S 1114 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING..MECIRI ICA 1 rgMlr"°. 1114
BUILDING DIVISION APPLICATION/PERMIT I'LUMRINJECT IDENTIPFc
ItU11.DIN1:PROJECT II1RNTl FICA'1'ION
r
BUILDING ADDRESS: (r+ SANITARY NO. APPLICATION SUBMITTAL DATE
`
( / 1 S f -<- J cX l.i $_4 2 z Z 3 �j ctTT
WNER'S NAME ) I t1 PHONE: C�p7 FRACTOR:S NAME: LIC NO.'0.e. 1 r/ k 0.T O 1.0 C j - " _ _IS r/v/' a N r"%C.S'O Nn (' NIC CONfkOLp
�IARCHITECDBNGINEER: LIC NO. y 3S. Ce'4i` �'t )¢_ /. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
yy�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MI!CH
El 11
I LICEN iD CONTRAMOR:S DECLARATION QTY. ELECTRIC PERMIT FEE
1 herenr affirm mat I am licensed under provisions of chapter 9 pornmenang JOB DESCRIPTION
❑aZ
vi PERMIT ISSUANCE
REIE,WOwtnlJDNTIAL
-f full farce and eR 2 3 ❑SIUWh
OKI'ICILN REMODEL
jUt in
Slusr Lica 5'4, Z -RESIDE -PIPE
FaiDate emrAPPLIANCES ENTIALOADDETION PLUMBING E
Fly ARCHITECT'S DECLARA'1'lON PANELS ❑MULTI-UNIT ❑STRUCTURAI.
O Z an an Z I understand my plane shall be used at public tecaNs ODIFICATION
UI"TO 2a)AMPS ❑INTERIOR Ih1NI, REPAIR
F4 t:Wl Licensed Professional 201.11)(MAMPS IMPROVEMENT IMMING 11001-9
OWNER.BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEIJREPAIR [I DEMOLITION
IY W Q I hereby affirm that 1 am exempt(lent the Contractor's Lic once Law for the
W O W U following.,i!a.(Section 7031.5.9usinoe and Prof..ions Cad,:Any city or comaSIGNS fiLECfRICAI. ❑OTHER
which requires a permit m canshuct,alter,improve,demolish,or repair any swmure
prior o iu issuance.olsorequires the applicant(orsuch permit n file a signed statement SPECIAL CIRCUIT/MISC.
C
art
that he is licensed pursuant to the provision.ofthe Contractors license Law(Chapter 9
(Momminant,with S,nmm 700(l)of Division 3ofthe Business and Yndessinro Code)., TEMP.METER OR POLE INST COMMERCIAL:
a a e that he is exempt therefrom inal the M1asis lot the alleged exemption.Any violation of ]NEW BLDG/ADDITION ❑DEM01.1'f10N
�m Session 70315 by anyap,haant fill. vorn,subjectsthe applicant mu,Nil penalty of POWER DEVICES ❑TENANT [I FOOD SERVICE
net more than five handled dollars(SSW).
=O I]Las owner of the property,or my employee.with wages as their sole compensation. SWIMMING POOL ELECT RIC IMI'ROVIiMIiNT
p., will do the work.and the xtmetum is not immndedor offered for sale(Sm.7044,Busineu ❑OTHER
W % and Professions Code:'The Contractors License law does not apply to an nwnet of OUTLETS-SWITCHES-FIX'rURPS
pn)pcny who halds at improves Ib,man,and who does such work him,clf or thmagb
his own emplayces,provided that.u[b improvements are not intended of offered lir, NEW RESIDENTIAL ELECTR SQ hT.
sale.If,however,the building or improvement is sold within one year ofcompichon,the SQ.IT FLOOR AREA 5/SQ.Fn
crbuildcr will have the burden of proving that he dd not build or improve for pm,
puce n[salcJ.
I] I,as owner of the progeny,am exclusively commaing with licensed mn ommire to T(y%L:
construct the price,(See 21H4,Business and Profession.Crxle;)The Contractor.Li-
must,Law does not apply mrat owner of properly who builds or improves damon.and QTY. PL MBINGPERMIT FEE
who contracts for such projects with a contractors)licensed pursuanno the Contractors
Lmno,Law. PER IS ANCE QMJ
❑ 1amexemptunder See. ,B&PCfur This rm,an
Owner Date - ALTs, '&VENT-WATER(EAI CITY VAI. N
1 hereby ulfi munder WORKER'S COMPENSATION DECLARATION g Jedamtions: BAC 'IAW P :CC DEVICE
Vr UQrcO i JI
VU
tdperjury one of VU
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn- DRAINS-FLOOR. ,AREA, ND.
