S 0590 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPERTINO BUILDING-ELECTRICAL PFTIT NO, 0590
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL, t`7
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NT-7—PP,ICATION SUHMITTAI.DATE
3
NE 'S NAME.: PHONE: CONTRALTO 'S NAME: ,�,,II hIC NOCONTROLM
:
'021
CG C<�\ PT �/-2 ��LI NIC
• ARCHQECT/ENGINEER: LIC NO ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consallant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT Ell
1 hereby a1Rrm that 1 am licensed under provisions of Chapter 9 Icomntencing JOB DESCRIPTION
CZO with Sation tgp)of Divixion3of the Business and Professions Cale,and mylicenu is
RESIDENTIAL,
F- PERMIT ISSUANCE
la Lumn.e full remClass
and eQed, Lg SPUWL ❑PLUMBIKITCHEN REMODEL
E-PIPE
aVV Date Class C i��ff_ __ Carte } t—40 APPLIANCES-R[SIDENTIAL []ADDITION [I PLUMBING RE-PIPE
Fsta1 Date '� _ Comm ( t L t`
Fly ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL.ZOr/r'Z 1 uncersmed my pinns,hull beusedas public recants 'v�sp DIFICATION
6z4t UPT0200AMPS INTERIOR MNEY REPAIR
rJa�W Licensed Professional 201-1000AMPS IMPROVEMENT �`•••• C]S MMINGPOOLS
0.0.0.''' OWNER-BUILDER DECLARATION
OVER UMAMPS BATH REMODEUREPAIR DEMOLITION
yy ty�Q I hereby ofbrm that 1 em exempt from the Contractors License law for the
pd O 6 U following mne,a(Rection]cont. t,alter, and Professions h,oo:Any city as ammY SIGNS ELF.CfItICAL [I OTHER
which requires n permit ex construct,,Iter,improve,demolish,or repair any cum structure
FpsW0y.1 prioteslicens ncpursuantto the thcvpplic,o for Commurminoicensle.e ned aw(Cha mcnt SPECIAL CIRCUIT/MISC.
that he is Iterated pursuant to the provisions of the Conuxtor's Manu law(Chupmr9
LLl 0 (commencing with Ssctuin 7WB of Division 3 of the Basin.,snit Professions Cole)or TEM R MET ER OR POLE IINST. ax
(-OMMFR IA
6 q 0Iz fG that he is exempt therefrom end the basis f n the alleged exemption.Any violain.of El NEW BLDOIADDITION ❑DEMOLITION
iaCl a. Section 701 LS by any applicant far a pemtitsubjects the applicenno a civil penahy or POWER DEVIC&S [I TENANT ❑FOOD SERVICE
'z} not mom than Eve hundred dollar,($500). IMPROVEMENT
Sap ❑I.as owner of the property,or my employees with wages.,their sme compensation, SWIMMING PORI.ELECTRIC
f- will do the work.and thesuncture is not intended or offered for 614
sale 7 ,Business 0TH
Uand Professions Cale:The Comr.nnex License Law does not apply to as owner of OUTLETS-SWI TCI IRS-FIXTURES
_ S
property who builds in improves thereon,and who does ran work himself a,through
his own employees,provided that such improvements me not initiated or offered for NEW RESIDENTIAL ELEGTR SQ PT. SSSppp
sale.If.however,the building.,imprewmcnt isenld withinorn,crenfcoandcriogthe Irl'.PLOORA ASO.FT.
,wncobuildcr will have the burden of proving that he did not build or improve for par- 48,1
pave of wile.). /t a /f,
❑ I,as owner of the propsety,am exclusively contracting with licensed contractors to TOTAL �j /yL
camuuct the project(Sec.7044,Business.nd P..Sessions Cade:)The Contrdctoes Li. -aC
cease law does not apply to an owner of property who builds or improves themon.end QTY PLUMBING PERMIT FEE
who contracts for such projects with a controemr(s)licensed purvu.ntlo theContracto's HI�s
License Law, PERMIT ISSUANCE /'•U
❑ I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(FA) VALUATION
Owner Date
• WORKER'S COMPENSA'T'ION DECLARATION PACK FLOW PRRTECT.DEVICE
1 hereby in.under Certificate
teperjuryoneof the following W.rkcelnrtp�Ihave and will m.inmin aCenilicam of CnnsemmsdGinwrtfor Workels Co.,.-nDRAINS-FLOOR,ROOIe.AREA.COND. STORIES TYPE CONSTRUCTION
,Edon,as provided for by Section G00 of the Labor Code,for the performance of the
week for which this permit is issued. FIXTURES-P17R TRAP
1 have and will maimain Workels Compensation Lnsionow,as required by Section
37M ofthe Latin,Colt,.for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCG GROUP APN
My Workels Compensation Insurance carrier and Policy number are:
Currier. Policy No.:/ IAcL 00117 5 GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHIINUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION ILFS
(This section need no he completed ifthe permit is forone hundrtddolTars($100) GREASF.TRAP
or less) on PLANCHECK TEF.
I certify Nut in the pefform.nce.f Ne work forwhich this permit is issued,(shall SEWER-SANITARY-STORM EA.200 FT.
not employ any persin any manner so as to become suhjat m the Workers'Compen-
ENERGY THE
z ,.tion Laws of California.Dat. WATER HEATER W(VTiNI'IELECS
ZQ Applicant t GRADING FE-r.
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTF.M)TREATING SOILS FEE
a ; become subject to the W.rkee n Compensation previsions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PL.MB. SQ.FT. Date Rcceipt p
L)O thereby offrin that there is a construction lending agency for the performance or
the work for which this permit is issued(Sao 3097.Civ.CJ
O (~ Lendels Name TOTAL: TOTAL:
Address BUILDING FEE
lY I certify that I have mad this application and state that the above information is
to correct l agree to comply with all city and county ordinances and state laws miming to QTY, MECHANICAL PERMIT FEE SEISMIC PEE
U building cemtmctien,a ad hereby authorize represenmtivcs of this city m eater upon the
above-mentiomJ property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of CLpeninn against
Iiahilines,judgmems.costs and expenses which may in any way acerae against said City ALTER OR ADD TO M ECR PLUMBING PER
in cnnseyuence afire granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,010 CFMI MECHANICAL FEL?
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IF."CFM) CONSTRUCTION TAX
Signawrc of Applicant/Codociar Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theii,iaud or future building a second some m handle hasantous material HEATING UNIT LTO INDW BTU)
us def ted by the Cupertino Municipal CNe,Chapter 9.12.end the Heath and Set ty
CMe.Section 255326.)4 HEATING UNIT(OVER IgkIXp BTU)
❑Ycs ❑No VENTIIAI[ON FAN(STNGLERESID) PAID
Date kccciprM
Will the applicant or future building occupant use equipment or devices which BOILCR-COMP(3HP OR Ig1,IXp BTU)
emit ha oudous air contaminants ax defined by the Buy Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,0DUBTU)
El Yes No
I have road the humrdous mancrials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE DATE
(omit,Urehh&Safety CMe,Sections 25505,25533 aM 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT,
building snot tly have a Mnanr,that it ismy res Iilily to notify the acupanl
of th h¢ ust ten pd.,1. Certificate of Overpency.
-1C�-N l
0,01hero t thartUvte TOTAL I ISSUED BY.
OFFICE