B0117 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUMS NO-FARMIA ICA vltBaur rvo.�O
APPLICATION/PERMIT 1'LUhIRINf. A1F.C11ANICAL
CAL
BUILDING DIVISION
BUILDING PNOJECT IIIE\TIFICATION
BUILDI NGADDRE.SS: SANH'ARY NO. \PPLI AT ION SUBMITTALUATE
:2 i q tAURf?TADR , cvOrI2TNo �
OW'NER'S NAME: PHONE CONTRACH)R'S NAME: LIC NO:
NIC CONTROL#
ICH I'I ECT//ENGINEER L O:G / V ADDRESS T//"" !NN'/'� ❑
NOIV G w Gsa �3
CONTACT: ,PHONE: BUILDING PERMIT INFO
405tOr- /A CAKGa �d96 - 9�-2a [:] Consultant Fees Paid M1y Applicant(Initial)
UG 2/ PLUMB MECII
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT - - FEE
1 hereby am.thm I am licenced under provisions of Chapter 9(commencing _ JOB DESCRIPTION
OCZ with Section 7")of Division 3 of NC Business and Professions Code.and my license is RESIDENTIAL'
WOO PERMIT ISSUANCE
FI= in tun ibrcc anA cora. ❑SPDWL El KITCHEN REMODEL
C U b- License Class Lm.M
ta U APPLIANCES-RESIDEMIAL []ADDITION ❑PLUMBING RF.-PIPE
F Z W Date Contractor
rn6L 0MUITI-UNE' ❑STRUCTURAL.
Dw ARCHITIiCPS DECLARATION PANELS
Z understand lh
my pans sall be upublic record. MODIFICATION
Orn Z Id
H_ sed as UPTO 200AMPS
OZ�O ❑IN'1'PRIOR El CHIMNEY REPAIR
Licenced Professional 201-11)(MAMPS IMPROVEMENT [D SWIMMING POOLS
ad C Q I hereby affirms the 1 am eUImDF.pt from the Contractor l 's License Law for the OVER 1000AMP$ C1 BAT REMOUEIJRIiPNR DEM01,1'I ION
3 W U following mccon.(Section 9031,5,Business and Profession Cash:Any city or county SIGNS ELECTRICAL -)OTHER
.
y which ocilonn a permit to conloum,alma improve,demolish,ar repair any sr ucuue
O� prior to its issuance,also acquires the applicant for such permit to file a signed statement SPECIAL Cl RCUIT/MISC.
kc that he is licensed pursuant o the provisions of the Committees License Law(Chopmr9
WClo0 (emanuncingwith Section 9000)of DivisianJ ofthc Businessvnd Pmfnsinnc Cala er TEMP.METER OR POLE INST. COMMERCIAL
�� (
a a e K that he is exempt therefrom and the basic for the allege)exemption.Any violation of ❑NEW BLUGIAUDITION M 11.'fION
XmW Section 7031.5 by any applicant for a permit subjects the applicant to a civil penaltyof POWER DEVICES ❑TENANT 2[2 ❑FOOD SERVICE
bs not more than rive hundred dollars 6511U). IMPROVE
�=Q ❑Lasawnerofthepropeny.onnyemplended withendfrsale(Sm.compensation, SWIMMING POOL F,LIiCTRIC
p. willdoth,dians and thehc cture Concis pots Liens,Law doforot apply
an veneris ❑DIHEk t
a w
and Pru!cion Code a The Commemh Limnee Law Jas not apply to an owner of OUTLETS-SWITCHES-Fl%TURES i
progeny whobuilds orimpntvththereon, pr whodocs sonotinhimself or throughugh
d Na
his own employees,proviJsuch improvements are not intended or offered for NEW HESNCNTIAL ELECTS SQ FT.
sale.Ir.however,the building mimparvermnt is sold within one year of completion.the SQ.IT.MOOR AREA S/SQ.IT.
owner-builder will have the burden of proving that he did sol build or improve for In- i
prow
nr-
pose of sale.).
