S 1705 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'1'INO BUILDING-FELEIII'RICAL Pl IT NO
BUILDING DIVISION APPLICATIONIPERMrfPLUMBING-MECHANIC-AL 1705
BUILDING PROJECTIIIENI'IF'ICATION
BUILDINGADDRESS: SANITARY NO. APPLICA'I ION SUBMITTAL DATE
Z 7 O $ �(
OWNFILAMB: 14/4 4 PHONE: CONTRACU RS NAME: PLIC N^fO,
1/CP r S /J fON✓s /V J J N/C CONI'HOL#
•I ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HI.DG ELECT PLUMB MECH
�- ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm than I am licensed under provisions(if Chapter 9 marancncing JOB DFSCRIPTION
FWON with Section 700B of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
1= in full forestall effwe. PERvirr ISSUANCE
IY V F- License Class `� Lar.R O r 9 ❑SFDWL ❑BE'I'CH EN REMODEL.
<-U APPLIANCES-RESIDENTIAL ❑ADDITION ❑1'IDMBING RE-PIPE
ZZW Dal Contractor S
Fpq ARCIIITECTS DECLARATION PANH S ❑MULTI-UNIT ❑STRUCTURAL
z O r/)z 1 undersmnd my Plant'holl Noted.,puhlic re,ords MODIFICATION
Oz'4o UP T0200AMPS ❑IN'DERIOR LAEfMFINEYREPAW
en.r, R. I,icenvee Professional
N201-1IAMPS IMPIFOVEMIEN'f (]SWIMMING POOLS
a�'^ OWNER-BUILDERDECLARATION (N0
OVER 1006AMPS ❑BATH RCMODFLfREPAIR ❑OIEMOLITION
1 herby affirm Nm 1 am exempt Ram Ne Commmoh Liame Lvw f r he
X It. following reaun(Section 7031.5.Bast nec and Professions Crane:Any city nr snarly SIGNS ELECTRICAL ❑OTHIER
WO m which requires a permit to connrct,alter,improve.demolish,or repair any immure
{{nn print n its issuance.also requires the applicant for such permit to file a signed smmemem SPECI At.CIRCUIT/M ISC.
Nat he is licensed pursuant n Bin provisions of the Contractor's License Law(Chapter 9
(commencingwmrt Section 91X0)ofDivision3oflheBusinessandivrnfcrrisoCadclor 'IEMIR ME!'I'I:RORPOLEINSI'. COMMERCIAL:
ii e eL that he Is exampl NcmGom orad the basis for the alleged excu Ption,Any violation of ❑NEW B DG/AUDITION ❑DEMOLITION
^ Secdon]d31.5 hynnynpplic,nl for a permit subjects the upplimnl ton eielllewdly of POWER DEVICES
..y ❑'1'ENAN'I' 01'0(1D SERVICE
man ws tho.owner
five h props dol lrrs my
IMPROVEMIENT
-F+ 6 hrsowne A,.rd oomm employees er es as their sale 044 roman, SWIMMING POOL ELECTRIC k^,
� ❑ property, YemP Y 6 A'
F. wllldothe wank,and IM1e mruclurc is nntintendednnmderW forsale(Sec.]M4,liueiness BOTHER
W 3 and Professions Code:'ILe Contractor's Licensc law does nal apply In air owner n( OUliEi1:5-SWITCHES-I IX'1'fIHIS
property who builds or imprn es thereon,and who does such work hiam,1f of untaught
bis own employees,provided that such improvements are not intended at olicred for NEW RESH)UN"L EC,
R
sada If,hawever,Ihe buildingor improvement is sold within one yearofeonmpleirn,the SQ,Irl.FLOOR AREA $/SQ.IT.
