S 0168 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ITU I[.DIN1:.ELF.C'I RICA], 19i$`, lT NO.
BUILDING DIVISION APPI,ICATION/1'FRMIT 1'LOMBINf,-MECHANICAL v 0168
IIUII,1)ING PROJECT IDF.M]'IFICA'1'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITIAL DAT
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UW BNIS NAME,: PIIONET CONI RAC OR:S NAME: LIC NO:
Z NIC _C<'
RECT/13 GINEEN: LIC NU: ADDRESS: El
CONTACT: PHONE HUILUING PIiRM1T INFO
S-1-1 r ❑ Consultant Fees Paid by Applicant(initial) .Dr, e1.ECT PLUMB MECH
I
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am liccnsw ower Wovislnns of Chapter 9(commencing
woJOB DESCRIPTION
withScetinn ANXq of Division]oftheHm'inass and PrnfessinnuCwe.and my licemeis P 1
W p p PIiRMIT ISSUANCE
Fy•ly= in full farce and effect. 'DWI. ❑KITCHIiN REMODEL
QUU License Class I.ic.p APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBINGRE-PIPE
F-Z(y DUE Commeoul
tnGa Em
ULThUNI'1' ❑STItUC'IURAh
Fpy ARCHITECTS DF.CIARA'TION PANELS MODIFICATION
zo�z Iunderstand myplanashall bemwd.spublicmvmds UPTO21X1AMPS
INTERIOR ❑CHIMNIiY REPAIRp2.N.
FBF-I�il Licensed l4olBmiomd 201-1000AMPS 1 IMPROVEMI?NT 0SWIMMING POOLS
O R13UH. DE S; ❑BAT'HREMOI /REPAIR ❑DEMOLITION
C C Q 1 hereby affmn that ata cxcmpi G or If a for '
3 following Aeon.(Section tB?L5.Hnsina mfc. ro'C ci SIGN. LEC lAL ❑DTIIEI'
y which require a Permit m Eow_n c, alter,t Ove,d re r a 'r coon /
0< prior m its iwuancc,nLsnrc ulrax th .tpphe such tle inn iC .CBC /mISC.
HE;!(y ma he is licensed most, I eche vision t on ms's Licen a 'lapse COMMERCIAL'
MO (co mmccem',vitbseainn B less and Pr si C O TEM IETIi RPC[ L T.
d e C that he is exempt therefor or the xemption ny slatinm ❑NEW BLDG/ADDITION DIih101,1'fION
I vi Section 7031 5 by any applicant for u pcmtit wbjxcl,the applicant m u civil penalty Of POW M : ICE ❑TENAN'T ❑FOOD SERVICIi
not moa than five hundred dollars($500). IMPHOVIiM M
Sp ❑ Las owner ofthe property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC El OTHER
F• will do the work,and the swcture is not intended or offered lin sale(See.TBM14,BU.aness
L 3
and Prolecsiens Code: Me Contranors License Law does not apply to an moner of OUTLETS-SWITCHCS-FI%TERES
poi who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEN'RESIDENTIAL M ECfR SV Il'.
e. w
If.hxvef.the Molding mimpmvcaut issold within one year N'completou"Im Sp.PT PLOON.HIiA EISV.FI'.
sal
owner-lutude,will have the burden of proving that he did not build on improve for per-
pose of salt.).
❑ I,as owner of the property,am exclusively contracting with licensed auntmcmrs In
onswct the projects,(Sec.]M4.Business and Pmfeaions Code:)The Cc 1mcl r'a Li-
scLow,does not apply mxo mvncr of propeny who build-,netanves,lomm.and QTY. PLUMBING PERMIT FEE (/
w�hmomruca far each pmjeK with a rnmmanas)licensed purs.an,o the Contractor's
License law. YIs _ q PERMIT ISSUANCE
❑lamexemptu rSec Yh 0. 6 B&PClnrmNmamn
ALTER-DRAIN&VENT-WATER(EA) VALUATION
737Mo°w°` — G�
WONK COMPENSATION DECLARATION RACK FLOW PR(IIECT.DEVI
I hereby affirm and hen ty of perjury one of the following declamtiom. 4-
IhaveandwillmaintainaCcnilicut.of Counwnttoself-i.xurc for Workces Conifen- DRAINS-IB.00R, ,COND. STORIES TYPE CONST RUCOO
l
ion,as provided for by Section 37W of the Ia1nr Code,for the i—iota...of the
rk far which this permit is lamed. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
the Lafsa Codef...the,eflor...nccuf the waak far whichnhis permit i-vued, GAS-EA.sysm 1 :TS J OCC GRO AI;N
yWmkeis Crimpe..Uion lmmence came,inl Policy numberm: GAS-EA.SYS :R4(Iirrier: Palley No.:
CERTIFICATE OP EXEMITION MOM WORKERS' GREASFIINDUS H'p5ylt EPrOR
COMP13NSSI'MN INSURANCE B .I .G DIVIS N {IS
(Thissection need not becompicUdi ifthn permit is lir one hundred dollars($100) GREASETRAP
PLAN iC 'IiE
or less.)
