S 0868 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LRC'PRICAL PF I?No.
APPIACATIONQ'ERMIT PLUMBING-MECHANICAL 086
8
BUILDING DIVISION BUILDING PROJEcr IDENTIFICATION
SANITARY NO. API'LIC1A'IION SUBMITTAL DAI'F.
IlwAADDRESS:
VNEWS NAM:: PHONE: CONTR NA LIC NO: NIC CONTROLA
W e c '?
ARCI HTECI'IENGINEER: LIC NO: AODRE '� O %^ '517.
❑
CONTACT: PHONE. BUILDING PERMIT INFO
( T r7_ �rm`iTe .5 -5 [-] Consuilanl Fees Paid by Applicant(Initial) ;9- ❑'.ELICT PI.1MH ME❑CH
/ ,h✓`'LICENSED CONTRACTOR'S DECLARATIONQpY. L•LECTRIC PERMIT FEE
1 hereby union that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
won wbb Rection 70 )ofDivision3 of eBusin auto] nfe iu .Cale,andm ",ands RESIDENTIAL
won W -_�� -yr R PERMIT ISSUANCE.
i-W� in full fotccandc to Ua ❑SFDWL ❑KITCHEN REMODEL
�UV Li,a.,aC a, Li, APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
.Foga Da¢ T'S DECLARATION
❑MULTI-UNIT ❑STRUCTURAL.
A CNITECTS DECLARATION PANELS
I-7 rn MODIFICA'CION
ZOI-oz-.Z., lundersmnd my plans shall Mused as public records UPT0200AMPS [I INTERIOR El CHIMNEY REPAIR
r.ar(-),F-,� Licensed Professional 201-BXOAMPS_ IMPROVEMENT [D SWIMMING POOLS
C � OWNER-BUILDER DECLARATION OVI7R ItHIf1AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C 1 hereby affirm that I vat exempt from the Contractor's License Law far the
caliqyx5 6 U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑(YI'HEk
W LL 0 V.F which requires u permit to construct,alter,improve,demolish,m repair any structure
prior to its issuance,also requires thcapplicarn fm such perream file a6gnednwearant SPECIAL CIRCUIT/MISC. Mill
ythat he is licensul pursuem to the pmvisinns ofihc Cnnvanors License Law(Chapttr9 COMMERCIAL'
W CC
that
he
exempt
Section-rtXadth Division 3ofthe Business anJ Prof Any l litti r TEMP.MIffER OR POLF.INST.
ay a that he is exempt Iherefrnm and the basis far the vllcsud exemption,Any vioimion of ❑NEW BLDG/ADDITION ❑DEMOLITION
XmY. Section 7031.5 by anyapplicamfor.permusubjecutheapplicam his civil Penalty of POWER DI; ICES ❑TIiNANT El FOOD SERVICE
Y1 not more than live hundred dollars(950X). IMPROVEMENT
=Q ❑ Las ownerofthe pmpeny.or my employttx with wagesaztheir sok compensation, SWIMMING P(N)1.F.LIiCTRIC
will do the work,and the stricture is not intendal or offered for sale(Sec.71144,Business ❑OTHER
and Professions Cale:The Contractors License Law does ned apply to an owner of GO LETS-SWITCH ILS-I'IXTU RES
property who builds or improves thereon,and who does such work bi mself or through
his own employees,provided tum each improvements arc not intended or offered for NEW RESIDENTIAL.ELECfR SQ ET.
