S0001 B0220 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT D NEN ONLYyGAL r� n
CITY OF CUPERTINO 1 PERMIT No. 0220
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BUILDING DIVISION APPLICATIONMERMIT PLUMBINGCIf IDENTIFICATION
50001
BUILDING PROJECT IDFMIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT(
`t5 C e 7' l�P `q8
O tR'S NA ke _ PHONE: C NTRACfOR'S NAME.: LIC NO:
C6 ')1^-p1 'f ` NIC CONTROLk
ARCHITECT/ENGIN[L• LIC NO',1( 1 L 1 AUDNISS: l ❑
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CONTACT: PHONE: BUILDING PERMIT INFO
s ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUME MECH
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P0 l -bZ1 ❑ ❑ � ❑
LICENSED CONTRACTORS DECLARATION RA
ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby o irm In.,I ton licensed order provisions of Cramer 9(commercial;
00z with Section 7004 of Division 3 ofthe Business and Professions Code.rndmylicemet. RESIDENTIAL
olp _ �j RMIT ISSUANCE
F-W o in full force and eR _3 6 D O 3 ❑SFUWL ❑KITCHEN REMODEL
M�FUU LicensafJass LiaM PPhIANCLS-HESIDENT L ❑ADDITION ❑PLUMBING RFPIPE
NQS Dam F- Camreamr ❑MULTI-UNIT ❑STRUCI'URAI.ARCHITECTS DECLARATIONNELS MODIFICATION
zOr�zJ Iundcosnd my plansshall be usedns public recordsPTO2WAMP$Oz ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Pofissind 1-IM)AMPS IMPROVEMENT SWIMMING POOLS
SX �...II OWNER-BUILDER DECLARATION OVER I"AMPS El BATH REMODEURFI1PAIR DE40LITION
L C Q I hereby of ion that 1 am exempt amino,Commend's License Lou for the cl.vrv.PR �pr<
d C q U following reason,(Section 7031.5,Business and Professioru Code:Any city or county SIGNS ELECTRICAL �'V •• �s �m
3 o ha which m mos,a permit to cnnswct,alter,improve,demolish,or repair any structure
prior to it,issuance,al.m requires the applicant for such Permit r file a signed statement SPECIAL CIRCUIT/MISC. •,
pSSp;W!�} thm be is licensed pursmnnothe provisionmfthe Conuuctor's License low(Chepmr9
IyapO (commencing wish Sectinn]IKKBof Division3ofthe Business andindeiei.m Gde)m TEMP.METER OR POLE INST. COMMERCIAL:
6 WW cy that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION [I DEMOLITION
Fad V. Section 7031.5 by any applicant for a permit subjects Ne applicant a civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
xy not mom than five hundred dollars(S500). IMPROVEMENT
Q ❑1,is owner of,he property,or my employees with wages as their sole campema,ion, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or..(fend for sale(Sec.7014,Business ❑OTHER
3 and Professions Code:The Contrectafs License Law does no,apply m an owner of. OI1TL1!TS-SWITCIIES-Fl%TURES
property who builds or Improves,hereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDFNTL` LECTR SQ FT.
sale.If.however,the huilding.rimprovemcm issoldwithmoreyem.f emalictinn,the SQ.FT.FLOOR AREA SISQ.FT.
