S 0731 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO,
BUILDINGIkIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0731
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL,OAT[
LA W C Z-�y-
OWNER'SN ME: PHONE: CONTRACTOR'S NAME:: LIC No:
NIC CO/NTROLp
.WHITECT/ENGI E R: LIC NO: ADDRESS: ❑ S /-
���000
CON'IACn l PHONn: - BUILDING PERMIT INFO
MAW,/ � -�f��� E_ Consultant Fces Plaid by Applicant(Initial) ByuG ELrc'r� PLUMB � MEcu
LICENSED CON'1'RAC'InR'S Dec1.ARAD(')N_( QTY. ELECTRIC PERMITFEE ®/
I nercby alum mal I am uccnxea aede,prnvldnnx lar enapmr 9(emninencing JOB DESCRIPTION
WOZth Section 7")o(Divislon 3 ofthe Business and Professions Code,and my license is O
IODi
wPERMIT ISSUANCE
� J
F+� nfull force and ellen. FDWI. ❑KITCfIIiN REMOUfiI.
U� License Class Lic.# APPLIANCES-RESIDENTIAL ❑ DDll]ON Ll PLUMBING RE-PIPE
Q Date Commemr
ARCHITECTS DECLARATION ❑MULTNUNIT ❑STRUM TURAL
Z,Doti,?-I understand my plans Ball be usedus poblie records PANELS
a' MODIFICATION
OZ- UPT02011AMPS ❑INTERIOR ❑CHIMNEY REPAIR
I:. W Licensed Pmfeaimed 2014000AMPS IMPROVEMENT ❑SWIMMING POOLS
a? OWNER-BUILDER DECLARATION fo
I hem he Comealm
OVER IIXX)AMPS El BATH RIiMODE1JRIiPAIR ❑DEh101-(TION
hereby affinn mot I en exempt loan t .,License Law for the
fallowing reason.(Section 7031.5.Business add Prol'es.ciuns Calc:Any city or county SIGNS ELECTEECAI. ❑OTHE
which requires a permit m construct,aim,,impmve,demolish,or rapid,any structure
prior to its issuance,also reywres the applicant for such Permit file a signed statement SI'ECIAI.CIRCUIT/MISC.
at that he is licm¢ed pnmtt
tano the proviximsof the Coal um
cr'a lase accLaw(Chaper9
� (commencing with Section 7000)of Division 3 ofthe Business and Profnssinns Core)it 'TEMP.M17fER OR POL13IN5 COMMERCIAL:
a la,a Ihe1 he is exempt therefrom and the basis for me alleged exemption.Any violaann of ❑NEW BLDG/ADDITION ❑DEM01.1'PION
�,mN
Section 7031.5 by any applicant burn pennitaubject,the applicant m a civil penalty of POW[R UEVICFS ❑TENANT' [D FOOD SERVICE
not mom than five hundred dollars(9510).
IM IR EVENT
=6 ❑I,es nwrtcr of me property.mmy employees with wngesa theirxole nsmPcmation, SWIMMING POOL IiLECTNIC
F-Mai will do the w.,k,..d,ha saume is ntcndedornffemd for sale(Sea 7044,Business ❑OTHER
ucm in
� O
3 land Pmra,,mns Cale:The Contommts License Law Arcs nm apply ,,nn owner of OU1fLET'S-SWITC111!S-Fl)CTURF.S
pmpeny who Nabs or improves thereon,and who docs such work himmlt m mrmtgh
his own employees,provided that such improvements aR not intended o,offered for NEW RCSIDENTEAL HTC'IR SQ FT.
sale.If.however,the building or improvement is sold within one year m earoulelion,the �� Ot SQ.FT.FLOOR AREA $/SQ.FT.
