S 0187APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII,UIN'1:-BLHCTRIG\I. I FEiRMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT rING PRO WMICHANICAh CI O'1 O-7
111111 ..INC PRf114:C1' IBf:NTIFIG'f111N �J .L O
.,\RCHITE I'/IiNGI E'R: I.ICNO:
ADDRESS:
CL PHONE.
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INTO
BLDG I; i 1'LUMIf MECU
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARAf1UN
hereby affirm that 1 am licensed under proWaon, of Chapter 9 (commencing
F.MhS�cdsmDivision 3 onhe Business and Rolcsxions Cute. and mylicereci,
slid cfRal _ G'0
hic.M
Cinnamon,iziARCHITECTS DECLA AT'ION
Imucaramnd my at .... bull Isemedas public.cords
t
QTY ELECTRIC PERMIT FEE
i
H DESCRIPTION
R' I TIPERMIT
❑SFDWI,KI'rCi1F;N RLh10Dli1.QUUCla
❑ADDITION ❑PLUMBING RF -1111117
❑MULTI -UNIT ❑S'I'NI1C1'URAI.
MODIFICATIONOZN�
NTERIOR CHIMNEY REPAIR
❑I ❑
IMPROVEMENT SWIMMING POOLS
❑BATH RI:MODIJJREPAIR DEMOLITION
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ISSUANCEesW�rce
APhLIANCF-S—RESIDENTIAL
PANGIS
UPT0200AMPS
Cnensed Pmfeminnal
OWNER -BUILDER DECLARATION
I Sancti, affirm mm 1 mit ceemM I'.m the Com........ License Law for the
following .coon (Section 70315. Husinoax and P.I'csxinnx Code: Any city lir Onlnny
which requites . permit to construct. alter, improve. Jemol'ah, m repair any swc.rc
prior to it issuance. also requires the applicant for such Permit o file asignsd statement
thatheis licensed pursuant o the pmvisicns ofthe Cnm.etor'c License Law (Chapter 4
(commencing with Section 7")of Division 3 ofthe Business and ProfmsionsCdc) or
-hat that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section]0315 by any applleam for.per...I,'runcr,the upplic.m m a civil penalty of
IOAMPS
2ULW
OVER 1091AMP5
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
tete
TEMP. METER OR POI.Ii INST.
OMM R IAI.
[I NEW BLUGIADDITION C] DEMOLITION
❑TENANT ❑FOODSERVICE
POWER DEVICES
W^N
SO
F
3 m
n more than live Into dnllud ($5(x1),
I, as owner of We prapcnY.onny elnpl..yees with wages us thcir.atle cnmpcn,a.inn,
will Ju the work, and the saucmrt is not intended or offered for sale (Sec. A94. Business
and Professions CNe: The Com.mnrs License law rows notapply 10 an mvner of
pves lherton, and who dues such work himself or through
property who builds or imro
his own emptoyaes, provided that such imprnvemems art not intended or offered far
sale. If, however, the building or Inlprovamcto is sold within one year lir Lump........, the
IMPROVEMIiN'I'
[]OTHER
SWIMMING POOL ELEC I' RIC
OUT'LE'1:5—SW'ITCHEY —PI%TURES
NEW RESIDENTIAL ELECfR SQ ITR
SQ. FT FLOOR AREA
$/SQ. ITT
ser -budder will have the burden of proving that he did nun build ur improve for pur-
'UYI'AI,
1
ow of sale.).
1, us owner of the Tru,n, am exclusively contracting with licensed contact... to
nsvueuhe pmjcct (Sec. 9044. Business and Professions Code) The Contractor's U.
cense law does not apply to an owner of property who builds or improves thereon. and
Who com.ns for such pmjecls with a contmctorfs) licensed pursuant o the Contractor's
p
A ID
QTY, PLUMBING PERMIT FEE
License Law.
n I an exempt under Sec. . H & P C for this reason
P1iRNII"1' ISSUANCE
ACITR— BRAIN &VIiN'I'—WATER (EA)JLUs?ION
YUC` wo
n
Owner Date
I1ACK FLOW PROTECT. DEVICE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of
lcpc Jury one of the tollicejr,are or derfarWimloc.ione
rthe Workers e(If the
cation, as provided for by Section 3]1X1 of the Lahr CNe, for the performance nl the
cation. as andwillmaintainectio i 3700of Consentr Code. for
W irk fur which tills permit is issued.
1 have addLi will maintain WorkLL, Cutup III the n rkfornc ff h n, Su J i i Section
3](X))nl the Luhnr Ctde. for She perlbnnmtecol the work fp�gr'whicWM1 t/his peon:. ix is)xuul.
