B0442 (2) i
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-ELECTRICAL 11 PERMIT NO10442 0 4 4 2
BUILDING DIVISION APPLICATIONIPERMIT DINGPLUPROJECT
FICSOOOI
BUILDING PROJECT IUNN'I'IfICAT'ION
BUILDING ADDRESS: SANT"TART NO. APPLICATION SUB HITAM DTI
a 3c,
OWNFJ]L!$N ONE. �aj CONTRACTOR'S NA MF,'. LIC NO: NIC CONUROLA
[J. /V
ARCNI'I'EGT/fiNGINEER: LIC NO:I ADDRESS. ❑
CONTACT: PHONE: BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDGEW PLUMB MI3Cfl
J ❑ ❑
LICENSE nhaID CON'nRACnder p DECLARATION QTY ELECTRIC PERMIT FEE
0 z Z 1 hereby a))af that 1 ntn licensed Bd under pmvisfns of Chapter 9 my Iterates,
is JOB DESCRIPTION
'm section]ap)of Divi:ion 3 onhe Business and 1'mPos.ion:nal,,and my license i.c RESIDENTIAL:
u1 Op with lull farce and cover. PERMIT ISSUANCE
F Imo '" ❑SFDWL El KIT RIiMODEL
QVZU License Class Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
vFi Z W Dam Ca dractm
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCf URAI.
'Dr/a PANI:IS
LPT0200AMP5
Z p v Z 1 umlersomd my plans.hall b,used m pobllc records MODIFICATION
OZ—,, El INTERIOR ❑CHIMNEY REPAIR
OL
¢„r j Licensed Prnleexion9l 2ol-]"AMPS IMPROVEMENT (]SN'Ih1MING POOLS
C�S OWNER-BUILDER DECLARATION
a OVER laIflAMPS [I BATH RF:h10UE1/REI'AIR ❑DEMOLITION
a Q 1 hereby affirm that 1 am exempt from the Commmor's License Law for the
W 3 a F following mason Permit
]onstrt.atsBusiness and ter.de in%demolish,
Code:Any city art acture SIGNS ELECTRICAL g------� ❑OfHF;R
y which requires n permit m construct."Icor,rand Pro demolish,de repair any r'nomy
CLL�g prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIkCUR/MIS
�to thath,,licetsedpursama ,,the pmodoo,ofOe Convucmr's License low Chapter
.14 mournendng with Section Division Sof the Business and Profestur,Cde)or 1EMP.METER OR POL lINST. COMMERCIAL:
a a e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of p T�`� !!.� 'I(� ONE W BhDGIADDITION El DEMOLITION
m Section A131.5 by any applicant for a pcmdt subjects the applicant to a civil penalty of POWER DEVICES it IM 0 `Y 999 ❑TENANT ❑FOOD SERVICE
not marc than five hundred dol lets($SW).
=Q ❑ I.as owner of the prapoey,or my employees with wages as their sole compensation, SWIMMING POOL EL RIC IMPROVEMENT
t. willdothework,a olve,ararm,isnot intended oroffered forsnle(Sce.7a44.Bminn. ❑OTHER
Wand Mathewson,Cole:The Commebut,License Law does nm apply to or mu'nvr of OUTLETS-SWITCHF4 flTURES
e. properly who builds nr improves thereon,amt who dsxs welt work himself art through s
his nwn employees,provided that such improvementsare not anot intended or offered for NEW RESIDENTIAL ELECIR--'-'-".
PT
sale.If.however.the handing or improvement issold widurom,yearmfwmphoion,the SQ.FT.FLOOR AREA $/SQ.FT.
aramer-frailder will have the burden of proving that be did net build or improve for put-
pow oLmle.),
❑ I,as owner of the pmpeny,am exclusively contracting with licensed contractors m T
instruct the project(Sec.]two,Business and Professin"s Code)'ITe Contractor's Lt.
