S 1121 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL PERMIT NO.
CIT, 0 CUPERTINO AppLICATION/PF.RMIT PLUMBING-MECHANICAL C 1121
�• ILDING DIVISION BUILDING PROJECT IDENTIFICATION �J .i
BUILDING ADDRF S: It
APPLICATION SUBMITTAL DATE:
601 C-�o Gvok C of �-,V o
OW 'S NAM! / I ONy:w(� CON RACIYIR:S NA E: LIC NO.
IN• {�6a1 CONTROL.
CHITECT/EiNGINMR LIC NO: ADDRESS:CONTACP. PHONE: DING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HIM IiLECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE
I hereby affirm that Iran licensed under pmvisions of Chapter 9(commencing JOB DESCRIPTION
OizZ NNection 78001 of Division3ofthe Business and Professions Code.imd my license is RESIDENTIAL'
u100 w PERMIT ISSUANCE
CWF mfullforceundefTect ❑SFDWL ❑KITCHEN REMODEL
aF.UU License Class Lic.p APPLIANCES-REMDEN'l ❑ADDITION ❑PLUMBING RE-PIPE.
N<L Umc CEl MULTI-UNIT ❑STRUCTURAL
Fly ARCHITECTSSDECL DECLARATION PANELS MODIFICATION
Z O r0 Z 1 understand my plans shall be used as public records UP TO 200 AMPS
OZ.p RIOR F1 CI
REPAIR
pp"u�f Licensed Professional 20i.10(g)AMPS OATH
ROVF.MENT DSWIM M INC,POOLS
gK2� OWNER-BUILDER DECLARATION OVER I(XMtAMPS RIiMODCIJREPAIR [I DEMOLITION
1 hereby affirm that I am exempt from the Contracture License Law for the
O y U following reason(Secion 7031.5,Business and Professions Code:Any city or county SIGNS ITL12M RICAL HER
311, which extu res a permit to consume,alter,improve,demolish,.r repair any structure
P. on prer"s its issuance,also requires the applicant for such pcon'in file o signed smtcmcm SPECIALCIRCUIT/MISC.
;!lad that six licensed gromarmthe pneisions.fthe Contmwoes Llecase Law(Chapters) COMMERCIAL,
H
(commencing with Section 7").f Division 7 ofthe Business and Professions Code)or TEMP.METER OR POLE INST,
d q o K that he is exempt therefrom and the basis for the alleged exentption.'Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
YXl Y• Section 7031.5 by any applicant for a permit subjects the applicant o u civil penalty of POWER DEVICESNTOTAL:
EITENANT ❑FOOD SERVICE
pry„ not mote than five hundred dollars(S50E.
IMPROVEMENT
not
❑I.as owner of Ne property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC ❑OTHER
will do the work,and the structure is not intended or offered for sole(See.7044,Business
and Professions Cede:The Contmmors Licenec Law does not apply to an owner of OUTLETS-SWITCHES-FIXTUR
p' .. property who builds or improves thereon,and who does such work himself or through
bin own employees,provided that such improvements are ant intended nr offered for NEW RESIDENTIAL F.LECTR
xale,If.however the building or improvement is sold withinane yearnfecopletion,me Sg6Fr FLOOR AREA $/SQ.FF.
ownerbuilder will have the burden of proving our he did not build or improve for par- PAID
of aIeJ.
L av twos"of Ne property,am exclusively contracting with licensed contractors to �( 11}�m thepct(Sec.7044,Business and Professions Cde:)The Contraamra Li- ANSran,Law Joos not appy to an owner ofpmpeny who builds or improves thereon and QTY. PLUMBING PERMJANI
who comms(."such projects with a conwetot(s)licensed pursuant In the Curnmemes T-s�
Licenre law. PERMIT ISSUANCE. '1
❑1 am axe ander 5 B&P C or Ni reason I f l Uh laUf Cf1 111\
ALTER-DRAIN&VENT-WATER(EA) VALUATION
worn Dote rvc)
WOR erp COM PENSATION DECLARATION BACK FLOW I'k01'ECT.DEVICE
I hereby affirm under penalty of perjury one of the slowing Jeclerminns�.
❑I have it will maintain.Certificate of Consent m self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. Sl'ORIES TYPE CONSTRUCTION
cation,as provided for by Section 37M of the Labor Code,for the perfumaace of the
work for which this permit is issued, FIXTURES-PER TRAP
❑1 have and will maintim Workers Compensation houmace.as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Workers Competastion Insurance carrier and Policy number are:
�y Cartier, Policy No, GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASKINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This if.nenot becompletd ifthe .it is farona hundred dollars S l(s) GREASHTRAP
w leu.7 rd PLANCHECK FIiE
I cenify mm in the pertamance nfthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to heroine subject m the Workers'Can,.-
ENERGY PEE
OZ salon Ls owof Cithfnrnis Dare WATER HEATER W/VENT/ELEM GRADING IEE
O Applicant '
y NOTICE TO APPLICANT:If,after mating this Cenifeme of Exemption,you should WATER SYSTEMiTREATING
a ; become subject f.the Workers C.mpensatlon provisions of the Labor Code,you must AA'D
.E
forthwith comply with such pmvisions or this permit shell be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RFSIDENI IAL PLMH. SQ.ET.
IO.1 Q 'l hereby amrm that them is a<.nswcti.n lending agency fm the performance of
Data R eiptg
H the work for which this permit is issued(Sec.3097.Civ.C.)
O U Lenders Name TOTAL:
III Lenders Address TOTAL:
P. I cenify than 1 have read this applicationand state that the above information is G /(A correct.)agree r)comply with all city and county ordinances and sate laws relating te QTY. MECHANICAL PERMIT FEEL) Z building combination,and hereby authorize repesenadves admi.scity teateTupon thePIiEshove-mentioned property far inspection purposes. PERMIT ISSUANCIi(We)agremince,idemnify andkeephmmlessthe CityofCupertino.gaunt C FECIiabilities,judgmems,costs and expenses which may in any way accrue against said City' ALTER ORADD TO MECH. G FEEin PLICAence of the grunting of this pemit.APPLICA UNDERSTAN SAND WILL COMPLY WITH ALL NON-POINT pIR HANDLING UNIT(TO 10.000 CFM) ICAL PEESOU�gI, GULATIf/N�S./❑/ ,' ! IhheAIk HANDLING UNIT(OVER Ie,(IfIO CFM) UCTION TAXSignmareofApplic f7mitractor tel!// (/l (( iPatn1 EXHAUST HOOD(W/DUC ) MITIGATION FEEHAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building oecupsnt state or handle hazmdess material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Core,Chapter 9.12,and the Health add SafetyCite,Section M532(a)T HEATING UNIT(OVER 100,00)BTU)
No
VENTILATION FAN(SINGLE RESIDI Date Receipt If
Will the applicant or future building occupant use equipment it devices which BOILER-COMP(3HP OR 100,00)BTU)
.oda hazardous,air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Oistn'ni
❑Yea ON. BOILER-COMP(OVER 100,010 BTU)
I have read the hxaamoox matenuls requeemmots ualcr Chupterb.95 critic Cali. AIRCONDITIONER ISSUANCE DATE
f"ram Ilwhh&Safety Crile,Sections 25505,25533 and 25534.I undersand that if the NEW RESIDENTIAL MECH. SQ.W.
building dess not expertly have uteared,that it ism,responsibility to mail,the eccupam
of the requirements which must be mat prior in issuance of a Cenifeare of Occupancy.
Owner ser euNodzd agent Date 'TOTAL: ISSUED BY:
OFFICE