er-bllllde,will have the harden of proving that hedid not hold or improve for par. # /
�w a m,ele.) '3 -B �3 r�
❑E,as Owner Of the property,am exclusively contracting with Licensed contractors m I OTAL:
noncan the project(See.7044.Business and professions-suc:)'IFIC COmtumorx 1-1-
can.Lawdoes firtappy to an awoor Of locIpany who mulds tit raprovos thervan,and
hccnsoLawdoesnotappytounawoorOfpcIpanywhomuldsotlmpmvoslhemon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a cormorants)Menaced pursuant tot he Contirmou"
License law, PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this reason
Owner Data M:fER-DRAM&VE T-WA'IIR(EA) VALUATION
nfollowing
Ii 3 —7S eo ofmROMPENSenlBACK FDW PR(T[LT
I hereby urunitpeory onfme fwing dearatos:
❑Ihavcund will nmimeln.Cunilleate nl Cnnsenl In self-innurc for Workar'x Compcn- DRAINS-FLOOR,ItOOP. RE
soma,ax provided far by Section 37M of the Labor Code,for the performance of the S'IY)RIES TYPE CONSTRUCTION
wool:for which this Permit is issued IBXTURES-PER TRAP
❑ 1 nave and will nama airs Workers CotrImmmion Insuranceas required by Section
3700 ofine Lobar Cole,far the parr mmmnec of the work for which this penult is issued. GAS-BA.SYSTEM-I INC.4 OUT Is. OCC,GROUP APN
My Worker's Compensation Insumnce carrier end Policy number arc: r�
Comer: Policy Nn.: GAS-F.A.SYSTEM-OVER 4 UA) y
CERTIFICATE OF EXEMPTION I7NOM WORKERS'
COMPENSATION INSURANCE GR IASIJINDUSTRI.WAST(;INTERCIiPIDE
&b ) ,PI VISION FI!I'!S
(This madirtueedntnbe completed ifthe pernll is Intone lmndmsi dollars PUM) GREASE TRAP
or let,.) PLANCHI! F P. O/ Q
I certify that in thetarlorinoneeoDfia work lir which lois actual islxsuod. da1l SEWER-SANITARY-STORM EA.21X1171'.
not employ any pennn in anyi net. Io bmpineNdi to the Wnrkerd Compcn- ENERGY I'I!B
7�O APPGcnm C n Ume r _X11// WATER HEATER WNENT/IiI.ECTR GRADING F.
F7 V) NOTICE' A L CANT:IL a' tan ting bit COnilieme of Bxnndion,you should WATER tiY5"IBM/fEY,A'fINO
F-I become subject to the Workers ompensation pmvisiom of die labor Cole.you must SOILS PBIi
{aZl sus forthwith comply with such pomix.crior this pemtitxnall be deemed rcvo4d. WATER SERVICE
0. Q
UO CONSIRUCTION
... LENDING AGENCY NEW RESIDEMIAI.1'LMIi. SQ.Ff. PAID Dam RM,,#
I Hereby affirm that mere is issued
em .auction0 7, agency for the perfnm mee of O e p
the work for which this permit is issued(Sec.3097,Co.Civ.CJ # O
0 1"' Lender's Name TO
U Lender's Address TOTAL:
PWi I cenify that I have read this application and state that ane above information is 'BUILDI HE i x'l
LE"i [q coned.l agree to comply with all city and county ordinances and state laws relating to QTY I MECHANICAL PERMIT FEE
U buildleg a,) auction.and hereby adhorimmloc,nnmlviceof this city m encrnpon me SEIS !
above mentioned property for inspection purposes. I'ERMI'I'ISSUANCIi 3
(We)agree m save,indemnify and keep bamiless the City of Cupertino against L:1. PBC O
liabilities,judgments,costs and expenses which may in any way secure against said City ALTER OR ADD1'0 M ECB.
in consequence of the granting or this permit. PLUM LNG FEE 0
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000 CFM) MI7CHA ]CAL FEE.
SOURCE REGULATIONS. 2
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTR TION TAX 12-
Signal..of ApplicanUConavcmr Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building maeoperadom or handle hazardous material HEATING UNIT(11)100,000 BTEI)
as defined by the Cupertino Municipal Cts c,Chapter 9.12,unit the Health and Safety
Cody Scam.255321o)? HEAPING UNIT(OVER 100,000 BTU)
❑Yes Fl No PAID
VEN'1'lLA'I'ION FAN(SINGLE.RF.SID) Dose Reccial#
WILL the applicant of future building occupant use equipment m devices which BOILER-COMP UHP OR 10.000 BTU)
.it hazardous air contaminants as defined by the Bay Area Air Quality Management
UlAlrit'1?
❑Yes [:1 No BOILER-COMP(OVER 100,000 BTI])
I have read the hazmdeux materials"montients under Chapter 6.95 of the Call-
AIR CONDITIONER ISSUANCE DATE
foam.Heart&Safety Code,Sections 25505,25533 and 25534.1 rotational that it the NEW RESIDENTIAL.MECH. SQ.IT, a
mildiagdoes not currently have a tenant,mal it ismy ,wmy to nilly the oceuP:m1 ` L o
of me r uimmentx which mu.0 be mo promo ixsuanec Of a Cenificam of(kcupuncy. t 0 7 3 DC
Daniell,authorized ,at Data C TOTAL: ISSUEDIIY:
OFFICE