Iceni fythainthll any umurrof,,,become
mefor whichthi,,permilis filled.C upro.I hall SEWER-SAN]I'ARY-$lT)RM PT.
not employ unY person ill any mnnnersn aµmhenma subjestmma Worked Cnmpcm ENIiR IlSE
Z satin.laws of Cali fomia.Date WATER I WATER W'NEN'I/ELl=R GRADWG PI3:
Z O Applicant
;:y NOTICE TO APPLICANT:IL after making this Ccrificate of Exemption,you should WATER SYSTEMITREATING SOLI S THE
fheroine subject m Ne Worker's Contpenmeon pmvisianx nl me[..hot Code,you must
rforthwith comply wimmch pmvisians or this permit shall he deemed¢vnkcd. WATER SERVICE
0PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENAL.PLMB. SQ.ITT Date vqA
C].1
Ihereby aff mlir rfm
at there is a constmetion lending agency the rcnamce of
U 0 the work for which this pcmtit is i..ued(Set.409],CO.CivC.)
Ol'AL:
U.Q Lcndcrs Name
T WLcndcrs Address BUILDING PEI;
ll I certify in.,1 nave rail this applu,nom and state that the above mfnntntlon is w,
F fA coined.1 agree m .,up with all city and county ordinances and slate laws minting to QTY MECHANICAL PERMIT FEE SEISMIC FEE; V
U Z building comtmclan.and hereby awlurlmrepresnnatives of this city m enter upon the
.hove mentioned pmpcily for impcmilm ptopn¢s. PERMIT ISSUANCE: ELT:CI'BIC Fit: O
(WO agree to save.indemnify and keep harmless the City of Culrcninn against
liabiliocs.judgmenu,come and expenses which may in anywayacemeagaitet mid City ALTER OR ADD TO MECH. PLUMHING VEE
U.,Omcalmance of the gaming of this ryrmit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IIk000CFM) MIiCHANICAI.I'lili
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER India)CFM) CONS I RUM 10N'IAX
Signumrc of APPlieuMGmwemr Date EXHAUST H(R)D(WMUCT) HOUSING MI'TIGKI]ON PE-E
HAZARDOUS MXf ERIALS DISCLOSURE
Will Iheappli,sm Or future building occupamstore Or handle botanicalmaterial HEATING UNIT(TO 100.00 11 TU)
as defined by the Cupertino Municipal Code.Chapter,9.12.and the Healm and Safety
HEATING UNIT(OVER IIp,IXXI 11
.coo
Gale Scow.255320)?
C]Yet, ❑NoVENTILATION FAN(SINGLE RGSID) PAID
Dore Receipt x
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(?HP OR IIXI,INX)BTU)
nu hutuNous air cn unnomms Us def nod by Ibc Buy Area Air Umliry Management 'I IDEAL
Uiadm' tlOILER-CUMP(OVEH IlNO.(X011'fU)
❑Yes ❑No
I have read me hnznnlous material.requirements under Chapter 695 of the Cali- AIR CONDITION ER ISSUANCE,DATE
fomia Hm.hh&Safety CUde,See mm 25505.255]3 aw 25534.1 undersand In.,if the NEW RIiSIDENTIAL MSCIL SQ.IT. /I p
buJdm,ow,mu cmrentl,Inco UrmnLthut it ism,m,foo,iMlly an.otify the oxc.panl leo
of the mgoiantems which moa he met prior m issuance of a CcNfcam of Csxn pancy.
Owner or authorized agent Dale ) I
UPI)RY:
OFFICE