30555 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F,LF.CI'RICA], PERMIT NO. �O
BUILDING DIVISION APPLICATION/PF,RMIT PLUMUIBING-MECHANICAL
BLDIN(:PROJEC'i'IDENTIFICATION
555
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMMAL DATE
02--7 VLsTXI g
OWNE IE: XHUNh: C AC OR'S NAME: LIC NO:
\ .7 �1 /r 'n NIC CONTROLX
EE
ARCHITECT/ENGINR: LIC NO: A )N.:S: l.CJ2! NlT SI ❑
CONTACE PHONE, BUILDING PERMIT INFO
❑ Consultant Fetes Paid by Applicant(Initial) eHLUG ELECT P Z
L
LICENSED CONTRACT'OR'S DECLARATION TY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed tinder provisions of Chapm,9(commencing JOB DESCRIPTION
"Z onSection 7010y.f Division 3 afthe Btumesstrd Professions Cnde,and myliccnse is RESIDENTIAL,
0
wr
{x10 ,r. PERMIT ISSUANCE
F� F' n full force am effedll e ❑SFDWL ❑KITCHEN REMODEL
Q V V License l.• Lic.p APPLIANCES-RESIDE []ADDITION ADDITION PLUMBING RE-PIPIT
F Q 6 Dam ++ Commclor
OOm ARCHITECTSDI!CLAE TION MODIFICATION PANELS
❑MULTI-UNIT ❑ URAL
y t�AZ IunJcrSmnJ my plans shall ba Beal ax public rccnrds - MOUIFICATIO:V
OZ-p UP TO 200 AMPS [I INTERIOR C3 CHIMNEY REPAIR
[-HAW Licensed Professional 201-100DAMIPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODELMEPAIR El DEMOLITION
Q 1 hemby affirm that I am exempt front the Contracmr's License Law for me
�e�(0M V following mecum.(Section 0031.5.Business tad Professions Code:Any city or manly SIGNS ELECTRICAL ❑OTHER
a13 LL F which requires a permit to construct,alter.impmxe,demolish,ry repair any storcmre
prior to its iw uune4 ulxo requinxthe applicant for such perminu Glunsig^edxtnmmenl SPECIAL CIRCUIT/MISC.
Flythat he is licensed pursuant the provisions ofthe Comtmctors License Law(Chapter 9
W p;O2 (commencing with Section 0(100)of Division3ofine Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
d d o y that he is exempt therefrom and the basis lin the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑POOL,SERVICE
net roam than five hundred delars(4500). IMPROVEMENT
Q ❑ Las owner of the Pmpeny.or my empl^Yea with wage as their sole compensation. SWIMMING POOL ELECTRIC
will do the work,and the xtrucmrc is not intended or offered for sale(Sec.IDW,Business []OTHER
LL1 m and Professions Code:'T Te Contmetors License Law docs not apply to an owner er OUTLETS-SWI'I CI I ES-FIXTURES
s3� pmpeny who build,,,,impose.+merem.and who max such work himwlfur through NEW RESIDENTIAL ELECfR SQ FT.
his own employees,provided that such improvements arc nut intended or offered for
sola.
If,Wwevea the buildoi,o,immorvcmmni is sold within one ycar of that,],,....,the Q.FT.FLOOR AREA LSO Ff.
er-builder will have the burden of proving that he did not build or improve for pur- ,
pose of sale.).
I.as owner of the property,am exclusively contracting with licensed contmm�rs m TOTAL: �q
,nstmGtho project(Sec.9194.I3usimexxmnd Pmfeaslons C.,,I he Co nimcnrz s LL / � '1
cense Use does not apply m an owner of property who builds or impmves thereon.and QTY. PLUMBING PERMIT FEE `r-,1 P 1 6 iggs
who contracts for such projects with a conoacmgU licensed pursuant to the Comencton s
License Luw. PERMIT ISSUANCE ,-
❑l am exempt Bader Sec. .B&P C for this reason .t.