TOTAL:
e
1.as r of the property,am exclusively contracting with licensed contractors to rl
instruct thepinjccl(Sec.9144.Business and Profession,COdc:)The Crnnmcter'x Li- _
a low does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects is a cnmmelor(s)licensd pursuant o the Contractor's
Liccs.w Law. PERMIT ISSUANCE
❑ 1 nm exmopt under Sec. .It&P C for this reuaun
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dmc +a ,
WORKER'S COMPENSATION DI!CLARAI'iON BACK FLOW PROTECT.DEVICE OQ
I hereby affirm under penalty of perjury one of the following dMmnti...:
I have and will maintain a Cerificate of Consenno self-insure for Workers Compcn- DRAINS-FLOOR.HOOP,AREA.COND. STORIES TYPE CONSTRUCTION
satins,us provided for by Section 3900 of due Labor Core,f the perfrnmnnce of the -
work for which this pemJl is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as requited by Section
39H0ol the Labor Code.for the pnrobomance of the work for which this stroll is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Worker,Cmnpenanum Insumnee came,and Policy amber,am
Career: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OI;EXEMPTION FROM WORKERSGRFASEaNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FRES
IThis section sed not be completd if the permit is Torose hundred dollen(EI00)
OR BASE THAI'
or less) PLANCIIECK PEE,
I ccnlfy that in the perfomutnce oflhe work for which this penton N o,tmd.lshull SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any�^ a'u c •s 12et m the Workers'Compen- IiNERGV FEE
Z. cation Law�syyf Calif UaEl-z WATER HEATER WNENT/ELF.CfR GRADING FEE
z O Applicant Y. L.
NOTICE TO APPLICNT: after making this Certificate of Exemption.you should Wq'IER SYS'1'EM/fR1iAi'INC O
h" become subject to the iters Compensation provisions of the Labor Code.you must SOIhs FEE
WL>-i forthwith emaply with inch Provisions or this permit shall be deemed revoked. WATER SERVICE Morn
0
CONSTRUCT ION LENDING AGENCY NEW RESIDIiNT1AL1'LMB, rL#Q I'll LAID. Date Be ipta
L)� Thereby affirm that there is a construction lending agency for the performance of W
cnathe workfor which th'w I'Lrn it is issued(See.309].Clv.C) 'TOTAL:
O ULenders NameLendersAddress IOTAI.: FIiISh connect.l agree m comply with all city and county orinances and state laws relating toECHANICAL FERMI'V FEE
V Z building convection.and hereby authonic representatives ofthis city to enter upon theSEISMIC FEE
above-mentioned proPcoy for inspection purposes. ANCE(We)agree m save,indunnlfy and keep hanalcas the City of Cupunino against liabilities.judgments,costs an it K.w,which may in any way a cmc against said CityD TO M ECH. PLUMBING WBin ns..scie nce of the gmnlmaof this permit.APPLICANT UNDERSTANDS AND WILT.COMPLY WITH AI.I.NON-POINTNG ONI'1'(TO 10,1XX)CFM) MECHANICAL FEE
SOURCE REGULATIONSNG UNIT(OVER IO.fXID CPM) CONSTRUCTION TAX
Signature at ApplicarmConteaclor DateOOD(W/DUCT) HOUSING Ml IGAI'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or boom building occupant store or handle hazardous material HEATING UNIT ITO HIT"
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cdc.Section 255321x)' HEATING UNIT(OVER 10).000 B'HA
❑YC ❑No VENTILM ION FAN(SINGLE RESID) PAID Mute mcue
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3111'OR 100.000 BTU)
nit harardous an cumaminams as defied by the Bay Area Air Quality Management
trio? BOILER-COMP(OVER IOq(n)B'I'tL
[3 Yr, 7N
I have read the barudoux materials acgviremenls under Chaser 6.95 of the Cull- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safely Code,Section 2550.5,25533 and 255;14.1 undenmod that if the NEW RESIDENTIAL MHCH. SQ.FT. ^ n
building does not currently have a mount.that it is my tcspons'ibility to notify Nim e occupa / 7
of the requirements which must M met prior to issuance of a Certificate of Occupancy.
VZ'
Owner or xinhurizel agent Ilam TOTA ( ISSUEUBY: • 14 I a-
OFFICE