S 0556 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINTPEN ONLYICAI
CITY OF CUPERTINO P J 'T"° 0556
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING iCT IB MECHANICAL
BUILDING PROJ F:CT IIIENTIF'ICA'1'ION
BUILDINGADDRESS: SANT I'ARY NO. APPLICATION SUEJIMIFI�AL DATE
OW .@'SN MLI: � �w PHONE: CONT 1'ORNAMf:: LIC NO:
�� tiN/C C(MTNOEIL LIC N(: AI OR4/(j��� '�'
Co CT. PHONE: eU1LUINO PERM NFO
ClFees Paid by Applicant(initial) ^ •' • BLDG
IB
Consultant MECH
� ❑ ❑
LICENSED CONTNACfOR'S DECLARATION QTY. 17LECTRIC PERM IT FEE J DESCRIPTION
1 herchy aRbm that I am licensed under Provisions of Chapter 9(Commencing
OaZ with Section 701g))nf Division Sof the Business and Professions Code.ond my liceneels RESIDENTIAL'
00 _ PERMIT ISSUANCE
yF
in fall fora and ctfect. ❑SFDWI. ❑KITCHEN REMODEL
�ULJ License Class Lia# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
II..ZI�i Data Ctmtmelol
fnG - ❑MUI.q'I-UNIT []STRUCTURAL
h.O h ansC all a use DECLARATION PANELS
OO 1 understand my plans shall M used as public records CHIMNEYREMODIFICATION
r� UYT02t%IAMPS
OZ— El INTERIOR ❑CUIMNIiY REPAIR
�� W Licensed Prnlesionil 201-11#00AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION ❑BATH REMODEIIREPAIR ❑DEMOLITION
6 1 reason.
(Oro that 1 1. exempt from the Comms Co Liana Law for the
OVIiR IWAMPS
igyx506U which inquitesa er into onsto Business and Pndcaianz Code:Any city ofcountySIGNS ELECTRICAL ❑OTHIiR
W 3 4 ye which requites a permit to condme,alio improve,demolish,or repair any xwment
Red he is fi cn.n e,mareant ui be Ile prxwki ti wftor ouch permirmicere.gneddmemrnl SI'IiC1A1.CIRCUIT/MISC.
�. Nor me ccensed Wrstion 70he of Division 3 the Cnmseneva nd Professions
Law is Code)or
COMMERCIAL
O p (cat he is
(Commencing it thec Finan and the Division 3the al Business end on.Any
Cabo or TEMP.METER OR POLF,1
See he is exempt therefrom and the pais for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑FOODDEMOLI
SEEM
Scclinn 7031.5 by any uPPlicom for upermit suhjects the applicant tato penahy of POWER DEVICES �TI;rypNT ❑FOOU SERVICE.
^ZQm of more than five hundred dollars(5500).
I,ssowner of the norm In ea with we ex ac their sole cam oration, SWIMMING POOL ELECTRIC IMPROVEMENT'
C ❑ Pope Y Yenap Y g pe ❑OTHCR
will Am the work,and the she Con is not imm�ded alar.chis s no,a(Sec.it,an Easiness
W and Professions Code:The Convuetnr's License do emus w apply himself owner h 011'TL, -SWITCHES-PIX'I'UNIS
his o ny whobuildsoyees,or improves themh i and who does sock wnrk dedoror through
his own employees,provided that such improvements art nm intended or offered for NEW RESIDENTIAL HLIiCTR SQ FT.
sale.IL however,the building or improvement is sold within one year ofcnmplelion,the SQ.IT.FLOOR AREA SISQ.IT.
owner-builder will have the harden of proving that he did not huild or improve for put.
pose of sale.).
