31160 (2) ` APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF,CUPERTINO BUILDING-ELECTRICAL. PERMITNO, 60
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
RUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUHMITTAL DATE
c
OWNEN'S NAM PHON : COMRACTOR'S NA E: LIC NO:
N/C CONTRO X
/ L "✓ vv
ARCNIT.C'1'/ENGINEE LIC NO: ADDRESS:. - ` ❑
r
CONTACT: tP�H•O(NE:(/ BUILDING PERMITINFO
/✓ (, �Y ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB SUCH
❑ ❑ ❑
LICI?NSED CONTRACTOR S DECLARATION QTY. ELECTRIC PERMIT FEF.
I hereby affirm Ilial l am bpa„s«I under prnxisiona of Chapter osai 9 ra,hOeiming JOB DESCRIPTION
XIZZ00 wiNSeorceaIXM))afDivision]ofNe Rosiness and Professions Code,and mylicense is
�O .n PERMIT ISSUANCE RESIDENTIAL:
�WUE 'Lo
full come and e[�c //ff t
E-ZW License Clan Lic.p ❑SFDWL ❑KITCHF,N REh10UF,C
rFis66 Dam I _Conuacmr �[tYa� APPLIANCES-RESIDENTIAL. ❑ADIJITION ❑PLUMBING R&PIPE
[[--..pry ARCHITECTSDECLA AI'ION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z p H 7J 1 undersand my plans shall h used as public reemcf, MODIFICATION
OZ— UP TO 2W AMPS ❑INTERIOR CI CHIMNEY REPAIR
F,'/L E' Licensed Professional 201-10)(MAMES IMPROVEMENT
App OWNER-BUILDER or the ImInceN
1 hereby affirm that I em exempt from the Cnmracmr's License Law fur he OVER 1(X10 AMPS ❑BATH REMODEL/REPAIR C1 DEMOLITION
Sf 36 U which ng reason(Section'o3L5,Rosiness and Professions Code:Any city structure
SIGNS IiLECIRICAI. ❑OTHER
roll W which requires v permit to0315,construct,riles m id nce.Isco demolish,de repair any r county
priorw is I....me,also requires theapplicanl farsuch permit ,Elea signed slvmmcm SPECIAL CIRCUEVMISC. -
y that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
(commencing with Section IINX)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLF.INST. COMMERCIAL:
that he is exempt lherefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iYCI Yy
Section 703 LS by any applicant for u permit sobject,IM1e appl team to a civil penahyof POWER DEVICES
not more than five hundred dollafs($501D. ❑TENANT ❑FOOD SERVICG
= G ❑ I,ssowner o(N<propcny,or my employees wiN wages as their sole rompcnsnion, SWIMMING 1'00 .GI'RIC IMPROVEMENT
GGGGC xilWn the wmk,and thastracame isnnl lmendulnroffend for sale(Site704T Husiness ❑OTHER
S3 and Professions Code:The Convector's License Law does not apply n)an owner of OUTLETS-SW ITC TURES
progeny who huilds or improves thereon,and who does such work himself or through
his own employees,provided that stair improvements xre not immnded or offered for NEW RESIDENT& L ELE SQ ET.
sale.IL however,the building or improvement kind within one yearufrnmp...... the FLOOR AREA $/SQ.FI'.
