S 0425 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOF CUPEMrINO ItUMBING-PJECHARICAI)CAI m:RMn'ND.
BUILDING DIVISION APPLICA'I'IONIPERMIT TING PROJECT
IDEM IC,M. S 0425
NIIUI,DING PR(3JECT IDENTUF'ICATIUN
SANITARY NO. API'hICATION SUIIMIMAL I3A1'li
UILI3ING ADDRESS:
60 2 MARY Ar aro -, cuP�r;,u0 or `+ 9So'1�- 13 al
EIIS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONTROL x
�N K�V �. Yog 36 co"Tao s Y TQM
•ARCHITECGI?NGINEER: LIC NU ADDRESS: ❑
CONTACT` PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MIiCH
LICENSED CONTRACTORS DECLARATION OTY ELECTRIC PERMIT FEE JOB UESCRIIa'I'ION
I hereby that I ant IicrnnW undo pr...tours of Chapter 9 lum....c g
Zzz With Seefi 7glo)uf Division 3ol'the Basin%s and Profe,otet,Code.medr,been.is PERMIT ISSUANCE RESIDENTIAL'
FWcy in lull lincc•unJ dlba, ❑SFDWL ❑KIICl IFN REMODEL
4UU Lmcnsc Class Lic.a APPLIANCES-RF.SIDEN'I AL El ADDITION ❑PLUMBING ItISI'll'Ii
HzW Date Contra°°" ❑MULTI-UNIT ❑SI'RUC'I'URAL
ARCH]'1'ECT'S DECLARATION PANELS MOUHICATIGN
Fy 3
z O I mdolrsuutd ray,lams o ll be mod uv puhlic ra..rds
v-❑ UP'Io210AMPS ❑ ❑
INTERIOR CHIMNEY REPAIR
O,z
F1F'W Liaised Prefieslnnul 201-IM)AMPS IMPROVEMENT [DSWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IBM AMPS ❑BATH REMODEUREPAIR DEMOLIrlON
C C Q I hereby of ion that I am exempt from the Contractor's License law fiat the ❑OTHER 1 G�
X O a U following reason.Serino 7031.5,Business and probe..:,..Cale:Any city lir county SIGNS ELECTRICAL
W 3 W F4 which rclaims a Forma,to construct,alter,improve demolish,or repair any structure
FSO.]
sawn,i¢issuunee.ako mquiresthe applicant(orsuch permit m file.signed statement SPECIAL CIRCUITIMISC,
fythat he is licensed pursuant the provisionsof the Contractors License Low(Chapter9 COMMERCIAL'
WWO (commencing with Section 700u)of Division 3 crow Business and Prnfcssinns Coll TEMP.METER OR POLE INST.
a rL A: Na he is exempt therefrom and the hth
ands for e alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
Wtom Section 703 L5 by any applicant for a permitwbjms the applicant to a civil Felinity of POWER DEVICES [I TENANT ❑FOOD SERVICIC
net more than five fanfold dollars 016001. IMPROVEMENTrrSp O L as owner of the property,or my employees with wages to their vdc covew cation, SWIMMINGPOOLELECTRIC ❑OTHER
F. will Jo the work,and the structure is not intended ontlrered mrsale(See.70W1.Business
and Podessions Gde:The Contractor's Licence Law docs not apply In an owner of OUT-Irl:S-SWITCHES-FIXT -S
property who builds or impnWcs thereon,and who does.such work himself or through
his own employees,provided that...h imConvenient,arc not intended lir otctcd for NIiWRESIUFNTIAL ELFC R Q IT.
FT.FLOOR AREA SISU IeII
sale.IL however,the building or improvement is.wld wallinone Y.1111 Conmlctioo,aa, SQ.