ALTER-DRAIN&VENT-WATER ELM ^VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
• hereby affirm under Penalty of perjury one(if the following declarations:
l have and will maintain a CertiOcam of Consent to self-insure for Worker's Creation- DRAINS-FLOOR,ROOF,AREA,COND. STORIES T'YPECONSTRUCTION
sctimn,ax provided far by Section 37M of the Labor Code,for the performance of the
work for which this permit is iemod. FIXTURES-PERT RAP
I have and will maintain Worker's Compensation Insurance,ns required by Section
3900 of the LaborCode,for me performance of the work for which this permit is issued GAS-CA,SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy No.: GAS-ITA.SYSTEM-OVER 4 LA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUINUUSTRL WASTC INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(ThNtc,tionneed ani he cnmplmcdd he Per mit is f hundred dollars S11X11 GR BASE'I'RAI'
or less.) 1'LANCf1ECK PIA:
I certify that in the perfianotice.f the work for which this permit is issued.],,hall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY ME
O Z ration Lawlor Cal Bi rma.Dam WATER HEATER WNEN'VELECTIi GRADING FEEz Applicant
NOTICE TO APPLICANT:If,after making oris Ccnificam of Exemption,you should WATER SYSTEM BEATING SOILS FEE
F� become subject to the Workers Compenxntion pnrvixion+of the Umar Code,you must
foMwith comply with such provisions-his permit mall tc JccmcJ revoked. WA'T'ER SERVICE
aQ
Dz
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.Ill PAID Dam ReceiptN
V Iherchy affirm that lsanntawation lGNimK agency for the Permrmance of
the work fur which this permit is issued(Sec.3097,Cie C)
OF' Lenders Name I'OTAI"'
V Leaders Address TOTAL:
�.r Wry
1 ccnify that I have read misapplication and statethat the aMvc inlbrmatinn is BUILDING ME
N correct l agree to comply with all city and county ordinances and.stare laws relating l^ QTY. MECHANICAL PERMIT FEE
V Z building conruction.and hereby aumoriu representatives of this city m enter upon the SEISMIC FEE
above-nmntlom it property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify Bad keep hwnJass the Cay of Cupenlno agaln.a ELECTRIC FEE
Iitbilitiea,judgmems.m,nmxl expenses which may inaoy wayattmeagaim,said City ALTER OR ADDTO MECH.
PLUMBING FEF:
in consequence of me granting of this Perot.
APPLICANT ONUERSTAN DS AND WI Li,COMPLY W I'TI I ALL NON-POINT AIR HANDLING UNI T(TO 14000 CFM]
MtiCi IANICAL FEF,
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IQI10)CFM) CONSTRUCTIONTAX
Signature of ApplicanUConuactor Dam EXHAUS"f HOOD(W/DUCT) HOUSING MITIGATION ME
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building macupmn amre orhandle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by me Cupertino Municipal Cute.Chapter 9.12,and the Health and Safety
Code,Section 25532(al4 HEATING UNIT(OVER Hoopla)BI U)
- Yes []No VENTILATION PAN(SINGLE RFSID) PAID
Data Receipt
WIII the applicantor Nome buildlnK occupant use cyuipmnn or devises which BOILER-COMP l3HP OR IlN1.W(x li'flq
-mit hamdous air ovnmminams as defined by the Nay Area Air Qaallty Management TUI'AL:
D°u'at? BOILER-COMP(OVER 100.000 BTU)
❑Yes [3 No
I have read the hazardous acarmio"toincrono,ta,under Chapter 695 at me Cali- T
AIR CONDITIONER ISSUANCE DATE
(omit health&Safety Code.Sections 25505.25533 and 25521,1.1 understand that if the NEW RESIDENTIAL MECIL SQ.Fr
building des not cumcmly have a mnam6 that it is my ms,i nsihilay to notity the.,.,an,
of me"mr,mems which must he me,Pri............ce of a Cenilicate nl'(kxupancy.
Ownernrauthommdagcnt Date TOTAL ISSUED BY:
OFFICE