o wnerbui&der will have the burden of proving that he did not build c r improve for Aur- �II
Ease of sale). Y / as
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.?014,Business and Professions Cede:)The ConuacuKs Li- I Y Y
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PF;RMI9' LUr'�(�I�
who caramels for such pmjecls with a convanor(s)licensed pursuanuo the Comreaoe% rl njo
License Law. PERMIT ISSUANCE
❑ I am exempt ander Sec. ,B&P C far Nis reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPHNSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby af0nn under pcnelry of pepury,one Older following declarmiona:
❑I have and will maintain a Certificate of Consenua self-insure for Workers Comped- DRAINS-FLOOR,ROOF,AREA,COND. STORIES "TYPE CONSTRUCTION
station,as provided for by Section 37N)of the labor Car,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP '
1 have and will maintain Worker's Compen.sution Inwtnnce,as required by Section - -
X&of Ne labor Code.Entire performance of the work forwhich thispenam is issued. GAS-FLA.SYSTEM-I INC.4 OUTLETS'
My WorkerSCompenylion In tce< lv and Policy number are OCC.GROUT' APN
Corrin: ae+n/✓��j�Pnlicy Nox:��U �9 / GAS-EA,SYSTP.M-OVER4(EA)
"- ERTII'ICA'TC OPXEMP&'ION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This seedon aced not h camplcad if Nopeorm,is for one hondmd dollar,($100) BUILDING DIVISION FEES
or lea.) GREASE TRAP
PLANCHECK FEB
Loy any thin in the wifforanymmanc,u s I work fnwhich this peramit the W.ke,,'Corna- SEWER-SANITARY-STORMEA,200FT.
not employ any person iany manncrvo as In become subject m the Wnrkerl Comped- ENERGY FGF?
,� Applicant WATER of California.aDale
� O A licam WATIiR HEATER WNENT/ELECTR
PP GRADING FEE
NOTICETO bJAPPLICWorkrs afterdakiugthis
ovisions afof l Timorodyoushould WpTL'k SYSTI?A1/1'kl?ATING
become su comply
the Workers vision, s his provisions h.1 df the Lahr Cede,you mmt SOILS FEE
Eta
forthwith comply wish such provisinnx nr this permit shall be deemed revoked WATER SF.RVICF. -
az CONSTRUCTION LENDING AGENCY NEW NtS1UENTIAL YLMB. SQ,FT. PAID
VQ &for which
lha.i,,issued( eeti3097.Clog agency forthe perfonnunceof Dem ReceiplM
IL F Ihework for which this permit is issued l5ec.3(199,Civ.C.)
U Lenders Name ItTAI.:
Lender's Address TOTAL:
ly 1 certify Nm I have read this application and start Nat the above information is. BUILDING PER
h coned.l agree to comply with all city and county radical and state laws reining to QTY. MC•CHANICALPERAIIT FGF.
V � bulWingconswdiomart Everchy Inirppresemmivcs of Nis city memm�mnn the SEISMIC PBG
above-(WO)agree
propene find inspection keeps PERM IT ISSUANCE(We)agree to save,indemnify and keep harmless the y no of Cupertino against City ELECTRIC FL
incodual suclu udgmf the costs and expenses whish may inane wary nameaguinu snit City ALTER OR ADD TO M OCH.
A consequence aE UNDERSTANDS
of Nis D WILL
PLUMBING FC'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0!1(1 CPM)
SOURCE REGULATIONS, AIR FEF.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONT
Signuwre of Applicau/COmrunor Dutc EXHAUST HOOD(W/DUCT•) HOUSING MITIOAT )N PER
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oecupam store or handle hmandous material HEATING UNIT ITO 100,00)[)TO)
as defined by the Cupertino Municipal Code.Chapter 9.12,and he Health and Safety
Cade,Section 25532(x)? BEATING UNIT(OVER 100,(X10 BTU)
El War [INo
" VIdS I RATION PAN(SINGLE RBSID) PAID ,
Date Rucipl#
-ranWill the applicant or Tuts building by the B use en AirQul lily Management
which HOILER-COME LIPP OR RKEPM BTU)
id hazallous air wmmminams as JcOned by the Bay Am,Air Quality Munngemem
District? TOTAL:
❑Yes F)No ROIL&iR-COM P(OVER&OO,Ikp RTU) -
I have mad the hazaNnus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Sections M505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH. SQ,Ff.
building does not urrently havmucnani,that it my n,,mrsdefity to notify the accupem
ofth/ryygm amens which must be mel piormissoance ofa CeniGcaleofoc panty.
0 nr rautHimzeduge^V��-051ee '- s TOTAL:
ISSUEDBY.
OFFICE „