B 0194 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY .,
BUILDING-ELECTRICAL PERMIT NO. 0
.. CITY OFCCPVISION PLUMBING.MECHANICAL
BWI,UING DIVISION APPLICATION/PERMIT - S6001I I :,:1 V ,BUILDING PROJECT IUEN'1'IEIG9'ION'(.' <f
BUILDING ADDRESS: SANITARY N(]. APPLICATION SUBMIT ITAI,DATI
o� s o�
OWNER'S A E: 1'IION - CONTRACID :g NAM • LIC NO.
r / O / // p NIC CONTRDI.N
I '✓ LIC NO',' A)DRESS: O� ❑ '
.�1 NCIHTFC/RNGINEI;k:
CONTACT: I'Hami:, - ,r, ;' 'BUILDING PCRMIT INFO
�`� - / �— ❑ Consultant Fees Paid by Applicant(Initial) BLO El IiUr/ PLUMB MECII
�� 4rJ,//
LICENSED CONTRACT ORS DCCT ARAI IO . QTY �/I I I CCTRIC I HRMIT�t I // .al TIL /" (
I hereby affirm thin 1 ata licensed I p : Chapter 9 t molal. g fall
-JOB DESCRIPTION
Woo with Section 9000)ofDlvsimn Sot mBOn dIs 1 Rale my is RESIDENTIAL'
610p y PERMIT ISSUANCE
F� in full force an B�cJ, .e2a� D 5 ❑SFDWI. CKITCIII:N REMODEL
�UU Lic,ns•Cl:ss LSN APPLIANCES-RESIDENTIAL ❑ADDITION .]PLUMBING RH PIPE
zw Dm, Cont ]
�<a ARCIIDECTS DECIARAV ON ❑MULTI-UNIT CSTRUCTURAI.
F.pm PANELS MODIFICATION
rZy'6 I understand my plans shall he used as public records
�O UPT0200AM15 ❑INTERIOR [I CHIMNEY REPAIR
W Liecaned Preirc man 201-10OAMP IMPROVEMENT ]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BAIIREM0 "JREPAIR ODEMDLITIDN
C C W Q I hereby anion that I am exempt from the Co:mactor's License Law for the
iqyx5 . OTHER
F U hlllnwginreason.(Sectloh]0313,Rusin re and Pmfessiens Code Any Oily or county SIGNS ELEC'T'RICAL ❑
W 3 WF'¢ which requires u Fermi,a construct,eller,improve,demolish,or opni,any ahacam l�-
F-�Oprior m ssuce
its ian .also imparts the applicant fineuch rm
peit m file usignedsutement SPECIAL CIRCUI VMISC. C
Cd.]r ]hot he is licensed pursue To,
provisions al the Contractor License Law(Chup¢r9
Lai OC nommuain,,rh See,ma 7000)4 Dlviminn 3of the Business and 11 fes—coCude)or TEMP,MET HL:
R OR POLE INST. COMMERCIAL
6 d e C that he in exempt Ihemboan and the hasis for the alleged cmmption.Any violation of ]NEW BLDG/ADDITION ]DEMOLITION
W^m Section 7031.5 by any applicant fm apemailmbjects the applicant 11)a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SEE
RVIC
our more]hurl fisc hundred dollars($500). -IMPROVEMENT
•
SF.E :11,ns nwncr of line pinperly.nr lay enlpinyeca with wngcv us their sole compenmtiom, SWIMMINGPOOLELECIRIC
will Jo tla work,und the slmcwre is notimenJedmoffemJ for sale(Sec.9044.Ru.viness COTfliil2
L3� and Pmfessinns Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-PIXTTIRES
pmpcny who builds or improves thereon,and who does such work himself or through
his own enlPlnyecs,pnsvidul her tach inapnwcromk arc not intended m m11mM for NEW REMLIHN-1 AL P.LECTR SQ I-T!,
SQ
sale.ILhnwwernhe M1uiltlingminapmvemem is sold within nuc yr.Ir ofcomplvTlnn,the F.FLOOR AREA SISQP
. I'.
owner will hast the buNen of proving that he did nm build m improve fur pmr-
prase oEsulu).
