28642 (2) APPLICANTTO FILL IN INFORMATION WITHINREDLINES-USEBALLPOINTFENONLY
CITY OF CUPERTINO BUILDING.FLEC RlCAL PERMIT NU. /Y O /1 !�
BUILDING DIVISION APPLICATION!PF.RMIT PLOhI11INc.MECHANICAL. L o 4 L
BUILDING PROJECT 10ENTIFTCATION
SANITARY NO. APPLICATION SUBMITTAL DATE
i BUILDING ADDRESS:
•• CT
OW ER'S NAME: `` PHONE: CONTRACTOR'S NAME: / ass LIC NU: NPC CONTROL.
f ❑
'ARCH /ENGINEER: LIC N¢ ADDRESS.
2�0 - S,
CONTACT: PHONE: o n� BUILDPIG PERMIT INFO '
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT _ FEE,_- JOB DESCRIPTION
1 hertby aRmn Nat 1 am licensed under previsions of Chapter 9(commencing
C with Section 7000)0!Division3of He BusinessanJ Pofeuions Cede.aril myliccnse is pERMRISSUANCE FT3WL ❑KITCHEN REMODEL
- m(aRfoceWe 703
:U�j Ucrnu Class Lica APPLIANCES ENTIAL ❑ADDRION ❑PLUMBING RE-PIPE
'Z W Due �'�� Cootie`n, eC /IIAr..) ❑MULTI-UNIT ❑STRUCTURAL
-Dec ARCHITECTS DECLARATION PANELS MODIFICATION
D .Z. 1 uodavand my plans WW1 be used As public records
UPTO 200 PS ❑INTERIOR ❑CHIMNEY REPAIR
I=0 IMPROVEMENT
til UcemedProfessionel 2(II�1 MPS
I J OWNER-BUILDERexemptDECe Conte ON OVE "AMPS ❑BATH REMODEIIREPAIR ❑DEMOLRION
d 6 I hertby eRrm Nat 1 em exempt form the Conuecmh License law for she O OTH As
a U fo0owing reason.(Section 7031.5.Business and Prefcssiam Code:Any city or cwnty S NS ELECTRICAL ill
R•�j which requira permit to comct..1mr,improve,demolish.er rtpav any swcmrt
e w
a,
❑� pilarwiuiwance.oleo require:the applicant for such pemdu0 fdearigned sutemeni SPECIALCIRCUIT/MISC.
,I>. this he ie li erred pursue,to the pMvi.i...Of He Convector.License law(Carrier
Y<� (commercwg wiH Smion 70001 of Divi.inn Sof the Businuxand Psufeui...C r TEMP.At
OR LEI ST COMMERCIAL•
Air C Ws he is exempt(Mmfmm and the buffs for Ne dleged exemption.Any vie ton of ❑NEW RLDUADDITION ❑DEMOLITION
,MW Session 7MIS by any epplicantfar.permit aubjau Ne applicant to A civil rerltyo( POWER DEVICES ❑TENANT FOOD SERVICE
Z p, rot nmae Nen five huMred dollen(1500). IMPROVEMENT
� DO LecownmufN Mp My,ormyemPloyeeswidlwagesupteirwlec=Nn tion, SWIMMIN CI'RIC ❑OTHER
wRldothewetandshetwcmmiswtinundalo,.ff Mfm We(Sa.7n .Bust M
3 and POMMUAns Code:The Convector's license Law does no(Apply to w owner f O WR -FI
property who builds or improves Ncreon,and who does such walk himself an Nroug N NTIAL L CTR SQ
his own employees.provided Nat such improvemenre u anot intended or offered for SQ.FT.FLOOR AREA $1SQ.FT.
