S 1488 (2) APPLIGAN I TU FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OA�CIJPERTINO PUII,DING-F.LF.C'TRICAL— PEg\kpIT NO.
BUILDING DIVISION APPLICATIONIPE,RMIT PLUMBING MECHANICAL V 1488
NUILDING'PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'I'S
OWNF,R' __T
LS NAME �� ��� "tl�. �r /� CONT C10R'SNAME:, LIC NO:
<' �/f N/C CONTROL#
ARCHITECT/ENGIN ER: LICNO: - ADDRESS Y2• ❑
CONFALT: , / -
� PHONE:
Ep/�!1 erk pL BUILDING PERMIT INFO
/PIO(d 17J J Wo yl ❑ Cnnaultant Fees Paid by Applicant(Initial) BLDG ELe PLUMB MECH
LICENSED CON'nRunder
DECLARATION _ .
11 ID
1 hereby altinu mra
at 1 ata licensed under QTYELECTRIC PERMIT FEE provisions of chapter 9(commencing
moo nim seene,loan mrin.iaimn3nnneeusmeaaana ProfJOB DESCRIPTION
easiena soda sacro Ilaense is
.,F full force and elbecl 74e L PERMIT ISSUANCE RESIDENTIAL'
<UV Licen. lass Lic.# ❑SFDWL ❑KITCHEN REMODEL
..ic' Dale Cono-unn G E APPLIANCES-k1iSIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION
Z O to I understand my plans'hall be used republic records PANELS ❑MULTI-UNIT ❑STRUCTURAL
524'O UP TO 201 AMPS MODIFICATION
P.y.It�.W4.t Lsen.,ed Profexnmral ❑INTERIOR ❑CHIMNEY REPAIR
CZ4 OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT IMMING POOLS
O I hereby arfrm that 1 ran exempt from 0th Contractor's License Law for theIOALMPS 1000 AMPS ❑BATH I PAI EMOLITI0N
3 W F following .(S lin 7031.5.H •ss d P f Code Any 'ry mu nY ELECTRICAL ❑OTHERlilWor. which reg :ae u I t t It l p dIi.Sn, P' Y autlureyspoI o o y tM1 ppl ma tl hp ion fl :g 1 t temeniAL CIRCUIT/MISC.thathc dp matt Ih p ns Itlt C t t rsI L (Chapter9
pC (commercmg wit,Section]0W)of Division 3 ofthe Business and Professions Code)or .METER OR POLE INST COMMERCIAL
'hot he is exempt therefrom and Ne basis for the alleged exemption.Any....Intim,of ❑NEW BLDO/ADDITION ❑DEMOLITION
Section]03 L5 by any applicant for a permit"th"e s the applicant m a civil penalty ofR DEVICESnot mom than five hundred dollars($500). ❑TENANT ❑FOODSERVICE
❑ 1,as owner of the Progeny,or my employees with wages as their sole crmpensaton, MING POOL ELECTRIC IMPROVEMENT
will do the work,and mesuucere isnot inteudeticumfiered forsale(Sce,7 4,Business ❑OTHER
and Promssians Code:The Contractors License Law docs but apply te an ownerofETS-SWITCHES-FIXTURESpmpeny why builds or improves t such i and who does such work hnn,elr ica d Ourhis own entpinyees pmvidal he.each improvements arc not imm�dal ur oBeral forESIDENTIAL ELF.C'1'R SQ FtT.sale.If.however.the building or improvement is sold%thin ono year of completion,the SQ.FT.FLOOR AREA $/SQ.ITP.ner-huildcr will hve the burdenmfoving that ht did not build or imprve for put-
semfsale').
