S0314 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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TY OF CUPERTINO BUILDING-ELECI'RIG\l. PIS 11TNO.
UILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL � 0314
BUILDING PROJECT IDENTIFICATION
LDING ADDRESS: HAPPLICAI[ON SUBMI MAL DATE
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ARCHITECI'/F.NGIN17ER: LIC NO: A DRESS$SS
MF'CONTACT: PHONE. - BUILDING PERMII'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG 171-ECI PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARAI]ON QTY ELECTRIC PERM II' FEE. JOB DESCRIPTION
I hereby affrantem 1 an licensed under provisions of Chapter 9(commencing
yOy�CZ with Section]1Xq)of Division3of the Basinccsand profession,Crdc.and my license is PERMIT ISSUANCE RESIDENTIAL
FNTIAL'
h�B infull'forceand fc{t. - ❑SFDWL ❑KITCHEN REMODEL
C U b- License Class Lia#
yQL DamComrenor AI'I'hIANCFS-RESIDEYTIAL ❑AUDITION fAl'IAMBING RE-PIPIT
[I MULTI-UNIT ❑STRUCTURAL
ARCHITECTS UIiC ATIO PANELS
F o,Z I understand my plans shall be used as public records MODIFICATION
Z Ori Oil[0200AMPS C1 IN ERIOR ❑CHIMNEY R17PAIR
OZ-O
F-h l-yl Licensed Professional 201-1000AMPS IMPROVCMIiNT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER Iq)B AMPS ❑OATH REMODELIREPAIR 0UFmOLITION
CG C Q I hereby a1Bno that I it,csice,Fourthe Contra'an"Licensee Live Por the ❑01LER
k,O a U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
W 3 U.y which requirts a permit to consvuct,alter,improve,demolish,or repair any structure
^�O<1 priort t'issuance,al: requires thet such Permit fl signed statement SPECIAL CIRCUIT/MISC.
fly math I' .ed pursuant thep ld C t' m Lwi.,1 w(Chnpter9 COMMERCIAL'
1 `YC� Icomrecormgxth section of Division 3 of the Burnes dP Professions Cde)or I EMP.MEWS OR POLE INST.
tl c,p C that he is exempt therefrom and the basis for the alleged exemption.Any viorlation of ❑NEN'BhDG/ADDITION El DEMOLITION
'1y Section 7031.5 byany applicant for apmmit,ancns the applicunnu%civil penalty of POWER DEVICES ❑TIiNANf ❑F(IOU SERVICE
not more than five hundred dollars($500). - IMPROVEMENT
f=� ❑1.as owner of the active .or my employees with wages as their sole compcnmtion, SWIMMING POOL ELECTRIC
F, will do the work,and the stmcture is not intended or otcied for sale(Sm. Business ❑OTHER
3 unit Professions Calc:The Contractor's License Low does not apply to an owner of OUTLETS-SWITCHES-FI XTUR
prnpeny who builds or improves ownerm,and who docs such work himself'ur dima,u
his ow'n employees,provided tem arc not improvements anot intended or offered for NEW RESIDIiNTIAI.BhLCTR IT
sale.If,however,the building,improvement ismld within one year of complelion.the SQ.PRFLQOR AR[A
m-huilder will have the burden of proving that he did not held or improve for par I�
you foal ) 'TOTAL
I owner f rh p pony earlinnely computing -m licensed r r :t,
commuct the protect(S 7013 Business nd priefessions Cade)The Contractors Li-
moseLaw does not applyt f property 'h builds or improves themen,and QTY: PLUMBING PERMIT FEE
weommmc¢forsuch projects with acontmods)licensed pursuant to the Convenors
License Law. PERMIT ISSUANCE V 1��•
El I am exempt under Sea ,B&P C for reason 'I
ALTER-DRAIN&V17N'T-WATER(EA) VAL TION
Owner Dme
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following Jeclaretiom:
'[:] I have and will undruina Certificate of Cun'enl to sell-in sure It Workers CanPm- DRAINS-FLOOR.ROOF,AREA,COND. STOR1pS 'TYPE CONSTRUCTION