My Worker Gnmttpami suran`'t urticrand
fi1r Q 1 Lo/`
DRAINS—fI.00R. ROOI',AREA.COND.
RIIiR/r
4T 11H CONSTRUCTION
V
FIXTURES —PER TRAIT
CAS—IiA. SYSTEM -I INCA OUTLETS
OCC. GROUP
AI'N
GAS —IiA, SYSTEM-OVIA4 SEA)
Carver:Pol cY Nu.r
FROM W(IRKERS'
CI:RLIrJCATE OF COMPENSATION
COMPENSATION INSURANCIi
GRIiASI%INDUSTRL WANT INTERCEPTOR
BUILDING DIVISION FE1S '
GREASETRAPY
PLANCHECK PEI?
(This sectionnmd not Ea rompldWiDM1epermit ix for line buMmlJollary lSlf01
O Zaction
O
p)
or loss 1
I comfy that inlb.peNamlaneeof ILL work for which l hi s permit is isu..1.1 shnll
nne employ any wpour in any manner so ares ,, become whim m the WoderJ Cumpca'
Laws of Cahi mia. Date
APPlicant
NOTICE TO APPLICANT: If, after making tis Cenifica e of Exemption, you should
becomesubjecuothe Workers Compensation provisions of the Labor Code. You must
forthwith suchpmvisionsor this pemtil,ledl be dccmcdmiriked
SEWER—SANITARY—STORM EA. 210 IT
ENERGY ITHI!
WA'I'T?R HEATER W'NEN'WELECI R
WATER SYSTEM/fRHATING
GRADING FEB.
SOU—S F62.
WATER SERVICE
QPAID
zz'z
L)Q
W
C) 1"'
} D.1
M.
F tR1
UZ
complywilh
CONS] RUCTION LENDING AGENCY
o....
sction lendingagcncy iia the...l'nnmti•
Iberebyallirmlhanhem N icunw
the wash for which this permit rs issued (Sec. 3109]. Civ. C.)
Lender's Name
Lender's AMOT
1 certify that I have read this application and stale that the above infonnmion is
correct. Iag.e to comply with all city and county ordinances and state law, relating to
M1uilding constmction, andhemby nuthmize mpescourves..f thiselly mcdcropon the
Date R.cequa
NEW RESIDENTIAL I'LMB. SQ. 1--r
TOTAL:
TOTAL-;
BUILDING ME
QTY. MECHANICAL PERMIT FEF:
SE ism IC W, 12.
ti
xhm'e-mentioned propcnY for inspection purpasm.
(We) agree n. gave, indemnify and keep hamdcs, the City of Cupcninn against
liabilities.judgments, costs and expenses which may in any wayiectueagainst said City
PERMIT' ISSUANCE
I!LEC'I'RIC Flili
IS.UMBING FEE
ALTER OR ADDTO MECH.
in consequence of the granting of this permit.
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT(1'O 10.010 CFM))
MECHANICAL IgiE
SOUR{'F.REGUI TIUNS� , '(1�(y
AIR IIANDLING UNII'(OVER IO.(NIf1CfM)
CONSTRUCTION TAX
EXHAUSTHOODOMMUCTI
HOUSING MITIGATION FEE
1J1�/7n� ,IT
Signature of Ap r UCo wept. .
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Building Occupant store lir handle havatdous material
as definW by the Cupertino Municipal COM. Chapter 9. 12. and the Health and Safety
Code, Section 25532(x1'
El yes E] No
HEAT] NG UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 11%).(X0 BTU)
PAID
Date RaciptN
VENTILATION FAN (SINGLE RESID)
AW
Will the applicant lir tutuce huilJing nen,am nw, equipment lir ill which
emit hazallous air coimminare, as defined by the Buy Arca Air Quality Management
BOH_FR—COMP (3HP OR 11x,100 RTU)
'I (YI'AL:
BOILER — COMP (OVER 100,000 BTU)
District!
�
❑ Yes ❑Nn
AIR CONDITIONER
ISSUANCE ji
I have mudtbc hmallousmoticed, ser dicmcros under Chapter 6.95of the Cali-
NEW RESIDENTIAL MECIL SQ, 17L
fomio Health & Safety Code, Section, 25505.25533 and 25534. 1 understand that if the
huilJing Jots nal currently have a wmmt, thin it is my.sMmsibillly m until Y mecic,n nd of me requirements which must M. met prior to issuance of a Ceni scam of OceupancY.
_
Tl D'AL:I
F
ISSUED BY:
Owner lir imareizcd agent Lime
OFFICE