S 0228 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CPLUMPING-MECHANICAL l�`�
ITY OF CUPERTINO BUILDING-ELECTRICAL PEgMIT NO. 0228
BUILDING DIVISION APPLICATION/IaERMIT BUILDING PROJECT IDENTIFICATION
BSANITARY NO. APPLICATIO
UILDINGADDRESS: N SUBMITTAL DATE
11x38 8488 2oAa UPGOr/A(o 6-4 95Di4 6 26.1
OWNER'S NAME F{ONE: CONTRACTORS NAME: LIC NO:
O RA 1d� o &2-5-,7S N/C CONTROLp
CHITBCfIF.NOWEER: I I U LOICINNSO:: :J ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG 1..1.ECI' PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby ulTrm That 1 sen licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�WW aZ with Sation]fX10)of Division Sof the Businessand Professions Cdcsandntylice.wis - RESIDENTIAL
:
full force and effect. PERMIT ISSUANCE
CK r m ❑SFDWL ❑KITCHEN REMODEL
aVV License Class o
ZW Dom Contractor
ctor' APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
InQa ❑MULTI-UNIT ❑STRUCTURAL
FARC bcLTS DECLARATION PANELS MODIFICATION
Z O olz 1 understand my plans shaallll M used as public recordsOZ4—p UP T02g1AMPS INTERIOR El CHIMNEY REPAIR
1-41") Licensed professional 201.1"AMPS ROVEMENT C]SWIMMING PO LS
OWNER-BUILDER DECLARATION OVER IIXNIAMPS [I BATH REMODEuRF.PAIR ODEMOLMON
y 6 1 hereby affirm that 1 am exempt(sent the Contractor's License Law for the
>(�ILU following rwson.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
614 O which requires a permit to construct,alter,improve,demolish,or repair any swemre
pnonoits issuance,also requims Ne applicant for such pertninofleasigneJ sutement SPECIAL CIRCUIT/MISC.
sit
that he is licensed pursuant to the provisions of The Contractor's License Law(Chapter 9 COMMERCIAL
(commencing with Section/0f10)of Division3 ofthe Business and Professions Code)or TEMP METER OR POLE IN ST,
Is. n in.,be is exemps therefrom and the basin for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
Section 703 t,5 by any applicant for a permit subjects the applicant to a civil penaltyaf POWER DEVICES [I TENANT ❑FOOD SERVICE
Z t more than five hundred dollars(S500). IMPROVEMENT
�F'^�6 �1.as owner of the property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
pC will dnthework.and the structure is not intended or uttered for sale(Set.11140.Business C1 OTHER
and Professions Code:The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employee,,provided diem such improvements are nm intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If
ever,the building nrimpmvemem is sold within one yearofromplditm.the SQ.IT,FI6QORJgAREA S/SQ.FT.
own vilder will leve the burden of Timing That he did not build or improve for purr- r A I D
02 ofsale.),
I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.704I,Business and professions Code:)The Contractor's Li- JU� _�Cm
Genu Law Juee nm apply towowner of pmpcny who huims or improves thercnn,and QTY. PLUMBING PERMIT FEF. �V U
who contracts for such projects with a cnntmctoH,1 licensed pursuant to the Contractor's
License Law. V
em exempt under Seo. A .P&PCfor Nis reason C�Ty
PERMIT ISSUANCE F VUrGUIIY - '
AI]ER-DRAIN ffiVENT-WATER(LA) VALUATION
Date
L S S TION DECLARATIOW BACK FLOW PROTECT.DEVICE 1-21
I hereby ill ll mai under Penalty of perjury one of the fnsumfog Wo&c(.i Co: W�
Thaw and
rovicklforbynection 37M of Ce Labor Cook,for the afformace of The DRAINS-BOOR,ROOF AREA,COND. STORIES TVPE CONSTRUCTION
wtion,as provided for mi Section 3]W of the Labor Cade,for the perfnrmance of the
work far which Nie permit Is issued. FlXTDRFS-PER TRAP -
❑I have and will maintain Workers Compensation Insurance,c repaired by Section
37M of the l�hsrCodgfanhe performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INCA OOfLEfS FICC.GROUP AP
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy Na.: GAS-EA.SYSTEM OVER 4(EAT ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASEANDUSTRI.WASTE INTERCEPTOR BI )IVIsiON FEES' ,
(Trisection nwtl nothc[mplcteJ if the permit is!atone hundred do)[.($100) GREASETRAP
ar less.) PLA CHECK Ks.�_
teertifythatintheperformare oft ework fo wbichthispennitisi.wuegl,hall SEWL'R-SANITARY-S"PORMEA.200FE
noglay say person in anymanses 'act the Wohers'Compen- FNERGVFiZwnlif n ia.Do a s WATER HEATER WN FNT/ELECTR
zO A GRAD( IiEN ) e ifiwte of Exemption,you should WATER SYSTEM/REATING
bceci t.the Worker Cam sac t isionx of the LuMer Code,you must SOILS F
(aTa forthwith comply with such provisions ,.his permit shall he deemed revoked. WATER SERVICE.
O
CONSTRUCTION LENDING AGENCY NEW HESIDENTIAI.PLMB. SQ.FT. PAID
V �a Thereby affirm that iso construction lending agency for the performance of ae Receipt is
H. work for which this permit is issued(Sec.NAY,Co,C.) TOTAL:
0 o Leaders Name
a t.Lcndcrx Address TOTAL:
I certify that I have=it NNis
is application and state at the above information To LOT PEE
Vi sslrrect.I agree a.comply wit all city and county ordinances and state laws relating To QTY. MECHANICAL PERMIT FEE
V X building construction,and hereby aahonce reprewntmovs.of this city to enter upon the SF.ISMI FEE
property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamdess the City of Cupertino against ELECT C FEE
liabilities,judgments,costs and expenses which may in any way accrue agmmi said City ALTER OR ADI(TO MECE I.
PLUMBINGIT
PI CANT UNDERSTA s AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,0XN)CFM)
St U ERL TIONS CONSTRUCTIONT
/f AIR HANDLING UNIT(OVER 1(I,IKKI CFM) CONSTRUCTION TAX
Signature of ApplicanVContnclor Disk EXHAUST HOOD(WIDUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building necupantstow or handle hamrdoas material HEATING UNIT CFO IIX1,11 RTU)
as defined by the Cupertino Mumci de.Chapter 9.11.and the Health and amey
Code.Section 25532(.)1 HEATING UNIT(OVER 100,000 BTU)
❑Yesn VENTILATION FAN(SINGLIS RESID) ' PAID Data Reesiptp
Will the applicant or
building occupant use asuipment or devices which BOILER-COMP Drds OR If10,000 BN)
mit haznNaus air comaminnms av fired by the Bay Arca Air Quality Management TOTAL:
'stria? BOILER-COMP(OVER Ifif"BTU)
❑Yes No
I have mad the havudoa mamnals requiremwss under Chapmr 6.95 of Ne Cali- AIR CONDITIONER ISSUAN E
We 1{wIN&safety code.Sections 25305.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
ing ticesnaw watenmL tit ismytesport ihi t mtifyt cuccupant
f o' she nt toi a eofoC p) e.. -
oath rix ag m D e TOTAL ISSUED BY:
OFFICE
20' REVISIONS . BY
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