[11,as owner of the progeny,am exclusively contracting with licensed contractors or P I T \
Cost the project(Sec.7814.Business and Professions CWC:)The CUntmcmrs Li-
cnseLaw does notapplytounownerof pmpeny whit huildx or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a contructor(s)licensed pursuant to the Commetors
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,E&P C for Ibis reason
AI:I'IiR-GRAIN&VEDS WrTI 13 VALUATION
Owner Ione -
WORKER'SCOMPE:NSATION DPCLARATION HACK FLOW PROTECT.DEVICE 02
III affirm once,Penalty n(perjury one ufine following declarations: (, wl/
❑I have and will maintain u Cenificote of Consemno self-insure for Worker's Cnmpem DRAINS-I FLOOR,ROOF, COND. STORIES TYPE CONSTRUCTION
satinn,as provided for by Section 3700 of the LaMar Cale,for the performance of the
work far which this permit is issued. FIXTURES-PGR TRAP
I,
have and will maintain Wodera Compensation Insurance,as mquited by Section
370)of the labor Code,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM-I I NC.4 OUTLETS OCC.GROUP MIN
My Workers Compensation Insurance Carrier and Policy number are:
Camicr. Policy Nn: OAS-EA.SYSTBM-OVEN 4(EA)
CERTIFICATE:OF EXEMPTION FROM WOR KERS' GRHASOINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE HUI 1 r DIV.ION FGfiS
(T his section need not hoCompleted iflhe perndt is formic hundred dollars(SIkh GREASETRAP
or lase,) Pf.ANCHECKF
I certify that in the Performance ofthe work forwhich this Permit is issued,l shall SEWER-SANITARY-STORM EA.NIO FT.
Cul employ any Person in any manner so as to hecnnm subject m Its, pe
e Workers'Cnmn. IiNERGY P
O ,7. satinn Laws.1'Cal1fornia.Ditto WATHR BEATER WNNN'I'NLECTR ORAOINO ''E
z 2 Applicant
tiNOTICE TO APPLICANT.If.after Woking this Cendica,of Exemption•you shoulJ WATER SYSIEM/TREAI'ING
a
Thee nme subject to the Workers Compensation provisions of the"bar Code,you mud SOILS FEE
{tl forthwith Comply with such provisions or this penult shall be deemed revoked WATER SERVICE
0. Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM11. SQ.IT. PAID
� z D rte ReceiPtM
U k for which tat thatmmil iis.sed(Sm.3n len ding agency for the performance of
f-a the work for which this perch Is issued(Sea.3f)9],Civ.C.)
0 Lender's Name TOTAL:
U Lender's Address TOTAL: .t
fy. up's I Certify that 1 have mad this application and slate that the above information is ❑UILDING Il:'
F VI correct.1 agmc to comply with all city and county ordinances trod state haws mladng m QTY. MECHANICAL PERMIT PEP.
V z building construction,and he ,authurim rspresenmtivesoftlikoity m enter upon the SEISMIC FITro above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save.indemnify and keep hamnlcss Ne City of Cupcnim against IiLECfRIC FEE.
liabilities,judgments costs mmde,xpeuses which may in any way accrue agni ant said City Ah1 HIR OR A DO TO MEET
in consequence of the granting of this Permit. PLUMBING THE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT IT lu"CPM)
MECHANICAL FEE
SOUR EGGLAvzIIONS.
1 ea 85/1 AIN HANDLING UNI'I'tOVF.R 10,000CPM) CONSTNUCI'ION TA%
Signature w`AppAppliCam(C I,ttir /ttm; J Data IiX11AUST HOOD(W/DUCT) 14OUSING MITIGATION ME
HAZARDCWS MATERIALS DISCLOSURE
Will the applicant or future building occupant more or handle hazardous matenA H13AI'[NO UNIT(TO Using)BTU)
as defi$CCned fi'Z by th
e Copeman Municipal Code,Chapter 0.9.12,and the Health and Safety
255320)? HEAPING UNIT(OVER](So"BTU)
❑Yes [)No VENTILATION FAN(SINGLE RP.SID) PAID
Dow Receipt
Will the applicant m fdture building occupant use eyuipinenl o,Haul...which
;Pit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL
OR IW,gIB BTU) TOTAL.
UrsBln? BOILER-COMP(OVER 100,000 F TIJ)
C]Yet ❑No
az
I have read the haNmus reamrials requirements under Chapter 6.95oftM Cali- AIR CONDITIONER ISSUANCE DATE
fmmia Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENT IAL MECIL SQ.FT.
u
building does ani cren0y have a recd.that it C my responsibility m nntlfy the aecapaan
mf Nc requirements which amen be mel prior m vuamcc of a Cenificme of O,1aPmcy. . 10
own<r or avthnn>ed agent Date TOTAL: ISSUED BY:
OFFICE