rIn Itr will have the harden of proving that he did not build lir improve for par- n 11
o .sole). 'rt put-
OTA r 9
eeue,aflow p-p ty ly lolorallual -mbeveled I' l ¢:
.. t t In,p ject(Site 7044.4 8 : d P f :Cods:)I C flouller, -
1 1 apply to fproperty h Wild, th A QTY. PLUMBING PERMIT FEEer" 29 g0[p
ab."i lrraus lair such projects with a wntmemr(s)licensed pursuant in the C mnact AU a 1{LO
License Lnw. )�4 /�r���,�." I'fiRh11T ISSUANCE MV f
1um-a.--/or rrSo,, BIkQ
ALTER-DRAIN&VENT-wATIiR IEA) �s 111. UrVB f1A'
Owner V
. N'ORKF.R:S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hcrehy o0irm under penalty,(perjury one of the following do rker's m:
❑ICommand will maintain aCcnifcao of Cnnwnu,self-insure for Worker's Cnmpcm DRAINS-FLOOR.ROOF ARPA.COND. STORIES 'I'YPIi CONSTRUCTION
scion,as pravided for by Section 37M of the Labor Cale.for the performance of the
work for which this Permit is issued. FIXTURES-PER TRAP
0 1 have and will mainoin Workers Compensation Inautance,as mquired by Section INC. OUTLETS
3)11(1 of the UaMa Code,far the Nemoream'e of the work far which this Permit is isGAS-IiA.SYSTEM-1
wed. OCC GROUP MIN
My Worker's Compensation In.wmnce carrier and Policy number at GAS-EA.SYSTEM-OVER 4(EA)
Carrier: Policy No:
CERTI PICATE OP EXEMPTION FROM WORKERSGREASP/INDUSTRL WASTE I NTERCEPOR
BUILDING DIVISION
COMPENSATION INSURANCE IgiIS
ITheurction need not be completed front,permitis formic hundred dollars Slot GRFASHTRAP PLANCHECK FEE
Io,on,than in the pedtamancc of thcw..rk fee whijM1 this thenar is glehall SIiWI?R-SANITARY-STORM EA.21X11'1'. IiNENGY FEE
nil.... my any Cola...In anymannennusmbecome suM1ledmthe Wnderv'Cnntpen-
Z .,ration Laws til Cnlllinnin.Date WAFER IFIiATER WIVBNT/ELIiC1R (11tAU1NG P1?E
C4
NOTICE FO APPLICAN'I`.11;oliomakingthis Ccnifmoteof Exnnptimn.you.should WATERSYSTENVI'BEATING SOILS FEE
(~ hcmnm subject m the Worker's Compensation provisions orthe Labor Gdc,you nmst
a ski forthwith co a,l,with such,inion,or this perreauhall be deconed revoked. WAf1?R SERVICE
i Q
a' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM°. SQ.IT. PAID
U Z Date Reaim a
U Q Ihe,%obiefmuhanherc issco (Set.3nlendie.agency for the performance of
� the work iia which this permit is issued(Sec.]099.Civ.CJ WTAX
AI.:
0 Lender's Name TOTAL:
LUS] Under's Address -
!1 I sonify Ilam I have mad this application and sure that the above information is
sated.l agree to comply with all city and county ordinances and sum laws mlating t" QTY MECHANICAL PERMIT FET?
U Z building construction,and hereby authorkereowan dives wfthis city to enter upon the
aMve-mentioned Company for inspection purfwsn.
PERMIT ISSUANCE.
(We)tomo at save,indemnify and keep hamtless the City of Cupertino against
Ii.bllities.judgmenm,costs and e.aperees which may in any way.ewe againstsaid City ALTER OR ADUTO MECH.
to consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,06X1 CP M) FE
SOURCE,REGUI.ATIONS.
AIR HANDLING UNIT(OVER 10,(N)BCIM) TA%
Signaturof ApplicanUCormictor )Jute EXHAUST HOLD(W/DUCT) HOUSING MI IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will tIte uppliemn or lunate huildle,mccupmtt somor handle hmmdunx real,Hul IIEATING UNIT(TO I W.IKK)BTU)
at delj ued by the Cupertino Municipal Gds,Chapter,9.12,and the I lealth rand Safely HEATING UNIT(OVER I(H)OH)BTU)
Co]it,Sic 35532(a)'
❑Vcs ❑Nn2 VBN'ULATION FAN(SINGLE RPSIU) PAH)
Dm, Receipt a
Will the applicant or future building occupant use equipment or device%which BOILER-COMP CHP OR 100.111X)13 1'U)
IW emit limardou.s air contaminants as defined by the Buy Area Air Quality Management TIrIAI.:
District? BOILER-COMP(OVER 100010 B U)
C]Yet, No
1 have mad the hmae.Se materials 155 requirements under Chapter hYS or the if the
AIR CONDITIONER ISSUANCE,DAT'li
bite:.Health m Sauey Cattle.Sections 25505.is my and 255]4.I a nand that if the NEW RESIDENTIAL MSCI{, SQ.I'f.
buildingJmz not currently have a tenant,that it is my respnnsibiliy m notify the¢c-par,
of the requirements which must he ten prim Rt issuance of a Certificate of(hxupmtcy.
'ISW
DW.Cr or authnti]rnl agent
Date TOTAL: ISSUED BY:
OFFICE