S 0461 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..E LECI RICA PIIBMI F NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMRING-MECHANICAN
L S 0461
BUILDING PROJECT IDPSI'IFIGk'r10
BUILDINGADDRESS: SANI'T'ARY NO. APPLICATION SURMII'1'AL DATE
03 e -�V
OWNER' NAME: PHONE: CONTRACIOR:S E: LIC NO:
S NIC CONTR(ILp
til�ARCH['T'IECI/F,NGINE LIC NO: AUURESS� [/ ❑
CON'I'AC"I': PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HLUO IELIECr PLUMB M17 11
LICENSED CONTRACIOR:S DECLARATIONOTY ELECTRIC PERMIT FEE
I h«any a1Brm that 1 am licensed under proomirs of Chapter 9(commencing JOB DESCRIPTION
O�Z with Smlinn]INI(11 of DivisionJnf the Businessland Pmfcszinns Cale.aypmyliansc is R QIDENTTIAL.
woo in PERMIT ISSUANCE
�,Z full frseemd effia .` K .A�� CSFDWh C1 KITCHEN RHMOU@,
QUU Liccn¢
Clays `eLic.p—o APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FZW U,,,{{{ccc Cantmnor
rnQa ❑MUIT'I-UNIT ❑STRUCTURAL.
ARCHITECT'S DECLARATION
,mini PANELS MODIFICATION
Z p y Z I understand my plans shall he used as public rccnrJs
OZ�O - UP TO 2BR AMPS ❑IN'I'h;Rll)R ❑CIIIMNIEY RIEI'Nk
FBF; LjenscJ Profcsiowl 201-I(NN)AMPS IMPROVEMENT SWIMMING POOLS
=k�, OWNER-BUILDER DIICLARAI[ON OVER IfAN)AMPS
y ❑HIM I I RIEMODEUREPAIR ❑DEMOLI'TION
C w Q 1 hereby affirm that 1 am cxcntpl(runt tnn
he Cmnrnr'a Licansl Law for the
x 3 L U following rcan.(Section 9061.5.Bushels and 1'mR+'vions Codr:Any city or volarly SIGNS ELECTRICAL ❑(JfIIIER
W a y w
which rcyulm,a permit Io,m lmcl,alter,itnpmw.demulid.m repair any nmauec .o a
primu,its iawunce.alsoreaux,lcappheirm linwch penniuo fileaslgnedsmramenl SPECIAL CIRCUFOMISC.
that he is licensed pursuonuotbe provision.,of the Conn:mush License Law(Chapter 9 1
I+)�p0 (Commencing with Section 70IX1)of Division)oftbc Buvivices and Professions Cde)ar TEMP.METER OR POLE:INS'I.
a a e C Thal he is exempt mereftom and the basis for the alleged exemption.Any vlola.ion of RLUG/ADDITION ❑DEh101.IT10N
X^v Second 7031.5 by any applicant for a Permit subjeets the applicant W a civil penalty of TOWER DEVICES TENAN ❑FOOD SERVICE.
not more than Eve hundred dallms(95011. IhIPkOVEh1FNT
=Q QLos mvncr of rhe propcny,ar my cmPloymwitb wages astheirwlemmpcnsminn, SWIMMING POOL ELECTRIC
F.. wllldothe work.souldeumcomeis maimand,do,iffiened farsale(Sec.TNA.Business [�� 00 HER
63 el) and Professions Code:The Contractor's License law does not apply to an owner of OUTLLTS-SWITCHES-FIX'TURCS
property who baildv or improves thercon,and who does such work himself orthrough
his own employees,provided that wch iniprovensm,arc not intended or uttered for NEW RESIDENTIAL rL ECI'R SU I"r.
mile.It.however.Mc building nr improvcownt iv salvo(wiihlnone Yc,norron,pl,foo,the SQ.FT.FLOOR AREA VSQ.IT.
crvhaildm will have the burden nl proving thou lm did nut build or improve lbr put- PAID
p ec ul sale).