❑ 1,as nwncr of Ibe properly,one cxclmively wnuveling with IlcemM cnninlmns to T� Y
amsuua line project(See Jo44,Business and Professions Code:)The Conifaclnds Li- .q - - - t.. -a).riy - ,.. ,•.i :J',-a r'
se law macs mtaFFly to an nwncr of pmpcny who builds or improves whereon.end QTY.I_ 0,'0, 1'IUMBING'PERMIT is. �� FEE')
who contracts for such projects with iicnpum
atrat Licensed rsint to the Contractor's ,
I.Icense Law. p,I1MI'1'ISSUANCE
0 l am exempt under See. .B&P C for this reason
ALTER-DRAIN&VENT. WATER(EA) VAI.WSTION
owner nate
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT UEVICII
1 herchy affirm molar penalty of perjury one of Th,following decimations: -
lhaveandwillmaintainaCenificamof Comentto self-insure far WmkeYs Cmnpen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TY I'll CONSTBUCfIOF
svlion,as provided for by Section 3100 of the Labor Cod,for the performance of the
work for which This permit is leaned. FI X'I'ORES-ITR TRAP -
0 I have and will maintain Walker's Compensation Insurance,an required by Section
37M of the LahotCode.for the perfomlauce f,he work far whidt this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS J11 OCC.GROUP AI'N
My Waryr C m ssmRongx ,Ins c(p� td P, le yWi)�^ryg:,a�3A CAS-9A.SVSTBM-OVHR4(UA)
CnrtieC �.�/+.1[ iw //IAKrr I'nbcy N.(s✓/Ii(jj YY _ D
CERI IFICATi3 FBXEMPTION Flt MWORKERS' GRHAMYINDUS'FRL WASTE INTERCEPTOR V
COMPENSATION INSURANCE BUILDING DIVISION FEES
('this section need not he completed it the permit is for one hundred dollars($1001
GRI3ASE TRAP LANCIIIiCK Pliii
loss)
Immi,dat in the pe rfnmmnceoffe,vort,fmrwhich Nis permit is issued.looll SEWER-SANITARY-STORM RA.200 FT.
urn employ any person in any manner so as to become.subject to the Workers Compen- ENERGY FEE
z Minn Lnw.s of Cullfoom,Date WA'I HR HF,ATER WN EPELF.CTN
Z Q Applicant I - GRADING FEE
NOTICE TO APPLICANT:If,after making This Certificate of Exemption,you should WATER SYS,EMITREA1'ING
F h Mmmasubject m harmed
the Worker's Compensation pmvisians of the Lar Code,youSOILS 193E
Wforhwith cn:nply with such provisions or This Fermi]shall be deemed revoked. WATI'.R SERVICE -
Q
:D CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI'. PAID Da NmciplM
UQ Ihcrehyieffirm that there isaconstmnion Iminingagency fur the perfom]ance of
L4 ,� The work In,which Ihe,permit is issued(Sec 3099,Cil.CJ
TOfAI.
OL) Lenders Name :
Leaders Address IOIAU
D.1
hat the ebnve information is . - ,. BUILDING FF.
fy I certify that I have read this application and state t
In curmcl.I agree to cnnipil,with all city and county ordinances and shoe Inws mlatmgm QTY. ( MECHANICAL PERMIT ' FEE'. I
fJ7 building construction,and hh
ereby aatmue mimesenwtives of']Oil city to coru
er pon The SEISMICITHE
r� above-mentioned propeny for inspection purposes. PERMIT ISSUANCE Is{_/ F.LEC7FRIC FEE O
(We)agree to save,indemnify and bareness keep harss me City of Cupertino against <
liabilities,judgments,crosband expenses whimmay in any wnyaccactimin'I'mm City ALIEN OR ADD TO MF.CH. PLUMBING FE
in consequence clue,'mating of this Fiction.
APPLICANT UNDERSTANDS AND WILL COMPLY.WITH ALL NON-POINT AIR HANDLING UNIT(1011(00 CPM) MECHANICALFE
SOUR GULATV'tt
/I / ,,y ^gni. G•/y AIR HANDLING UNIT(OVER 10,11tCFM) CONSTRUCTION TAX
Altar,ofAApppL�icaauk-mlamtirr Dma, EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAT17RIALS DISCLOSURE
Will the aloivaut or 6nnrc building necupnntamre err handlm haealloasnnamwl 1117AFING UNIT(TO IOR0IE BTU)as definal by the CupertinoMunicipal Code,Chapter 9.12,und the Health unit SafetyCode,Section 255321v)^ HEATING UNIT(OVER 1(0.000 BT0 Yes 0 No VENTILATION FAN(SINGLE RESPAID
Dais Receipt4
Will Ne applicant or future building occupant use equipment or devices which BOLI BR_COMP(3HP OR 1W,IAIemit heeanlous air contaminants as defined by the Bay Area Air Quality Management T'OTA
Disuiia? BOILER-COMP(OVER.I 1000 B
0Yes ON.
I have read the hazmdous materials te9viremenn under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUAN/CE1 DATE
Blmia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RES]DENI'IAL MECH. SQ,PT / r ��]
buildm• ICI h��ly him,It ��.Tem 11 is rusponsibillry Nnotifyhteeccupuw /V�l• I
n �/ u.vyfjny'pnnni Ice ofa Cenif/pme;f Imc
O utladmd aaggent ' Dale TOfA -� ISSUED BY: r`
OFFICE