S 3188 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUDDING-ELECTRICAL PLtII'NO. 3188 188
BUILDING DIVISION APPLICATION/PERMIT PI,UAIB NG'•MECHANICAL CV
BUILDING PROJECT IDENTIFICATION
BUILDINGADDR7 SANITARY NO. APPI.ICATH SUBMITTA,pDATE
M. � eu 7/1/0 eh � .2;r- 1419
O y�: — PHONE CON7RA 'UR' NAMIi:� y LIC NO:
'I(II ( - SIC CON'fROLp
6—in 9;2el1JU&A6yC_,e6--
ARCIII'I'ECI'/HNGINEEIt; L1'NO: ADDRESS: ❑
CONTACT: - DONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ItLDG EL¢ PLUMB MEECCHH
❑ ❑ CL
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 um licensed under provisions of Chapter 9 Uomnwncing JOB DESCRIPTION
G kYZwith Semi..n]I1B0)of Division3of the Business and ProfessionsCede,andmyliceawis RESIDENTIAL'
O PHRMTI'ISSUANCE
O in full force and effect. ❑SPOWL ❑KITCHEN REMODEL.
ain("� License Class Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
F Z I.1 Date Commcmr
ARCIIITECM S DECLARATION PANELS ❑MULThUNIT ❑STRUCTURAL.
OZ-Z L understand my plans shall Ie used z public records MODIFICATION
O UP TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
F WI:WWW Licensed Professional 201-100AMPS IMPROVEMENT [I SWIMMING POOLS
OWNER-BUILDHR DECLARATION OVER IIgI(IAMPS [I BATH REMODEIIREPAIR DEMOLITION
I hereby affirm that I um exempt from the Contractors License Law for the
O L U following reason.(Section 7031.5,Ruthless and Professions Cale:Any city or county SIGNS ELECT L IL I
[]OTHER
_
which requires a permit to connrum,alter,improve,demolish,nr repair any swchim ^� _
�,iI0� prior to its issuance,also requires theapplicant Rursuch Permit big a signed statement SPECI L UTI'
�-,!tW!�j,, thatheixlicensediumsuam..thePowl&innsofine Gmtmmors Llmn&e Law(Chapmr9 019 4:
fGOo (commencing with Section70NHUf Division 3 ofthe Business and Professions Code)of O N. COMMERCIAL:
ct.W q m z mat be ix exemPt there!.....and me lack for the aIle,[]exemption.Any violation of [I NEW BI,DGIAUDITION ❑DIiMOLIT10N
tc Section nD1.5 by any applicant Own permit subjects me applies.,m a civil penalty PU I ❑TENAN'T ❑FOOD SERVICE
not mnreham five hundred dollars S5W1.
O ❑ Las owner of Ne property,or my employees with wagesastheir node to ion IN ECTRIC IMPROVEMENT
ii'GG'r will Jn the work.and the xlmmurc is sol inlcndcA or nlTemJ 1'ar sale(8e tl []OTHER
Oil and Professions Coe To,Contractors License Law does not a.owner ItLTS-S CHCS-I:I%TUHF.S
0. ^ property who builds or improve&thereon,and who Aces ouch wilt self or rough
his own employees,provided hm such improvements am not intent for RSIDHNTIAL HLECI'R SQ Ff.
sale.If,however the building or improvement in sold within one y[aro ran,the SQ.IT.FLOOR AREA 5/SQ.IT.
awnervbuilder will have the burden of proving that he did not ha]it or i ve for pu-
toof sal[.).
es owner of d.a propenY,nm exclusively asmn¢.ing wi0.IiunaeA cu m T
cEnSWct.he prnjat(Sec.JOf4,Business and Professions Calc:)The Cam ors Li-
censeLuwdocsnmapplyman�wnerofpropertywhohull]sarin.proven thereon,unJ QTY, PLUMBING PERMIT FEE
wins contracts for such Fo jams with u contmctodO licensed punuanuo the Commmors
License L PERMIT ISSUANCE
I n exempttitle, A .B&P C for his mason
ALTER-DRAIN&VEND-WATER(HA) VALUATION
Dote
' WOR ,R'S O P ATION DECLARA'1'[ON
-. RACK FLOW PROTECT DEVICE �`S--
Ihercbyuffrmunderpewltyo elary ane of he followingdeclumouns
Hairrindwill maintain eCenifica ofConmnttorelf-insumforworkees Compcn- DRAINS-FLUOR.ROOF.AREA.CO )RIBS TYPE CONSTRUCTION
aatlon,as provided for by Semina 3J of the Labor Code,for the performance of toe
work for which his permit is issue]. FIX'rURPS-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section t
3700ofthe Labor Code,for the pertmmancemthe work for which this permit in issued. GAS-EA.SYSTEM-I INC.40171.2 'GROUT' AI'N
My Worker's Compensation Insurance corder and Policy number arc:
Cardec Policy No.: GAS-BA.SYSTEM-OVER 41EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' 11
GRIiA51%INDUSTRL WASTE INTER( !