whirr.as provided for by Section 3700 of the Labor Code.for the perfomtance of the
..,it for which this carrion,i...vd. IIXTURF_S-PER TRAP
O I have and will maintain Worker's Compenc cion Insurance,as required by Section
37Wofthe Lab Code for the perfomwncc of the work for which'hi'perntit is issued, GAS-ITA,SYSTEM-1 INCSOUTLE-IS OCC GRODP AVN
My Workersp. tw n I spectra, and Policy It tw urs:
Carter ty,-�AqL�—Policy No.:�V\'sa( 2NL+4Y7 GAS-EA.SYSTEM OVER S IEA)
CER IFIC OF EXEMPTION FROM WORKERSGREASE/INUUSTRI.WASTE INI'ERCFVIOR
COMPENSAIION INSURANCE. BUILDING DIVISION PEES
GTissamon ncWnotheeompleled ifinepmnitisfomrmhundred Aollars($nMl) GREASEIRAP PIANCHECK FF.E
or lee )
Ice"Ify[her In the perfmmanevof the work forwhich this Permit is issued,[,hall SEWER-SANITARY-STORM HA.^_WPI.. ITN17RGY FEE
not employ any person in any nnmna'o as no Frost'clever us the Workers'Cmi
Z ration Lw%of California.Date 'W'ATER HEATER W/VPYVELECTR GRADING IEE
OO Applicant 1
Z NOTICE 10 APPLICANT:It,after making this Certificate of Exemption,you should WAFER SYSTEMO BEATING SOILS PEE
F "N" Iccome wbjen to the Worker's Compo ,'lion provisions of the Labor Code,you must
a fono,ith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.pT. PAID
U z nate Ree r
U O wor.hich oti mamerdssued(m.30lending agency n,r the perrormaaa or
{w F the work for which this puma is issued(See.3t1J].Civ.CJ TAC
O Lender's Name 'TOTAL:
r headers Address BUILDING FEE
y 1 certify that 1 have read this application and%tate that no,above inf+m,am�n i'
F' h mrom,Iagre<to comply with all city and county ordinances and suite laws relating In QTY. MECHANICAL PERMIT FEE SEISMIC FI i
U Z building connmedon,and hereby anmonae representatives of this city to enter upon the
above.nmminned property Pr inspection purposes PERMIT ISSUANCE Ii1.liCfRIC Ilii?
1wq agree m save,indemnify.,,it keep bar I...the Of,of Cupertino agoimr
Liabiliriesjudgments.cases and expenses which may in any way accme against said City AITERORADDTOMECH. I'LUMRING IE, n
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILLCOMP Y WITH ALL NON-POINT AIR HANDLING UNIT(TO 10, CFMMSCI{pNIC TEG
SODRCE REGUTATIOFJ.S. (O
� ' �w I,�-�
AIR HANDLING UNITVER 10.000 CPM) CONSTRIJCI'ION %
Signs of Applic c/Contmcma Dam EXHAUST HOOD(W/DUCT) DOUSING MI'TIGATI( FEE
HAZARImUS MATERIALS DISCLOSUBE
Will the applicant or future building occupam sere or BE
nax.Mous macnaI HEATING UNITGO IW.000BTU)
as dcfnud by the Cupcnino Municipal Code.Chapter 9.12,and the Hearn and Safety HEATING UNIT OVER 1010110 BTU)
Code Section 255320)?
OYc: ❑No VENTILA'T'ION FAN(SINGLE RESID) PAIDD "
ae Raripr#
Will the npplleam nr future building ocliTain ace uluipmem or devices which BOILER-COMP(3HV OR 1111,(1X)BTII)
mrait Nadro s air contaminants as defined by the Bay Area Air Quality Nbc ngcmenl TOTAL:
District? BOILER-COME(OVER 100.000 BTU)
❑Yes ❑Nn
1 have read the made.Se urs,materials 5.B53 anuls under Chapter understand
of the Cdl-
AIR CONDITIONER ISSUANCII DATE:
fomia Health&Safety Cede.Sections 5505.25533 and 25531.1 undcmtand ma if me NEW RESIDENTIAL MECH. SQ.FT.
building does on,cutrendy have a Ienam,that it is my responsibility to notify the swcupant
of the r•quirecomo,which must he met prior to issuance of a Cenificvm of Occupancy. yQ M
Owner or authomcl agcm
Date TOTAL: ISSUED BY
OFFICE