,an....as provided fur by Section 37(X7 of the Labor Code.halite performance fpm
perforof IM1e STOklliS TYPE CONSTRUCT 0?
work for which this permit is issued. FIXTURES-PER TRAP
I]1 have and will maintain Workers Compensation Insurance,as required by Section SC
370(1 of the Labor Cede,for the ptromanie ofthe work for which this permit is issued GAS-EA.SYSTENE I INC.4 OUTLETS OCC GROUP APN
My Wark, ,CnynlreJlmtion lnsumnx cum rani Policy pumgcc�rG I J y W S O
Cnrticr: C 1 le•+�b `Policy Nn4-7 L GAS-F.A.SYSTENI- VERJ(iiA)
CERTIFTCA OFEXEMYTIONPROMWORKERS'
COMPENSKRON INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This sCClion need not h asmph¢d if Ihcp,rmil is forme hundred Jnllun($1 0()) BUILDING DIVISION PHES
or less) GREASE TRAY PLANCHGCK FEE
lcerify that in thepcfformarmofthe workforwhich this permit is isuued,l shall SEWI7R-SANITARY-STORM EA.200 FF.
not employ any fama in any mannerle-ns I�^Z syhjr6t m the workers Carbines ENERGYFEE.C) Z cation Lawsuf Califomia me 7 `� WAI'ERHEAHiRW/VENT/ELECTR
Z 2 Applicant SCG- -..Iq . GRADING F11!
M NOTICE TO APPLICANT-If. ng this Cenif[am of Exemption,you.hnuld WA I ER SYSTEMA R EATING
a , hem.suhject to the Workers Compertsainn provision,of the labor Gds,you must SOILS FEE
W forthwith comply with such provisions or this pernil shall be deemed revoked. OVAL ER SERVICE
o.
UO CONSTRUCTION Ltion[eGAGENCY NEW kESIDEN'f1ALPLMB. SQ ff. PAID
I her by whiaffirm thatmrso i isoco (Sec.3097,0 .agency for peRommnee of Hine R ciptp
W U the work for which this permit is issued(See 3009.Civ.C.) ift
Q Lenders Name TOTA I,:
WI<ndcr'IAodrcss TOTAL:
1 cmify that I have read thes application and smm That the aMre information is BUILDING IZIi
(AA correct.lagrcem comply with all city and enmity ordinances and mate laws relwiag to QTY. MECHANICAL PERMIT I°EE
U Z building construction,and hereby monetize representatives of this city to enter upon the SEISM IC FEE
abnvo-mentioned property far inspection purpose., PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,foliation,.,ev.u;mdespcn.sc.which may in any way al against said Ci ty ALTER OR ADD TO MECIL
in conwla,nce of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO 10,000 CIsMl
SOURCE REGULATIONS. MECHANICAL TEF.
Ir+1 6 / — �! AIR HANDLING UNI T(OVEN III,gXI CFM1D CONSTRUCTION TAX
.//luq'Ai Y(J
Signature ill Applamon/Cunwnto Date EXHAUST'HOOD(W/DUCT) HOU SING TIG
MIATION PI
HAZARDO S MATERIALS DISCLOSURE.
Will the x,licam ar fnmre huilding occupant smm or handle ba'eanlous mumriat HEATING UNIT(TO 100.000 BTU)
as defined by the Clipcnino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Smainn 25532(n)'! HEATING UNIT'(OVE 101.000BTU)
C]Yet ❑Nn
VF,NTILA'1'ION FAN(SINGLE REMD) PAID
Will thea applicant or Ileum building t use equipment or Devices which Dale Rttcipl a
Pp dby the
.At,Oil
BOILER-COMPCHPOR 100.00BIU)
,mil hamrJnu,air mmaminanla as def ncd by the tluy Area Air Quality Alanagement TO IAL:
Ld�,mx,o,mlul,
s �No BOILER-COM P(OVER IIXLIXXI BI U)
read the htcarrou.materials re domma,under Chapter 6.95 ofthe Cali- AIR C(INUI'I'IONER
4 ISSUANCE DATE
&Said,Cot Section,25505,25533 and 25534.1 undersmnd ded if the NEW RESIDENTIAL MECIL SQ.Irl'.
mx,o,mluly haveamnum.Thal itLs my resgmeibildy moody the occupant -
m[nle which mutt ix and pdnr10 issuance o(a GMIBeaI['of Occupancy.
orired agent Uwe '1 rH'AL: ISSUED BY:
OFFICE