S 0648 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING-FILECI RICA]. PI [I�NO 0648
BUILDING DIVISION APPLICA99ON/PFRMIT PLUMBING-MECHANICAL lV
BUILDING PROJECT DENTIF'ICATIOIN
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI['1'At.DATIi
a � ` ohk P- �h , u
OWppiN'S NAME: PHONE: C A OR'S NAME LIC NQ:
—IL\T ' N/C CONTROL.
A:ACHI'I EC)"ENCINEER: LIC NO: ADDRESS: ❑
CONTACT: //k` PHONE: BUILDING PERMIT INFO
I l� �Y ra 9/a 9�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARA'T]ON QTY ELECTRIC PERMIT FEL
heresy mfirttt Ism I am Imenaed ander prom,dmns oral enamor 9lnammenamg JOB DESCRIPTION
DaZ with Suction 71011q of Division 3 ofthe Business and Professions Cale,unit my license is RESIDENTIAL:
00 in full force unA t. PERMITISSUANCB
0spOwL C KITCHEN REMODEL
ZZ V,1.icc lass Lie pppL1ANCES-RESIDENTIAL ❑ADDITION C PLUMBING R17-PIP,
y Q L Date Contactor
AR ITECPS DECLAR O C MULTI-UNIT C STRUCTURAL
F to PANEIS MODIFICATION
Om Z 1 understand my plats shall he used as public recoNa
Z-� UPT02MAMP5 CINTIiR10R CCHIMNEY REPAIR
[:.�F'ad Licensed Prnfexsi...I 201-101MAMPS - IMPROVEMENT E]SWIMMING POOLS
Ys OWNER-BUILDERDECLARATIONCLARATION OVER 10013AMPS C BATH REMODELREPAIR 0DEMOLITION_
q O�6 1 hereby uRrm that 1 am exempt from the Contractor's License Law for the �� /�., �_ ,' `/—
x 3 W F following mama.(Section 7031.5,Business and Professions Calc:Any city or county SIGNS ELECTRICAL ❑OTHI"N
which requires a permit to contact,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file u signed statement SPECIAL CIRCUITIMISC.
} that he is licensed pursuant to the provisions of the Contreclnrs License Law(Chapter 9
W K700 (commencing with Senior7W0)of Division 3 ofum Rosiness and l'rolesxions Code)nr TEMP.METER OR POLI?INST. COMMERCIAL:
a y e rG thathe is exempt therefrom and she basis for the allege)exemption.Any violation of ❑NEW IihDG/ADDITTION ❑DEMOLITION
iC m k Soctinn 111.1IS by nny applicant for v permit sobject,Ihesppliwnl m n civil penin,of POWER DEVICES
'
❑ RHN
B
El FOOD SERVICE
tmorantilaxIMPROVEM?NT
wi Lits owner
l due property,mmyemployees with wages m(heir compenseSWIMMING POOL IA.iCI'NIC
will e siok,amt the structure is not Intended orofficacd for (See 7144,Business C QTfIN
ant[Professions Code:Ta Contractors License Law does not apply to an owner of
OUTLETS-SWITCHES-PIXTIIR'
63^ tannery,who builds or improves thereon,and who docs such work himself or through
his own employees,provided tam such improvements am not intended or offered for NEW NESIDENTIAI.IA.IiCfR Q FT.
sale.If.however,the building or improvement is sold within ane year ofcompletion,the SQ.FT.FLOOR AREA $/SQ,ET,
owner Wilder will have the burden of proving that he did not Wild or improve for pur-
pose of sale.).