sale.If,however,the building or improvement is sold within one year ofcompinion,the SQ.PI'.MOOR AREA SISQ�FIL
mamer,hailder will have the burden of proving that he did not build(it improve for pnr-
Prot,of sale.). TOTAL: p'CF�� A"pp
i I D
❑I,as owner of the property,am exclusively contracting with licensed cum aeons ns
construct the project(Sec.7644,Business and Professions Cale:)The Contrunors U-
easeLewdoes not apply it)anownerolproperty who buildsor improves thereon,and QTY. PLUMBING PERMIT FEE n^®� n� �
whocommets forsuch pmjects with acotnrector(s)bacrisedirursoam mthe Comm
mors 4� �
License I.uw. PERMIT ISSUANCE
t1nn,
m exempt under Sec. .B&P C for this reason
ALTIiR-DRAIN&VIiNT-WATER(EA) )N
Data
IOWORKER'S COMPENSA?IOn DECLARATION BACK Fl.OW I'R(JI'ECf.DEVICIiI hereby e a, under penalty of perjury nos e(Ne Inllowing Jedumiinns:
ave and will maintain a Certificate of Consenuo self-insmx for Worker's Compen- DRAINS-FLOOR,RODE AREA.COND. STORIES TYPE CONS?RUCTION
mien,as provided for by Section 3700 of die Labor Cork,for the pcd'mmunce ol'the
oak for which this permit Is issued FIXTURES-PER TRAP
I have and will midnight Workers Compensation Insurance,as required by Seciam
37 ofthe Labor Cale.for the performance of the work for which this permit is issued. GAS-EA.SYS'fEM-IINCAOUTLETS OCC.GROUT' APN
My WorkcAyrfjs, yds' -wngroy- trlcPnldy No.Y lew 6- GAS-P.A.SYSTEM OVER 4(CA)
Comer: LlT /�r(JAE(. V
CERTIFICATE OF EXEMPTION FROM WO KERS GR ASEIIN DUSTRI.WAST E INTERCHVI'OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('Thi.section need not he completeda the permit is lin one hundred dollars(51001 GREASE RAI'
or less.) PLANCI IIiCK PEE
I embfythat in the penormmmnf the work!..which this permit is la sued.Is hall SEWER-SANITARY-STORM EA.200 FT.
not employ any pa am in any manner On,as to become subject o the Workers'Comper. ENERGY FLIT
Z anion Lawsof California Data WATER HEATER WNENT/ELECR
zApplicant GRADING FEE
tr .Na NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IREATING
f" become subject to the Workers Compensation provisions of the Luba Chide,you must SOILS PEE
forthwith comply with such facamonsor this permit shall M:Jcemed revoke]. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW REMDENTIAL PLMB. SQ.FT. PA06 IL) Doc ec nq
V Ihereby affirm that there iso construction leading agency for the perfmmman.f
Ito f'+ the work for which this permit is issued(Sec.30197,Civ.C.)
O Lender's Name TOTAL:
Lenders Address TOTAL:
y rtily the(1 have reed this npplicmion and stun that Ibc above infonnvilnn is BI/1LDING F
to correct.I agree to comply with all city and county ordinances arri laws relating to QTY. MECHANICAL PERMIT FTE SEISMIC FEB
V Z building construction.=it hereby authndze representatives of this city to enter uMasaue
ra above-mentioned prepemy for inspection purposes. PERMIT ISSUANCE ELECTRIC FEF
We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MSCI I. PLUMBING
In consequence of the granting of this permit,
9PPLICA UNDERS'ANDS D LL COMPLY W'H AL1,NON-POINT AIR HANDLING UNII'O'01O,(XOCFM) MECHANICAL FF.
SOURC RF,GU -� �
/� AIR HANDLING UNI'f(OVER 10,000 CPM) CONSTRUCI'ION'fAX
.ignamre.f Applica Coinmcror Data EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION I'FE
fIA2ARDOUS MATERIALS DISCLOSURE.
II
Will the epplicam nr future building occupant more or bundle banardnm material IiA'TING UNIT(TO 100.0N)ITU)
ns defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda Section 25HEATING UNIT(OVER 110,501X1 BTU)
❑Yes /�No VEMI7IATION FAN(SINGLF.RESIUI PAID Date Receipt
I Will the applicant or future building("upaill use equipment or de vice,which
BOILER-COMPIJHP OR IlI0,Ul10 BTU)
emit heeaNnus air contandirmis es defined by the Bay Area Air Quality Management TOTAL'.
District? Yes Nn (0 BOILER-COMP(OVER 100,0BTU)
�
I have read the functions materials acquirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomio Health&Safety Code,Sections 25505.25533 and 25503.1 understand that if the NEW RESIDENTIAL MECH. SQ.FR
building does not camently have a¢matt,that it is my responsibility to notify the occupam
.(the r.gaircmcnts which mus.be met prior to issuance.(a Cmificam of Occupancy.
Great,....ithorfred.gent Date DYTAI- ISSUED BY:
OFFICE