S 0919 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ]III I I,DIN'G-ELECT RICA 1, 1•li`�f1'F NO.
BUILDING DIVISION API'LICATION6'ERMIT PCUNIRINI:-NIECHANICAL �J 0919
BUILDING PROJECT 111EN'I BuLATION
aNO. APPIACX1 DATI!
BUILDING AUUHISS.OW '.SNAMG 1'110 E: ON'I'H CfOR'S NAME:: LIC NO: pr ARC ITEC/ENG( EER: LIC NO AESSCONTnCf: PHONE:
❑ Consultant Fees Paid by Applicant(initial) nLD ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby ufhrm the I an,b,ce,d under uovkinns of Clame,9(commmucing
�aZ 1M1 Scctinn 91NX0 of'IlivisionJnDhc lj sines unJ l'mlisxiore Code and lay licca-is pIiRMIT ISSUANCIi RESIDENTIAL:
WOO ;a full force and ]tiPDWI, El KI I'CI IFN REMODEL.
d u Licena la Lis APPLIANCES-NIRIDENTIAL ❑ADDITION ❑PIAMIIING RE-PIPE
�<i Uae�Cnmmam
ARCIII'I'T:CCw DECLAR 'PION PANELS ❑MULTI-UNIT ❑STRUCTURAL
~T�Z I mudenland my plans shall he used ax public records CHIMNMODIFEY
REPAIR TION
ZOy,,, Oil 10 ❑IN'f1iR10R ]CIIIMNIiY REPAIR
oz—o
�r3,F„W Licensed panic....mal 201-HKOAMPS Bill VF.MI;N'T []SWIMMINGPOOLS
ac, n_' OWNHR-BUILDER DECLARNI]ON OVER IIXXIAMI•S ❑RAI If REMOI)IillRlil'AIR ❑DIiMOLIr[ON
IY=Q I hereby anon that I am exempt from IM1e Contractor's License Law for The ❑OTHER
�d 6 U following reason.(Section 7031.5.Business and Pmfessiunx Code:Any city or county SIGNS ELECTRICAs
413 LL N which requires a permit to construct,alter,improve,demolish,or repair any suucmre
F U¢ prior to it% 1. q ' .the ppl t far suchpcmin file i,i,neddatmart SI'LCIAL CIRCUIT/MISC.
�y but -dn - u th p : ' nM1 C '' ' L I' (Cna1119 COMMERCIAL:
G'QO leo unam ngu%Tn Section 700(oof I)vson Sol the liusav, adP f ': nu'Crddor I FMP METER OR POLL INST.
0.C.a but he is exempt mcrefrmn and the bmeis far Be ullegeJ cxcmpGan.Any Violminn of ❑NEW BIAG/ADUI'1'I(lN ❑UEM(11,1'1'[ON
X^E Section 7031.5 by any applicant for o permit subjects the applicantto a civil peachy of 1POWER DEVICES ❑TI?NANT ❑FOOD SERVICE
not more than five hundred dollars 01500). IMPROVENIENT
=O
[D 1.as owner of the property,or my employees with wngcs as theirmle compensation, SWIMMING POOL ELECTRIC
will do the work,and them dere is not intended ornRered for sale(Sec.70LL Business OTHER
F- UfITLETS
-SWI'ICHLS-FIXTURILS
W 3 m and Prtdcs,inn.e Gale:The Cn unic-,License law does not apply to an owner of
profs"who builds or improvers merem,and who Anus such work himself a mnmgh NEW RE9URN"TIAL ELECTR SQ PT.
his own employees,provided that such improvenary arc not intended or allured far SQ.FT.Ft.(Ok11t A
tli� &SQ.FR
sale.If,however,the building or improvement is sold within one year of completion.IM1e / Vf
wne,huilder will have the buNen of paving Ina he did not bund or improve for pmt
pose of sole.). TOTAL: Nov
(]1,ate owner of the propery,ant cxcluwvely comranlny with licensed contmetom
mto
com et the project(See.7044,Businco and PmN
resxions Code:)The Contractors Li- •C 1/ tai
nrn
Ur sc Law d—rot apply to tunnwnvr of property who baddsnr impmvice Themon,and QTY. PLUMBING PERMIT PEP, v
uwaKu
n contracts for such pmjeco.with a eamracmr(s)liceowd mourn,m the Coul aa'sn" 11 Y LLs r,
License law. PERMIT ISSUANCISSUANCE `url,T"N�
I]I am exempt under Sec. .B R P C far this reason
ALTER-DRAIN K VENT-WAI ER(EA) VALUATION
Owner Date
• WORKER'S COMPENSATION DECLARATION BACK FLOW FRORiCT.DEVICE
I handy ullirm under punulTy of rjuryoneof the following Jednx'.