C I,as owner of the property,am exclusively contracting with Ilia nmA contactors an O T AL:
construct the project(Sec.7041,Business and Professions Gde:)The Connector's Li-
sense Law does not apply manowner of property who builds or improves menton,and QTY, PLUMBING PERMIT 70, FE. Pr A t D
who contacts for such pri with a contractions)licensed pursuant ua the Contractors
License Law. PERMIT ISSUANCE ap 26
El I am exempt under Seo. ,B&1'C for this revum
Owner Date ALTER-DRAIN&VENT-WATER n VNIRIJU3JDN
WOR KHR'S COMPENSATION DECLARATION BACK FLOW PRO FCL DEVICE /s
I herchy aliinn under penalty of perjury one of One following declaiminns: CI11yv
Ur VIJf'CI'(I�NU
I hirve unit will nntinminnCenlficam of Gmsem mmlf-insula fur Workers Cmnpmr DRAINS-FLOOR,ROOF,AREA.COND, SIORIES TYPE CONSI'RUC'I']ON
station.as provided liar by Section 37W of the Lvhor Calc,for the purronrpam t of the
work for which this permit in issued. FIXTURES-PER TRAI'
C I have and will maintain Workers Compensation Insurance,as required by Sectio
37(10(if the Labor Cod,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I I NC.4 ORD_ECTS OCC,GROUP APN
My Wn is m 'vn tin soon ecamerand PnlicY.l[be
C `9fF ��5 GAS-EA.SYS'I'EMOVHR4(EA)
amiePulicy N,:- l
CCRfIFIC N FROM WORKERS'
COMPENSATION INSURANCE
GREASFIINDUSTRL WASTIi INTERCEPTOR
BUILDING DIVISION FEES
('This section mint ton he completed if permit is forme hundred dollars lSlgl) GREASCTRAI'
or Icssd PLANCHT:CK IEE
I cenify that in the perapposeofine work for whichthis tomtit is ismed,l shall SEWER-SANITARY-STORM EA.200 FT.
nm employ any peaon m any manner so as In hmm
ecoe subject the WnrIm,'Counted ENERGY FIA:
z
on ion Laws of Colifomia.Dale WATER� IIF"AB'1:RW/VENI'/I?LF.CI'R 1 Applicant GRADING 1:12r,r~Ni NOTICC 710 APPLICANT:If, her making this Cenifievm of Exetnption,you should WATER SYSTEM/TRI3AUNG
a > become subject 0a the Workers Compensation provisions of the LaMa Cade,yam must SOILS FEE
W Forthwith conn,with such provisions.,,his permit shall he Jnmted revoked. WATER SERVICE
0
O CHNSTRUCDQNLtion lending agency
NEW RESIDfiN'fIAl.1'hMB. SQ,IT. PAID Date Receipt 1 hereby affirm that constructionlethere i.va construction agency Gar the peI'limtnnnce of P
I--I the work for which this penult is issued(St 31197,Ci,C.)
0 U I.ender's Name TOTALLender's Address TOTAL:
1 dayda,I have real this application unit state that the above mfornatima is BUILDING FEAT
fV) correct?agree to comply with.11 city and country oMisenccsvndsmm laws achda,m QTY. MECHANICAL PERMIT FEE
V Z building contraction,and hereby anthorim represemativesofihis city tocnter upon the SEISMIC ME
eMve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the Ciry of Coatagainst F:LECTNIC FBF.
Inhilities,judgmrnts,emotion]expenses which may many weyaceacti,most said City ALTER OR ADD'TO 11.
in cmucy....a d the Forming d Nis permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT
AIR HANDLING UNIT(TII III,011 CFM)
MECHANICAL ME
SOURCEREGUL ONS Q
✓� % AIR HANDLING UNI T(OVER IOdsu CFM) CONSTRUCTION TAX
Signal/o /Apt n omrecmr g Elate/ EXHAUSTHOOD(W/DUCT) HOUSINGMITIGATIONME
HAZARDOUS MATERIALS DISCLOSURE
Will One applicant or future haddi ng nccupom store or hundlc hueanlousniamnill ME ATI NO ON[T(TO I oo,gID it
vs defined by the Cupertino Mi nJeipal Code,Chapter 9 12,and lie Health anti Safety
Code Section 2553260? 1 HEATING UN1"T(OVER 1111/1)(111 BI U)
C Ycs 0.No VENTILATION CAN(SINGLE RESIDE PAID
Dam Receipt.
Will the applicant or future building byoccupant use equipment or dM ina ement BOILER-COME'(3HP OR 100,01 BTU)
emit hazardous air ammminund as defined by the?ivy Area Air Quallry Mnnvgemem TOTAL:
District? BOILER-COMP(OVER 100,111 RTU)
❑Yes ON.
AIR CONDITIONER
1 have rc:ul the ha>eNnus materials requirements under 1.1 and r 93 of the Cali ISSUANCE DATE
.is Hmlth&Safety Cade,Sections 25505.25533 and ns53J.1 tom understand the
that if me NEW RESIDENTIAL MECH. SQ.FT.
iddhengdI not curtcn0yh t t,about isua ce of.hilirymnntify the rccummt
oftho t mnv gissuonce araCcm
Ow cr olio Date nc TOTAL: ISSUED BY: VIC
OFFICE