maintain Worker's Compensation Insurance,as rerptircd by Section
3](li the laborCode,far the perfomarce of the work far which this permit is ivnOrd, GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUT' APN
My W..le��(jJ��C��orn r ti:}n ty�carrier and Policy rowtt
Curricr._ (I h,u( aMN Policy No.:�s1 -IGAS-EA.SYSTEM-OVER 4(17A)
CERTIFICATE OF EXEMPTION FROM WORKERS' GNIiASFJINDUSTNI.WASTE INTERCHITOR
COMPENSATION INSURANCE IlUILDING UI VISION IFES
(Thissc,ion nein net heermpletel ifthe pemit is for one hundred dollars($100) Gltl?ASETRAP
or less.) pLANCHECK PiB3
Icerifythm intheperformnceafthe work forwhichthiapemtit is issued,l slmll SIiWf:R-SANITARY-ST(3RM11 GA.2(X1 FT.
not notiltoy any p,ad in vny to norm,m m,vt beennc sulpe�p'h`Wnrkers'Contpcm ENERGY FEL?
Z ration Laws of Califon, WAS PII LL WA'I'IiR HIiATER W/VENT/ELRCTR
z Q Applicant hCL�=aQ;,yQ�•�fj�— GRADING hlili
r Et NOTICE TO APPLICANTI':11,after making this Ccnilicme of Exemption,you should WATER SVSTIiM/IRIiATING
F , became suints,(.,he WnrSores Compennmhon pm ikions of the"hot Code,yon must SOILS FEE.
Wfoohwithcomply with such provisions ar this peourn hall be famed revoked. WATER SERVICE
Q
CONg'TRl1CTION LENDING AGENCY NEW RESIDENTIAIL111. . ' ^'^
SQ.PI'. PAID
L) 0 I hereby affirmmat there is a commseion lending agency font,.perfot �
mmrc of Date p,N
lL F the work far which this permit is issued(Sea 3097,Ci,C.) TOTAL
�],,�,
0 U Lender'.,Name 1 ANSsI'l"
W Lender's Address juN AL:
G Iecnify that l have read this application and state that the abdac Womtetioro is BUILDING PIA:
aF.wy coned l agree to complywire all city and comayordiances radium Laws Matingm .QTY. MECHANICAL PERMIT FEE
UK building eon,auclim,and herchy mother,represmtlmivea alOil city no ane,upon the /' SEISMIC Pi?ii
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertlna against [LEL9'RIC FEE
Iiuhi lilies,judgments,coats and expenses which may in any way accrue ngainu.aid City' ACI'ER OR ADDTO MECH.
PLUMBING 19iE
Aconsequence NNE RSTAN of this p WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00(i MECIIANICAI.FEF:
SOURCE REGULATIONS.
AIR HANDLING UNI'I'(OVEIt IB,IIfXI CFM) CONSTRUCTION'FAX
Signature of ApplicvnuConaanor Dam EXHAUSTIi00D(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant score or handle hmardous material IT RATING UNIT(TO I00,000 BTU)
as deliroed by the Cupeninn Municipal Code.Chapter 9.12,and He Health and Safety
Code,Section 25532(.)'1 [1HATINO UNIT(OVER I W IXXI BTU)
❑Yes $No Date Reacipt M
VI?NTIIATIDN FAN(SINGLE ISs PAID
Will,he applicant or future building occupant use equipment or Jevl.cs which 13f]ILER-COMP(AIiP OR IIMI.q)ll li'TU)
mail hazallous air contaminants as definW by the Bay Amu Alr Quality Management 'TO'1'AI,:
Nunn,? BOILER-COMP(OVER 1(M.000 BTU)
Ej Vex T�lkVn
I have read the hezudoux materials mluimntents under Chapter 6.95 of the Cali- A I R CONDITIONER / ISSUANCE,DAT/E1
Inman Health&Safety Code,Sealme 255115,25533 and 25534.1 understand that Hthe NEW RESIDENTIAL MECH. SQ.IT. /'!1 ^I ops
.f,hengdocsnotcurrcntly hove:mnun6,butt lsnty respunsCeinfintefy thenmmum ,�`/ C:!
afthemquccraaww mal Ip auatmc vCcnificmc offk pagTy. _
OemOrmnuthoned ugenl Date TOTAL: ISSUED B'7 � O
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