S 0181 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO HUI LDINC-HLEC'I'RICA I. PI!eIRMI'I NO.
RUILDINGDIVISION APPLICATIONIPERMIT PLUMBING-bADENNICM. J 0181
IIUIIAIBG PR(FJItC1'IIIENB'IFICATION
BUILI�CADDRESS: /V x / SANITARY NO, AI'1'1.1(AI'I(O ti11IIh11�1,UA'lli
WER'll'//JXJXNIIAME: PHONE W CONTRAC'IOR'SNAME: LIC NO: CO 9
�2 y 1 �f ZjJi NlC N'IROI.p
C ITECT/ENGINEER: LIC NO: ADDRESS S `1 ❑
(Y/ C
CONTACT: PIIDNF.: Bl11LUING PIi12M1'I'INFO
�
El Consultant Fees Paid by Applicant(Initial) III❑DC qL li«' PLUMB MI!c]I
1 LICENSED CONTRACTOR'S DECLARATION
QTY. ELEC--TRIC PERMIT FEE JOI3 DESCRIPTION
1 hereby nffrm that 1 vin licensed antler pnrvilionx of Chapter 9(uirii,nense i,
X50 with Section 700X0 of Division Sof the Business and Pmfessions G,de.nnd mylicenm iv RPSIDFNTIAI:
I'HRMII'ISSUANCE
IW-'�� in full force and ell ❑SPDWI, ❑KI'I'CIIIiN REMODELIUV License Clues Lick APPLIANCES-Rf SIDENTIAL ❑ADDITION ❑I'LUMBING RI.PIPli
N4,a Date Contractor �ie-e-�- ❑MULTI-UNIT' []STRUCTURAL
ARCHITECTS DECLAR TION PANELS F m Z 1 undenwnd Iny plans shall W uwJ us Oubliv recinds MOUIIsICA'TION
-Z�.Z4_a UPTONHIAMPS CIN'I'FRIOR OCIIIMNEYRIiPAIR
2t:
F Yw Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
wF
OWNER-BUILDER DECLARATION OVER IIMXIAMPS ❑BATF{REMODELIREPAIR ❑DEMOLITION
IY 6 I hereby atlim,that 1 am exempt front the Contraaur's License Law for the
0:O U fohowing marom.(Section 90315.Bminess and Professions Code Any sely nr muntY SIGNS ELECTRICAL ❑(YI'flliR
1+13 LL y¢ which regaires a permit to con.amm,ager.impmve,demnE.m,or mpmr any shacm,c
Ofn.] prior to its issuance.also requires theapplicuat forsoch worad 1.fileasignedewtemrnt SPECIN.CIRCUIUMISC,
� y that he is licensee pursuant m the Pro isions of the CommnoLs License Law(Chapter 9 COMMERCIAL
W C, (commencing with Section 7000)of Division J of the Business and Prnfesome,Code)m 'TEMP.METER OR POLE INST
a e fy that he i.1 exempt therefrom and the ba in for the alleged exemption.Any violation of ❑NEW NLUGIADIIIPION ❑UIiM01.1 TION
a
Xn Section 90315 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑'THNAN'T FOOD SERVICE
'� intraedonfivehunireldollars(SSW).
-F+=Q I,as owner of the norm Ioees with woes as theirsole compensation. SWIMMING POOL ELECTRIC OTHER IMPROVEMENT
O grope Y Yemp y 6 Penin El OTHER
IY=� will do andc: he Coreactornot smneed nse Crewderoror applyto an Boner Of
W
3� and Professions GiJc:The Contractors License Crew does nor apply m an owner of OUTLETS-sWITC1{ES-PIX'1'URES
property who lailds ser improves thereon,and mike,Hach work himself onhniugh
his own employees,provided that.such improvements mount intended ser offered for NEW BESIIIENTIAI.EU R SQ FI'.
,life IC however.the building or inipnwemeal is sold within one Yenr of uimplmion.the SQ.IT FLOOR AREA $ISQPI'.
