S 0637 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-BING-MECHANICAL Ph:RMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT IDENTIFICATION
S 0637
BUILDING PROJECT 1DF:NTIFIL'ATION 1
BUILDING ADDRESS: SANITARY NO. APPLICATION SUItMITTAI.UATF.
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1 -3
10 SPAM.o d /ONE CONTRA Rg AME: O
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AR IITECI'II!N 1 PER: .C O' Al30RE5S: ❑
l 17-1
CONTACT: l 11 BUILDING PERMIT INF
❑ Consultant Fm Paid by Applicant(Initial) LEDFLI2LT PLUMB MECH
n IIsT�� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(Commencing JOB DESCRIPTION
,O,r*lOZ with Sectiun7lXgb nl DivisionJallhe Business and&afw.rions Cole,and my license is RESIDENTIAL
�Fin
full force and effect. ISSUANCEect. ❑SFDWL ❑KITCHEN REMODEL
License Class 1.10.# APPLIANCES—RESIDENTIAL ❑ADDITION 1-1 PLUMBING RE-PIIRi
Date Comraaor ❑MULTI-UNIT C)STRUCFURAL
Z 0= �. mused re
ARCHITECTS DECLARATION PANELS
1 understand y plans shall he es public cords MODIFICATION
OZ=1 N"1'020B AMPS [_1 INTERIOR [I CHIMNEY REPAIR
F��t3 Licensed Professional 201.10MAMPS IMPROVEMENT C]SWIMM ING POOIS
4 ........1111 OWNHR-BUILDER DECLARATION OVIiR IfkNIAMPS El HAITI RF.MODEVREPAIR ❑DEMOLITION
L 1 hereby affirm ..it I exemptm nt
frothe Coractor,License Law for the ❑OTHER
OyU following reason.(Section 7031.5.Business and Professions Code:Any city m county SIGNS F.LECfRICAL
a W which regmres a permit m construct,slot,improve.demolish,or ,,i,any surefire
�O prior to its issuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant o the provisions of the Contractors License law(Chapter 9
q0 (commencing with Section 700(dof Division 3 of the Businwsand Proadoinns Code)or III MP.METE R OR POLE INST.
L that he is exempt therefrom and the basis for the alleged exe.ptint.Any violation of F.W BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by soy applicant for r permit suhjuts the applicant I...vil penalty of POWER DEVICES ANT ❑FOOD SERVICE
>m not more than five hundred dollars(SSW). IMPROVEVIE
FC6 Dl,as owner of the property.or myempinyeeswith wages us their sole compensation, SWIMMING POOL ELECTRIC
F=.O will Nr the work.and the sourcum is not intended oroffered forade(So..7614,Business ❑OTHER
tyr�
and Professions Cade:Th,Commerce's License Low docs oat apply towner owner n( OUTLETS—SWITCHES—FI%TDRIi$
a 3.. property who builds or improves thereon,and who does such work himself or through
his non employees,provided that such improvements arc not intended or offered for NEW RESIDEMIAI.ELECTR SQ IT.
sale.If,however,the building or improvement is sold within one year of Lmoodelno,the SQ.FI'.FLOOR AREA S PT.
ovenethuilder will have the burden of proving that he did not Wild or improve for pur-
po n of sale.).