pner-hudder will have the burden of proving he did not build or inmpove Iia put- /fin
e if svlcJ) mm EI
i] I,us owrar of the propnny,En esel."vely cnntmaling with licemed"oh;.......I, TOTAL:4i'w,r,
runs,mel the protect(Sec.704UU Business and Pradesh.....Cade)The Contractor's LI-
roeLuwdoesnot apply toanowner ofprpenywho builds or improves lhemor,and QTY PLUMBING PERMIT FETE
who contracts for such projects with a rontmeions)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑ I um exempt mder See. ,B&P C for this reason
owner Dam ALTER-DRAIN h VEMll WATER A VALUATION
y_
WORKER'S COMPENSATION DECLARATION MACK FLOW PROTECT.DEVICE
I hereby dulla underpenain ul perjury rancorthe following declinations: —1�i_ 7 Q V
❑ I have andwill maintain a Cenincom orConsent in self-insure for Workers Compery DRAINS-FLOOR.ROOF,AREA,COND. snoRIE$ '1'VI'C CONSTRUCT ION
anion,as provided for by Scotian 3701ll of the Labor Code,for the parformarme of the
work fn ich this permit is issued FIXTURE'S-1'IiR TRAP
[y:pf end will mainmin Workers Compensation Insurance,as required by Section
371X1nflhe labor Code,fn the perfnrmnnceof the work far which this permit is issued. GAS-1lA.SYSTEM-1 INC.4 OUTLH1TS [KC.GROUP APN
My)V ke(JII Cntop
unsmum Nwrranc arricr rymd Policy.. �c
CrriccN/Y:w�ul icy Nn.: u rL9d 3C '- GAS-FA.SYSTEM-OVER4 UiA1
CIlR 1'IPICA'..!OP EXEMPTI ON FROM WORKERS'
COMPENSATION INSURANCE GRIiASIVINDUS'IRL WAS I'It IN'I INCEPTOR
BUILDING DIVISION
(This section need nm he complelul It Nepermil is forone hundmldoll�rs($LIN]) ORI
iASE'I'RAI'
or less) PLANCNIiCK PEI'
I cenifytha in neperfonnaacenf Ne work for which this Permit isi.vsucd.I shall SEWER-SANITARY-STORM EA.200 FT.
hilt employ any person in any manner so as to become s�ubjecOo the Worker' te CompeENERGY PEI!
s:nion lass of Califomin.DoneQ WATER BEATER WNEN IPLECI'R
7 O Applicant GRADING ITC
y NOTICE TO APPIACAN'n IL after irking this Ccm ica c of Exemption,yrs should WAII7R SYS,l!M/TREATING 5 soil's I>Illi M1u.ume sobjeooo the Wwker s Compensation provisions of the Luh Codm
e,ynunm
J fnnhwim...mply whh such pmvislans ar this per it ahndnw deemed mvaeed. WA'I lit SERVICE
7z CONS'[RUCTION LENDING AGENCY NEW NESIDIlMfIAL PLM118. SQ.Ef. PAID
L) O I for
permit I is..ed(Suction len ding agency for Ne performanceof Dme iPtp
" P IN wmkfar which this)can't iv issued(Sec 30N)7.Ci,CJ
O U Lendeh Nome '1'0I'AL:
Isnders Address - - TOTAL:
I certify thin av
1 he read this rppliemiond n asone that the above informal n is - BUILDING Il. �
V) correct,lagme turn 1,whh all city and ,,only ranlinancm end scala lows relulin6lo' QTY. MECHANICAL PERMIT FEE?
U buildingconsWeliun,nM lemhymill rritorepmhemlaliva,of this city to enter uP^ithe SEISMIC ITL!
nhnve-amationed property or inspection purposes PERMIT'ISSUANCE
(We)agree In wve,inni
demfy and keep harmless the City of Cupertino against ELECTRIC IB fi.
IiuM1ildws,judgmemy cos lsandexpenreswhoh mryinonyweyaccrengairetnuid City ACIER OR ADD TO MECH.
in msequence of the gmnfng of this)coni,. PLUMBING FEE
APPLICANT UNDP.RS'I'ANDS AND WILL COME' , WITH ALL Nosi-EmNT AIH HANDLING IJNI'1'(TO 18.(x)CINESOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER I0p80 CPM) CONSTRI]C'I'ION TAX
Signal. uanll onlmcor Dam EXIIAUS'I'HOOD(W/DUC'lT HOUSING MITIGATION FES
HAlAItUOUS MATERIALS DISCLOSURE
Will the applicant orfawre buildingmmnpanl shore orhandle hazardous material HCA'1'INO UNIT(T0100.000]11 U)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cale,Section 25532(u)? HEATING UNIT(OVER 100,000 if
❑yes FI No
VIlNT'ICATION FAN SINGLE RISID) PAID .
Dam RocciPt M
Will the applicant or future building Occup nt use equipment or devise which BOILER-COMP(3HP OR IfN1,IXN1 BTU)
mil hoznNous air annuminunts as define)by the Bay Arcn Air Quality Management TOTAI
Uixolctl
❑Yes ON. I1UILlill-COM P(OV ER I0II,00II11'IL)
I have mid the hozmdous mmerials re nems under Cha ler fi 95 of the Cali- AIR CONDITIONER
quiml p ISSUANCE DAT'IE
OfowmlaHealth&�owr ululh.nzrSizaSafety/uyg�Cad,SeMctionsiand 15534.1 understand
nd N:n
if the NEW RES IDENTALMfCllSQ.FT.building
does
not ,enly arms,thatiismya nfmOfycpwt
nlheryuremverss whsnin" "mo' doroissuancetifnCeiiclefOcupacy
^tee- p
r/ D
Oam V V ATOTAL: T •�
ISSUED BY:
OFFICE