neLaw does n"imply it)anowner ofpropeny who btdldn or improves thereon,and QTY PLUMBING PERMIT
who commas for such pretests with a c"nmicums)licensed purstmntto the Connecters
License Law. PERMIT ISSUANCE
(] Ienex,mpt Jer Sec. ,B&PCurthe ctoon
AI.TE,R-DRAIN&VENT-WATER FA)
Owner ALUATION
Lam
O RKK OffCO'M-N- N 1 BACK FLOW PROTECr.DEVICE r\
1 hereby affirm under penalty of perjury onfof the following dcelarlBOnf— dJ-T
I have and will maintain a Cenifcate of Consent to self-insam for Workers Comped- DRAINS-FLOOR.ROOF.AREA,COND STORIG. T PG CONSTRUCT](satin.,as pn,vlded for by Section 3]W of the lather Code,froom pefrmwxaa of me
work for which this permit is issued. FIXTURES-PER TRAP
0 1 have and will maintain Worker's Cnmpensaion Insurance,as required by Section
370gof Ne Lfam,Code,for the pcRommnccof the work for which th,lu,not roosted GAS-FA.SYSTEM-I INC.4 OU1'LETS
OCC GROUP AI'N
My Worker's Compensation Insurance c:ud<r and Policy number um: o
Carrier Polity No.: GAS-Ii.SYSTEM OVER J(EA) 'rj �fQlf4 ��
XE
CERTIFICATE OF EXEMPTION FROM WORKERS' J Q�J
COMPENSATION INSURANCE GREASE)INDUSTRI,WASTE INTERCEPTOR
IThk section need not beccmpletN ifthe permit is forma,hundred dollars(S 1000 BUILDING DIVISION FEES
or Ins.) GREASE'1'RAP PLANCIIECK PEE
I certify than in the permainncv fee e work forwhich this permit is issued,Ishall SEWER-SANITARY-STORM EA.2W IT.
not employ any person in any nenner so as m become subject o the Workers Comped- ENGkGY PIeE
ZZ cation Laws of California.Date WATER HEATER WNETHMLECTR
O Applicant t GRADING IT
y NOT ICE IO APPLICANT:11',alter making this Cetiifcdm of Exemption,you should WATER SYSTEM?REArING
F�
free ome sobject o'he Worker,Compo"sem"pmvisinmofma Labe Code,you must SOILSF1,E
bmhwith etmply with such pn,i......or this pvrmtt,hall be deemed revoked WATER SERVICE
Q
CONSTRUCTION is a TION LENDING AGENCY NEW RESIDF,NTIAh PhMP SQ.FI'. PAID
V ,hereby which
this
that there isawmuugion lending agency for the performancemf uh RtteiplM
� E' the work for which this permit is issued(Sec.3097.Civ.CJ
O :.endo,Name TOTAL
r lenders Address TOTAL:
I evenly that I have read this application and state that the abase infi,tm cion is BUILDING F
rv4) correct.l agree to comply with all city and county ordinances and stare laws relating to QTY. MECHANICAL PERMIT FEE
)Z building aonwmetion,and hereby authorize a presentiovesofthis city menteruponthe SI..ISMICMIz
.. above-mentioned progeny for impaction purposes. PERMIT ISSUANCE(Wq agree ret nave,indemnify and keep harmless the City of Cupertino against ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way rectae against said City ALTERORADDTOMECH.
in amsequence of the granting of this permit. PLUMBING FEE
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00 CFM)
q MECHANICAL FEE
SOURCE kliCllL '1(JNS LIT
AIR HANDLING UNIT(OVER IO.IXp CFM) CONSTRUCTION TAX
Signmurc of plicr omranm ` u Dae EXHAUST HOOD(W/DUCq HOUSING MITIGATION FEE
HAlARDOUS MATERIAE DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNI'r(TO I00.000 BTU)
as defined by the Cupeninn Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 255320)1 HEATING UNIT(OVER IStaff BTU)
p Year
VENTILATION FAN(SINGLE kESID) PAID
Will the applicant or Ginn building occupant use equipment or devices which Date Receipt M
emit hazardous air contaminants an defined by the Hay Arca Air Quality Matwgement BOIL12R-COME(3HP OR I00.000 BTU)
Distinct BOILER-COME(OVER 100.000 BTU) T
❑Yes S/"°'t
I have read the hanrdons nwterial.s requirements under Chatter tl.95 of the Cali- AIR CONDITIONER
4 p ISSUANCE DATE
fomiu reaut&.'afety Cale,Sections 25505,25533 and 25534.1 and,tsmnd that it me NEW RESIDENTIAL MECH. SQ.tT.
builtlingJces cu cn yhaveam ankior ymswfaCilityto dfy.h c
id ther a ofa Cenific f cy
watt � p"° ""_e �f�'YtsiB�
orc,0,umba"cau agent m TOTAL: ISSUED BY: r
OFFICE