COMPENSATION INSURANCE f s BUILDING DIVISION FIMS
(This section need not be compldeA if th<pennit is for onehudreciduldato ON011 GRHASIi TRAP
or lass.) PLANCHECK FE
Ic[nify that in hfo
e perrmance of the work for which thixpe.it is issued,Idali SEWER-SANITARY-STORM EA.2W FT.
not employ any person In any reamer so as m bee ne,subject..the Worker,'Cmnpm- ENERGY FEE
O '$ wtian laws of Celifnmia.Dam WATER HEATER W/VHNT/ELECI'R GRADING PEE
rj Applicant rx
.7 NOTICE TO APPLICANT:If,after making this C[nificme of Exemption,you should WATER SYSTHMOTREATING SOILS FEE
a ; her.nno subject us the Wader's ComP[nsmion pmvldnns of the Luhor Axle,yon most
W IOMwith comply with such pnrvisinnx or Permit hall be deemed revoked. WA'1"ER SERVICE
Q
Uz CONSTRUCTION LENDING AGENCY NEW RESIDCNTIALPLMB. SQ.FT. PAID Oae Receipt#
L,Q I for
rwhich that penned i isaca (See.30on lending agency for Performance of
H the work for which this permit is issued(Sec.3119],Civ-C,)
� Lender's Name 'TOTAL:
LUiI L.endcrs Address TOTAL:
4L 1 certify that I have read this application and state that the above informadmi is BUILDING 1"
V) correct.I agree ns comply with all city and county ordinances uml.vtme laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby au.horice representatives ofthis city to enter upon the SEISMIC FEF.
�' .bovomentioneA"s."o,for inspection pntpnws. PERMIT ISSUANCEO
(We)agree to save,indemnify and keep felonies, ILECTRIC FEE
rnies,Be City of Cupertino against E
lidhiliece,pJgmcnts,costs and[apenms which may inany way acemeagainur said City AUIER OR ADD TO MECH.
in an mcce of the granting of his rmit PLUMBING LLB
ICA UNDHRSTANDS I W COMPLY WITH ALL NON-POINT AIR HANDLINGUNITTfO 10,000CFM)
OIIRCE RE ILATIONS. MECHANICAL FEIi
/, AIR HANDLING UNIT(OVER U1.000CM) CONSTRUCTION TAX
tort of ma Commcmr Dom F.%IIAUS'I'H(%)D(ed/DUCT') HOUSING Mii'IC,A'1'ION PEN
HAZARDOUS M 3RIALS DISCLOSURE
Wil eapplicummfmumbui a,ce. antsmreorhandlehanMt)usmatedal r HEATING UNIT CTO IN),000 BUD)
as defined by the Culwnino Mumcip Code,Chapter 9.12,and the heal..and Safety P01 =11
Code,Section 255321.)? HEATING UNIT(OVER 100,000 BTU)
C]Yes E]No VENTILATION FAN(SINGLIi RESID) PAID
Date Rttrci t#
an
Will the applicant or future building Occupant use equipment or devices which
eROILBRCOMPQHP(1R Ifi0,gk'1 BTI1)
mit h tOurbos air contaminants as defined by the Bay Arca Air Quality Manageme -
nt OT
District? BOILER-COMP(OVER 100,055 BTU)
❑Yes ❑No
I have read the hanmlous mmeriuls requirements under Chapter 695 or the Cali AIR CONDITIONER ISSUANCE/DATE: n
Tania Health&Safety Cove,Satimn 25505.25533 and 25534.I understand mat if the NEW RESIDENTIAL MI3CH. SQ.FT.
building sues not comically have a tenant,that it is my responsibility to notify the wrapam
of he"gradients which must he amt Prior to issuance of a Certificate of Occupancy. -
Owner or tun imimd agent Dote AL: 01 ISSUED BY: -74
OFFICE