❑ h us owner of the property,am exclusively contracting with licensed aontmctas la,
TOTAL'
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense law does misapply too?awmerafproperty who Wildsor improves thereat,and QTY PLUMBING PERMIT FEE
who cnmrvas
forore n!jecw omrvcmas)licenmd pursuant to Contractors
Littns PERMIT ISSUANCE
❑lam sae er See. &PCfor chis rcanon
ADTFR—DRAIN&VENT—WATER(EA) A a VaUAT ON
r m W si
WORKER'SCOMPF.NSATION DECLARATION BACK FLOW PRf31E=DEVICE eN
I hereby alto.under penalty of perjury one Ut6c following deduratiour:
FI I have and will maintain a Certificate ofCnsent to self-insure for Warker'.s Cooper. DRAINS—FLOOR,ROOF,AREA,COND. F1rffrGRJj3TYPECONSTRUCION
sation,as provided for by Section 37M of Ne Labor Cade,for the peffamence of the
work far which this proton is issued. FIXTURES—PER TRAP 1
Fl have and will maintain Worker's Compensation Insurance,as required by Section CITY Ty
37p1ofnhe lase Coda fonhc perfmmerce of the work for which this pemtit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS OC(70ROUP1 IIIY(J APN
My Worker's Compcnadion Insurance carrier and Policy nmmber um;
Carrier: Policy No.: GAS—EA.SYSTEM-OVER 4 EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASFJINDUSTRI.WAS'11;1MC:RCEPB)R
COMPENSATION INSURANCEBUILDING D VISION PEES
(Thissectionnewt,otbecompletedifthepermitisforonehundreddollam($[MI GRIiASETRAP
t or less.) PLANCHECKFEE
I terrify that in the perfomainecoffic work for which this permit is issued,I shell SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner areas 1.became subject m the Workers'Cmapen, ENERGY FEP
Zn
sedan laws of California.Dam WATER HEATER WNENTIELECTR
o 2 Applicant GRADINGI VA
li
C. y NOTICE TO APPLICANT.bluffer making this Certificate of Exemption,you should WATER SYI EM/TREATING SOUS F
h became subject m the Workers Compensation provisions of the labor Code,you most
forthwith comply with such provisionsonhis limit shall he dread revoked. WR'I'ER SERVICE
CONSTRUCTIONLENDING
ngAGENCY
agency NCW RFSIDPNTIAI.PCMB. SQ.FT. PAID
VO Ihercby affirmthauhercisacnnstrvmion lending agency for Neperliumenernf D:e Receipt#
f' the work for which this permit is issued(Sec.3097,Civ.C.)
Q Letdcr's Name TOTAL:
Lender's Address TOTAL'
y I certify that 1 have read this application uad state that the above information is BUILDING JEH V
y conut.lagreem comply with all city uad county ordinances and nam laws relining to QTY. MECHANICAL PERMIT FEF.
V building construction,and hereby authorize representatives of this city to enter upon the SEISMIC E
above-menti oned property for inspection ptaf , s. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC 'EP
liabilities,judgments,costs and expenses which may in any way rectae against said City ALUM OR ADD TO MECH. PLUMBING \E
in comae ince ebbe ,ting of this�;t
APWT . STANDSWITH L -POINT AIR HANDLING UNITQ0 10.(g ubb MECHANICALP-
S, IONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TA
i mu eoAplicantlContry r Dam EXHAUST HOOD IW/DUCT) HOUSING MITIGATION P
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wildingredupant store or handle hazardous material HEATING UNIT(TO I OGEE BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safcty
Cale.Section 25532(a)l , / HEATING UNIT(OVER 100.000 BTII)
T]Yes n VF.NI'ILATION FAN(SINGLE:REST DIPAID Date Receipt#
Will the applicant or future Wilding occupant use equipment or devices which
BOILER—COMP(3HP OR Ilp,(IW BTU)
emit humNous air Wma omm s as efineJ by the Boy Area Air Quality Management TOTAL:
District? BOILER—COMP(OVER 100.1100 BI U)
Cl Yes Na
I have read the hvurchimnmmrials instruments under Chapter 6.95of the Cali. AIR CONDITIONER ISSUANCE DATE
fnmia Health&Safety Code,Sections 25505,M533 and 255M.I unlerm nd that if the NEW RESIDENTIAL MECH. SQ.FT
building does not currently have a indoor,that in is my responsibility mnonify the occupant
of the requirement which most be tact pnor to issuance of a Ccruricrm of(keupancy.
Owner nr aothonzcd rgmt Date TOTAL: ISSUED BY
OFFICE