.
ova
er.builder,will base the burdennfpmvingthat he did not Will or impmve for par- � ' D
pose of sada), TOTAL
❑I,as r of the property,am exclusively Contracting with liecr ard connncom,to
cpmswm the product(Sec.7114.Business and Professions Cale:)The Cnmmetor'e IJ- p�pyy
ccnse Law does not apply in an owner of property who buildsor improve,mercon.and QTY. PLUMBINGPE MIT FEE ��� U 1164U
who contracts for such projects with v coo racmred licensed pursuant to the Commuters FI 2 11
License Law, PERMIT ISSUANCE
1 am exempt under See ,B&P C for this reason
ALTIiR-DRAIN&VENT-WATER 1
Ur ktjt�F,
Dam
W
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
hereby affirm under penalty of perjury one mf the following declarations:
I have and will maintain a Cenificate of Conant mself-insum for Workers Compen- DRAINS-FLOOR,ROOKAREA,CONDSTORIES 9'YPC CONSTRUCTION
cation,as provided for by Scefion 39W of the Libor Code,for the perfomunce Of the
work for which this permit is issued. FIXTURES-PER TRAP
n I have and will maintain Workers Compensation Insurance,as acquired by Section
3900of the labor Cade.far the performance of the work for which this permit is ismed. GAS-II.SYS]EM-I INC.4 OUTLETS OCCGROUP APN
MynieWorker's Compensation lnsumncc carrier ane Policy nu�m�bs$�r$L�q� �/ GAS-EA.SYSTEM-OVER 4IRA)
Cac e"r/r-i.. /ACI3 Policy Na:-a'l✓✓r�2--AJI=f9-
CERTIFlCTEOFEXEMPTIONFROMWORKERS' GRFBSEINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PliliS
(Thisssction needoot becompletedifmepeound a firronchundrddollars(SIW) CREASE TRAP
PLANCHIiCK PIiE
or le".)
Ioy any that in the anymarwnces, stubec for subjectch to the W isissued.lshall SEWER-SANITARY-STORM EA.211(1 FT.
not employ any Person in any manner so az to become subject to the Worker Cmnpcn- IiN[RGY Igili
Z cation Laws of Califnmia.Date WATER HEATER WNENT?LECTR GRADING FEE
Z O Applicant
NOTICE TO APPLICANT:IL after making this Confute of Exemption,you should WATER SYSTHMOTREATING
> sons FFEE.become subject n,the Worker's Compensation p evidi e,of he Labor Code,you must
forthwith comply with such pmvi.vions at this Permit shtilbo Deemed revoked. WATER SERVICE.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL 1'Lh16. SQ.fq'. PAID Date Receipt k
U O l hereby affirm that mere is a constivmion lending agency for me Performance of
the work for which this permit is issued(Sec.307,Co.C.) TOTAL:
C) F- Lenders Name TOTAL:
r IULI Lenders Address BUILDING IEE
6. I anify that I have mad this application and nate dandle above information is
r N correct.I q.to comply with all city and county ordinances and state laws ahting a, QTY. MECHANICAL PERMIT FEE SEISMIC FHE
U Z building connmctiun,and hereby authorim mpremntmlves of this city to enrcropon the
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELEM RIC FEE!
(we)agree m save,indemnify and keep harmless the City of Cupertino against
liabilities.judgmnns,costs and expenses which may in any way eases against said City A[.TERORADDTOMECH. PLUMBING FEE
in onsequence M are granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]T ITO 10,000 CFM) MECHANICAL REE
x
SOURCUIREGULAiT$01,21,
AIR HANDLING UNIT(OVER MORROW) CONSTRUCT ION TAX
Si mreofApplicanVCimmaxor Date EXHAUST HGOD(W/DUCT) HOUSING MITIGATION FET:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store at handle hrrNons mmerial HETI NG UNIT(TO I Od"BTU)
ax defined by the Cupertino Municipal Code.Chapter 9.12.and the Ifiri and Safety HEATING UNIT(OVER 100.000 BTUE
rade.Section 25532(ap
❑Yes 0 N VENTILATION FAN RESIDE PAID
ccaddhoceackme,loommum
Date Receipt k
roWill the applicant or fure Wpailding occunt use equipment or devices which BOILER-COMP(3HPOR 100.000BTU)
muses asdefined bythe Bay AcaAirQuality Mammernmet TOTAListrict" BOILER-COMP(OVER 100.000 BTU)
❑Ye. ON.
I have mend the hrrallous marmarialsrequirengairs under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
folia Health&Safety Code seniors 25505.25533 and 25531.I understand the if the NEW RESIDENTIAL MECH. SR FC
beithen a uhm nor
ce currently have a wwnp mato is my ins asp a Cerny to cafenotify the ccular occupant
nfthe acquiremenu which man be met prim m issuanc<of a Certificate of Ottupanry.
Owner or urban ul agent Date TOTAI'u ISSUED BY.
OFFICE