] Ihuve nnJwllnminamor,
uCaridcme of Caa-m mond'-inmmfnr Wnrkcr'sCnmpcn- DRAINS-FLOOR.ROOF.AREA,CIINII. $'('DRIES$ 'IYPIi C(1NS'TRUCTI(IN
scion,us provided for by Sectina 3700 of The Labor Code,for the pcdomnanac of me
work for which this pe.it is issued Il%TURF_S-PHH'I'RAP
I have and will mainmin Workers Compensation Insurance,as required by Section
Old of IM1e LaborCale.for the peHornance ofmc work for whichthis peranit is issued GAS-EA.SYS'("bid.I INC.4OUTLET'S (ICC.GROl1P AI'N
My Worker's Compensation insurance carrier and Policy numbs are: GAS-EA.SYS'I FNI-OVER 4(17AI
Cartier: Policy No.:
CF,RF1FLC,O E OF EXEMPTION PROM WORKERSGREASOINDUS'I'RL WASTE INERCEiPi'OR
COMIRNSATION INSURANCE BUILDING DI VISItIN IgiliS
(this nommoca lbecomplmed ifthepermil isformalaundm4dollarx(8100) GREASETRAP PLANCHECK IEE
or less.)
cenify tont in the pcdommm"'orthen ak lar which this permit is inmeJ.I shall SIiWER-SANITARY-STORM Ib\.21X)f•T'' ENERGY FEE
oat employ any pees in any it li ti ea to the Wnderi Compen
oz cation Lawv ifAbat, Da' I�{�j�] WA'T'ER HIiA'IIiR WIV1iNTlEl.liC1R GRAVING FEE
Z O Applicant�(..A MP..M� /• ^'F
NOTICE'(T l-APPLICANT:11,tuber making This Ccmfilme of F,semplmn,yon should WATIiR SYS'I ENUTREATING SOILS P[G
? becona sahjccl to the Worker's Compensation pmvidons of the Libor Code,you must
forthwith comply with such pookmmorthis Permit s1mLIM deemed revoked. WATER SERVICE
(] PAID
G CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI'. Ilam Receipt p
5 z Ilncmhy olhmnnal user:ixaum,me6on lending agency lorThe perlimnanaof
W R the work lin which this permit is Issued(Sea 1097.Cl,C I 'I OTAL:
O Lender's Name TOTAL:
U Lenders Address BUILDING FEE
G I certify that I have read this application and sea that the above information is
F-' 1n correct.l agree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U z hundmgconslmcuna.and hereby authorise mpm%cnteives of naiivity ,,enter upon the
msoc-oeaioned property lis inxpcaion Imposev. PERMIT ISSUANCE IiLECI RIC FEE
(We)agrcc to xuvc.Indemnify vad kelp hornless the City of Cupenlno against
Iiahilities,judgmems,costs and expenses which may in any way accrue against said City ALTER OR ADD'1n MECH. PI.OcHUNG FEE
in conscqucnce of the gmming of this permit.
APPLICANT UNDERSTANIXWND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO I0k000 CPM) MECIIANICALFEH
SOI C REGULATIONS. I IO k I'
� r
'In ,`�1(/ NR HANDLING UNIT(OVEH IO,IXXI CFM) CONSTRUCTION TAX
Sig�mm n ApphcenUContrah EXHAUST IIUUD(W/DUCT) HOUSING MITIGATION PEIi
HAZARDOUS MATERIALS DISCLOSURE
Will the apphenT or future building occupant store or handle hmardous material HEATING UNIT(TO I W,NX)BTU)
as do F. it by the Cupertino Municipal Cove.Chapter 9.12,amt rhe Health toad Safe,, BEATING UNIT(OVER 10(.0!0 HILI
Coda Section 15532md?
❑Ycs Fl No VENTILATION EAN(SINGLE RESID) PAID
Doc Hceciplp
WIII The upplkam or rotors building occupant use eyuipmum in devices which BOILER-COM('13HY OR IMOX)11'I'UI
mit haemdaue air emamm lista s ate Jcfiavd by The Buy Are.Air Quality Management Tlll'AL:
Dolma! BOILER-COMP(OVER I WJXNI SITU)
❑Ycs ❑No
AIR CONDITIONER ISSUANCE DATE
I have read the haedons matenals requirements under Chapter M195 of the Cali-
a""fomia Hcallh&Safety Csde.Screde a 25505,25533 and 25534.1 understand that if the NEW RESLDEN'I'IAL MF,CH. SQ.FT.
huilJing Jrmsnol curmmly deuce lcnant,mmlt ismy rcsslv+nsibilily To amity Tlmrxivpum
of the myuiremems which numl be met prior at issuance life Cenifiene nl(kcuPural.
Owner intrulodzel agent
Date TOTAL: ISSUED BY:
OFFICE