1,us owner of the properly ata exclusively Conant,ing with licensed eon tra m TOTAL:
ttatrucI the project(Sec 7f .Bla,incs,and Profession,@dc:)The Contractor's Li-
wLawdoe.,not apply to an owner ofpmlwrty who build,or improves thereon.and QTY. PLUMBING PERMIT FEE RECD Q RECD�
whocomncfin-chorch projects with acontm luras)licensed pursuant tothe Contractors V
Liam,law. PERMIT ISSUANCE
❑ I am exempt under Sec. .B&PCfordtismas I {
ALTER-DRAIN&VENT-WATER(IEA) TION
Owner Date
WORKER'S COMPENSATION oerp ,on DECLARATION RACK BON'PROTECT.UEVICIi
• Ihcreby affirral andamder, Carl fiyofperjmy one ofthe fallmvingWrker',Co
hove:mo will for by Section BamC of the Labor
Cml adc,fore for Worker', of the HNAINS-FLOOR,ROOF,AREA.C(INU' STORIES TYPECONSTRUCTION
worksation,f as provided fine by Section 1]lW of the Luhnr Cada,for the Performance of the
work have
and
this Permit is issued. PIX'NRES-PER TRAP
37 hila emutwillmainmin Worker's Conoid the
wrktorwhihlhaulCJd I Section
9]fNl ollhu Lobos Cale,rnv the Perfnrmanm ill the work for which Ibis pemtit is issued. CAS-IEA.SYS'fEM-I INCA(lll'I'LI?'I'S OCC GROUP AI'N
My Worker: ' In wml bane,cu ier laid Pula,numb re
s GAS-EA.SYSTEM-OVER 4(IIA)
Currice; Policy Nn:
CCRTIFICA G OF EXEMPTION FROM WORKERS' GRHA,.'ANDUSTRI.WASTE INIERCLHr1OR
COMPENSATION INSURANCE BUILDING DIVISION PI};S
(')Tis section need not like completed doe permit is formic hundred dollars(SIIX) GREASE TRAP
nr IusJ PLANCHECK PEE
I cenify Ghatbathe peifmmancelothe winds far which this permit is issued.Ishu11 SEWER-SANITARY-STORM EA.200 IT.
not employ any Pasubject wn in any manner so as to became subjeco the Workers'Copan- ENERGY FEE
s^lion Laws of Califamla.Date WATER HEATER WNENTIELECER GRADING REE
Applicant
=haeseNOTICE TO APPLICANT:If.,filer making this Ci,ion am of Exemption you ashould
mom WATER SYSTEM/rREA'1'ING
[ bodiwiwhjeoty the Worker'svisons or this provisions nrthe Lobar Cmde,you mull SOIf9FTEs
wfnnhwilh comply with such provisions or This pcnnit shall be dcmnlJ revoked. WAFER SERVICE
�.
z CONSTRUCTION LIENUINO AGIENGY NEW RES IDENTIAL PLM){, SQ.PI'. PAID
I hereby atirm that there is a cmulmetion lending agency for the perhmnance of Uute Raaiplp
LUL the work for which This permit iv Issued(See 1(19'1,Civ,CJ TO'IA L:
L V LsnJcr's Name
Isndcrs Address TOTAL:
>' 6. 1 cenily that 1 have read this application and.aura that the alwve information is BUILDING FEE
rN c+nca.I agrecto comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V z M1vilJing mnamcrion.and hereby amhnriu repremnmtivesofdr,city memerupmm the SEISMIC REIT
abovamc roiomml property far inspection porposs, PERMIT ISSUANCE
011e)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC 1y31i
5.5
Iiahiliries,judgment,costs and esPemes which may in any way seems,against said City ALTER OR ADD TO MICH. PLUMBING FEE
nuyucnce of the granting of thin permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO HI.INm CPFU MECHANICAL PER
SOURCIiI rGUL ONS.
7 AIR HANDLING UNIT ?R 10,000 CFM) CONS'I'RI1C'I'I(IN TAX
Slglamrcof Appli nU onlmcom Data EXHAUST HOOD(W/DUCT) HOUSING MI'I IGA ION FEE
H ZARDOUS MA-1'1311AII DISCLOSURE,
Willthea 1' m or formic holding twcopanl store to handle harordous mmcrial HEATINGUNIT(TOI00.000BTU)
ns defined by the Cu,mm,Municipal Code.Chapter 9.12,and the Health and Safety
Cos.Section 25512W)' HEATING UNIT(OVER 100.0o)BTU)
0 Ycs XNa VI7N'II LATION FAN SINGLE RCSID) PAID
lyata Receipt p
Will the applicant or future building occupant use equipment or devices which BOILER-COMP GHP OR Ig1.E(p)ITU)
mit hazardous air contaminant,as defined by the Bay Area Air Quality Managarmant TOTAL:
District? u�Vn BOILER-COMP(OVER 100,10)131'U)
❑Yes
I have read the haxmJnus mmcrialx¢yvitCnmms under Chapter 6.95 a1 rbc Calk AIR CONDI HONER 4[SSNCE DATIi5anin Iledlh&Safety CodeSections 25585,25513 and 25594.1 understand that i1'the NEW RL'SIDENTIAL MIECH, SQ.FT..
'mgdw,not cu Ely have a truant.than It is illy responsibility lonatify thoacupant
Intl chmil etpsi trtonsucnsruuthoris. ogntDal TOTAL: ISSUIEDB
OFFICE