ownervhuilder will have the burden of proving that he did no,build car improve for par-
,am of wd'.). TOTAL:
❑I,as owner of Ne property,um exclusively contracting with licensed coruscation 10
comshdd the project(Sce.70W,Business and Professions Csde:)The Contracmr's Li-
ver.law does not apply,.an rwnerof property who builds or improves thereon,and QTY. PLUMB] IT FEE ,
who commas for such Pmjems with a cammemr(e)licensed pursuanuo the Crmmchsls
License Lw. PERMIT ISSUANCII
1 am exempt under Sec. .B&P C for this rersa r
ALTER-DRAIN&VENT-WAITRI �� Q� VALUATION
Owner Dole s�
WORKER'S COMPENSATION DECLARATION BACK FLOW PRtTIECT.DEVICE
I hereby affirm under penally of perjury one of Ne following declinations: a s
Ej I bweund will romminno Cemum.,e rf Continuo self-insure for Wrrkcr's Camper- DRAINS-FLOOR,ROOV,AREA.COND. sJ" q{ TYPE CONST"RUC'TIO
setion,as Provided for by Section 37M of the Labor Code,far'he performan¢of the
work for which this permit is issued. VENTURES-PER TRAP _
Q I have and will maintain Worker's Compensation Insurance,as required by Section - t ••s`<
37M of the labor Code,for the Performance of the work for which s permit is issued. GAS-EA.SYSTEM-I INC.40VfLFTS
NiC� s C.GROUP APN
My Worker's Compensation Insurance carrier and Policy number art:
Carrier. Policy Na: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE/INDUSTRI.WASTE IN'rERCEPfOR
COMPENSATION INSURANCE BUILDING DIVISION(>F.65 _
is motion nape not he completed if Ne pannll is for one hundred dollumIS 1 Old GREASETRAP s.
.r las.)(ThPLANCHECK FEE
I certify that in the pedm.rnce ufthc work forwhich thispormit is issued l shall SEWER-SANITARY-STORM G.20)M.
not employ any pets.. y.onne so as m becyptFsubjectto the Workea'Cnmpen- ENERGY FEE
z cation laws of CARD c �•O WATER HEATER WNENTMLECR, GRADING FEE
70 0 Applicam,y If nS +
q y NOTICET APPLICANT:If,after..king tai Cenifiy�r Exemption,you should WATER SYSTESITREATING
F become rohjoel 1.the Warnes Cr nymmaion ppi Ism of the Labor Cade.you muse SOILS FEE
W Q forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE ,
a
ENDING AGENCY NEW RES IDENTIAL PLM B. SQ.FT. PAID
z CONSTRUC7HON LDoc R int H
V O (hereby affirm(list there ieamm�mc,ion lending agency for the performance of
IF the work far which this permit is issued(Sec.3097.Ci,C.) TAL:
C)U Le rba"Name TOTAL:
W Leade/s Address BUILDING FEE
As 1 certify that L have mad,his application and state that he above information is
hcorrect.I agree to comply with all city and county ordinances and state laws relating m QTY• MECHANICAL PERMIT FEE SEISMIC FEE
7
(„) G htildingoradaretior,and herebyouthotim representatives of this city to muerrpon the
above-mentioned property fill inspection polioses. PERMIT ISSUANCE EhECfRI
(Wel agree to save,indemnify and kap harmless the City sof Canadian against
liabilities,judgments.toss nndeapenus which may in any woyiacrue rgatimmid City ALTER ORADDTO MECIL PLUMBINGF
incorugamee of the granting of'his permit. • I
APPLICANTUNDERSTANDS AND WILL COMPLYtWITR ALL NON-POINT' AIR HANDLING UNIT(TO ID"CFM) MECIIA 'AL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CPM) CON TRUCTION TAX
Signmureof AppllcandCotnmHimctor DEXHAUST HOOD(W/DUCT) HO 'LNG MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE.
Willtheapplartar or farm buildlngoccuptm store it,bundle hazordrus.merlal HEAGNG UNIT(TO 100,0110 HTUI
as defined by Ne Capetian,Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.0(10 or
Cale Section 25532(07
❑Yee if ��r�. VENTILATION FAN(SINGLE RESIDE IA Date Rereip,M
Will the applicant or future building occuprm use equipment or devices which V10.000BOILER-COMPV10.0001IP OR IIXBTU)
ourn hazardous air contaminants as defined by the Bay Area Air Quality Management T(H'AL,
District? BOILER-COM P(OVER IW,(M BTU)
Dyes KN.
'S• AIR CONDITIONER ISSUANCE DATE
1 have read the hamrdous materials requirements under Chapter bust of the Calm /
main &Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr. ` / <S
building does hot commonly haver roma,thin i,is my responsibility to ratify Ne oecupant VV0 t O
of the requirements which must be nm,prior to issuance of a Certificate of Occupancy.
Owner m imrmired a,cut Ude TOTAL: ISSUED RY:
OFFICE