El 1,as owner of the property,am exclusively contracting withamedoennsnuct the project(See.](144.Business and Proessions Code:)TItCommtc se Law does not apply to an Owner of property who builds or improves thereon,and PLUMBING PERMIT FEE �mwho contracts for such projects with u c ntraeter(s)licensed pursnaa,m heC(mmemrsLicense Law /./t T ISSUANCE.❑ 1um exenrpl See B Cir t�asmn weer -DRAIN&VENT-WATER(EA) � VAI.WORKF.R'SCl ,IPENSAIIONDECLARA'FION BACK PLOW PROTECT DEVICE ~
I hereby affimt underpenalty m perms,anont the following declarations:
❑ I baveand will maintains CenlOrmeof Catera,In self-insarefor Wmicef,coni DRAINS-FLOOR,ROOK.AREA,GOND.
mtlian,as provided for by Section 37M of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued FIXTURES-PER TRAP
❑I have and will maintain Worker's Cmnrptmation Insurance,as required by Section
37W of the Labor Code,for he performance of the work for which this penult is issued. GAS-BA.SYSTEM-I INC.4 OUTLETS
My Workers Compcarrier OCC.GROUP APN
Compensation Insurance ca ier and Policy number am:
Carrier Policy Na': GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANOU$TRU WASTE INTERCEPTOR
(Thissectinn neetl not hecmplmed ifihepennitis for mnehundred dollars($I W) MPLM& SQ,
BUILDING DIVISION FEES
or less.) P
PLANCIIECK FEE
1comfy that in the say manner o as
far whineels permit is issued,lshall
not employ troy alimara any manner so us to become subject mons Wnrkers'Coumem ITARY-3'TORM EA 200 Fr. ENERGY FEE
Z ,Z ration LataenfCulifomla.Dale ERW/VENT/ELECTR
Z NOTIA,upliCE
( GRADING FEE
17" ti NOTICE TO APPLICANT:If,Co making his vis:n s of of E abor o d you should M/TREATING
04 > become comp to i Worker's Compensation provisions of the latnor Code,you mullSOILS FEE
Qfanhwih comply with such provisions or his permit shall be deemed revoked. ICE
'z CONSTRUCTION LENDING AGENCY TIALPLMB. SQ.FE PAID
V QI hereby affirm'hot there is a cmnsrmlimn lending agency for the Performance orDate Receipt#
W,
the work for which his permit is issued(Sec 3097,Ci,C)
Leader',Name
G Lender',Address TOTAL:
W TOTAL:
a 1 certify that I have read this application and state politic above information is BUILDING FEE
UZ) counter I agfee m comply with an city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
a hrilding construction,and hereby authorize representatives oflhis city temper uponht EELE�RTC
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)-gree m rine,indemnify and keep harndes the City of Cupenin,against -liabilitax,judgments,cons and expenses which may in any way acme against said GtyALTERORADDTOMECH.in conequemoOf he grunting of his ermit.APPLICANT UNDER.'fANDS ND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO 10.000CFM)SOURCEREG TATIOSS /0 ll s 7'�V� s+ AIR HANDLING UNIT(OVER 10,MoCFM) AX
Signature
fAD EXHAUST HOOD(W/DUCT)
AZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEF.
Wilby(kc Clleam or future building Code,Chapter
store 912,handle Health ad nttrhd HEATING UNIT(TO IOQaNI BTI])
C de.Sed by the Cupertino Municipal Code,Chapter 9.12,and the Health nail Safety
Cwlc,Section 25532(x)7 HEATING UNIT(OVER 1040000 BTU)
E-1 Ye,, FIN.
VENTILATION PAN(SINGLE RES]I)) PAID _
. a Will the it Gz tel orfuture buildingaccurateth,B use equipment or devices which - Datc Reccipl#
rahjaI7 . Ps air contnminama as definul by he Bay Area Air Quality Management BOILER-COMP(3HPOR Ia1,01N1 BTU)
Dixtrict'1 TOTAL
❑Yes - E]No BOILER-COME(OVER IOO,IIIMIBTU)
I have lead he hazardous material.,re,mocments under Chapter 695 of he Cu, AIR CONDITIONER ISSUANCE PATE
Future Health&Safety Code,Sections 25505,25533 and 25534understand
.1 that ddr, NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have tenant,that It is my rei m ribility In notify he occepant
..f he requlameu¢which"in"he met prior In issuance of a Cenifcam of(Ncupami IM
Owner or autbnmed agent Date TOTAL: ISSUED BY
OFFICE