We.IL however,the building m imptnventem is sold within ane year of campimUm.the -
owaer-AdIde,will he barren of Moving he did nom build or improve for put, !L -
poseof ai ak have Hg NOTAL: ~,
❑1,m Overall of the propcny,an exclusively contacting with licensed conummrs to
couvum the prejav(Sec.Inas.Best..end pnedwai ns Code)Tam Cmamemes Li.
came law,dm m apply to an owner of property who builds m improves Hereon,and QTY. •PLUMBQxNG PERMIT j' M FEE ' F� 1819
who anwecuforsuch pmjMs wiH aeonmrector(s)Iiunud pursuant to Ne Convu(or's - gC
U.Law. PERM ISSUANCE I'r! ' a8
0 1 Am exempt Arabi,Sec. .B&P C for this mason
ALTER- IN VENT- R(FA) '- ALV1•TION
Owner Data V
4
WORKER'S COMPENSATION DECLARATION BACK FLOWP EVICE
1 thereby aR vain apaWry of perjury One of she following decimations:
I love and will meinuinCertifcau of Comer to ulFinsure for Worker's Compen. DRAINS-FLOOR.RODE AREA.COND. STORIES TYPE CONSIRUCr10
etion,ex provided for by Section 37W of Ne Labor Code.for the pedmormna of the
wok for which Nis permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance.as required by Section
3700of the label Code,fm Ne perthannoceof the wok ferwhich this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wahers Compensation ivsunnce ismer And Policy number are: GAS-EA.SYSTEM OVER 4(EA)
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE _?""' ' '•'BI78DMGDNI510_N
(This section need not hewmpletedif Ne pamtit is!Drone hurdmidollan151001 G TRAP PLANCHECK FEE
or leu.)
I cenif3'person Ne mRormance of Me
;totem for which this th.W isissuC.MK.- / SEWER SANRARY-STORM EA.ZOO FT. ENERGY FEE
not employ soy person sh any owner w u m become subject so Ne WOrlcrs Camper
•z anion Laws of California.Data R HEATER WNEN IELECTR GRADING FEE
ZO Applicant
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING SOILS FEE
become subject to the Walkers Compensation Provisions of He labo Code,you must
0 foMwid,comply wish such provisions or this pared shall be deemed revoked. WATER SERVICE -
�"
CONSTRUCTION LENDING AGENCY NEWRIDENTIALPLMB. SQ.FL PAID
ZDau Recaipt N
J O Ihareby affmn Nat them is a construction lending agency fnr Ne performance of
Ne work for which Hmit is peris issued(Sec.3(97.Civ.C.) TOTAL:
:3a F leaders Name
}L&ILerWars Address _ BUILDING FEE
0. 1 cenBy that 1 have read den application and sum that Ne above information is
h cornet,l ague to comply with ell city and county on inancea end sera laws,term,to QTY. MECHANICAL PERMIT - FEE= SEISMIC FEE
.�2 building eoutmcli.,..d hereby sushodee repmuraxavas of His city to enter upon the
'—' above-mardMad property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep harmless she City of Cupertino Against
liabilities,judgencnu.emu And expenses which may in my way wane against said City ALTERORADDTOMECL PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTAND AND JI,'ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(7O IO,OW CFM) MECHANICAL FEE
SOURCE LATIO.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Sign re of Applie onvamal \ CDaa EXHAUST HOOD MIDUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSIL
W11 dr,,piicam orfutum building occupant Nom or handle hvmfiiux mautial HEATING UNIT CTO Ind."BTU)
u defined by He Cupertino Municipal Code.Chapter 9.12,and the HeaIN and Safety
Code.Section 25532(.)? HEATING UNIT(OVER 100.000 131
[I Yes Otho VENTILATION FAN(SINGLE RUM) PAID Date ReciptA
Will Ne applicant or future building Occupant use equipment Or devices which BOILER-COMP OHP OR 100.000 BTU(
rit louUmbms air coaminwu As dc6ned by the Bay Are Air Quality Management TOTAL:
Dism
vim? BOILER-COMP(OVER 100,000 BTU)
C]Yes ('I No
1 have road the hmmdnus materials requirements under Chapter 6.95 of Ne Cali. AIR CONDITIONER ISSUANCE DATE
fond.Health S Su(ny Cade.Sections 25505.:5533 and 25534.1 understwd put if the NEW RESIDENTIAL MECH. SQ.FT
building does not cuscri have jigreard,UP,it is my ea fusibility to notify sac Occupied
of Ne rcqui hich n r to issuance ole C'mricaa of Occupancy. is
Ownerou Noved.ge /Dau TOTAL: ISSUED OY:
OFFICE