S0876 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-PI-EC'IANICA PI'S No 0876
HUILDwG DIVISION APPLICATION/PF.RMIT rl,mtelNc.SB:cunNlcnl. J
BUILDING PROJRCT UDPN'I'IFICATION
DUMBING ADDRF_SS: SANITARY NO. APPLICATION SUBMITTAL DATE
'A�3I I VZ
OW ' 'S NAME: PHONE: CONI'BACTORlS NAME: LIC NO. NIC CONTROL#
lhA1J S1
!!5 ❑
ARCHITEC-PENGINEER: LIC NO. ADDRESS. .
1
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG .LECT LUMB AfECH
❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY. " ELECTRIC PERMIT FEE JOB DESCRIPnoN
1 hereby affirm thin I am licensed under previsions of Chapter 9(commencing _
oa'Z with Seaian]0(10)ofDfvfsion3ahhe Fullnessand Pmfessionx Carle,and m,Tense is RESIDENTIAL:
typo 1112RMIT ISSUANCE
F 131 in full farce and effect. ❑SFDWI, ❑KITCHEN REMODEL
aVU hittn.xc
Class Lick APPLIANCES-RESIDEN'UAL ❑ADDITION ❑PLUMBING RE-PIPIT
PZW Dam- Contructu ❑MULTI-UNIT ❑STRUCTURAL
to ARCHITECT'S DECLARATION PANELS
F.
on Z I understand my plans shall be used as public records' MODIFICATION
QZv)Q UPTO200AMPS INTERIOR 11 CHIMNEY REPAIR
[=.L/!:yl Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-PUIIDER DECLARATIONOVER 1000 AMPS ❑BATH R' DEIIREPAIR ❑DEMOLITION
C 1L'Q 1 hereby affirm that 1 am exempt from the Contractors License Law for the
1Ky ow
3.F outlawing ream..(Senn..7031 5,Rosiness and Professions Code Any city m county SIGNS ELECTRICAL R
y which requires a permit to amarum,alter,improve,demolish,Om repair any stmcare
pif I,its issuance,al,dua cox the applicant formeh permit to filea.vigned xa¢menl SPECIAL CIRCUIDMISC.
- 1hmM1 .licensedp ; It IM1 1 fn C t r I I (Chapter9 COMMFRCIA].
W�G�O (m 'rib withSection]INN))of Division l [the 'Holmes dl fie.:' :Code).1 'TEM I'ME'1'ER ORPOLEINS,U
d Xm y that he is exempt therefrom and the basis for the alleged exemption n An)violation of ❑NEW BLUE/ADDITION ❑DE.MOLITION
':2A Section]031.5 by any applicantfor a permit subjects the applicantto a civil penalty of 1'OWIiH UIiVICES [I TENANT ❑FOOD SERVICE
in not mac than five hundred dollars($500). IMPROVEMENT
=E D I.as Owner of the progeny.or my employees with wages as theirmle c in,suction, SWIMMING POOL ELECTRIC
(.., will do the work.and the suuclum is not intended or offered for self,(Sec. Business ❑OTHER
W_m and Pmfe ter,Code:The Contractor's License Law deal not apply b)an owner of OUTLETS-SWITCHES-FlXTURfS
a 3 progeny who builds or improves thereon,and who does such work himself Or through /
his own employees,provided that such improvements are not intended Or offered for NEW RESIDENTIAL ELECTH SQ FT
sulc.If.however,the buildingom Improvement is sold within one year of completion the SQ.PT.Fl! OR $I$Q.IT.
owner-milder willhve the beakn of poison,ffizil hdid no,bid(it improve lpar-
"'o
ar., I ).
7 PILO
I n f the m pe ty I ly l k ]h I' 1 councillor,to �(1
i I
ommonaursPjetSee.o" B :' ..and Pf.: :Cel )ThCI t :Icruse Law '
does not applyt fpropeny who builds hurproves thervoic and QTY. PLUMBING PERMIT FEF, (s ['
whoccout for ouch pmfects with a contmetor(s)licensed p r nare to the Cimmeemrs V 1Ty1,wr-UUrtpH I9� N
License Law. or PERMIT'ISSUANCE VAI
O 1 am mpt exeunder Sec. ,tl.F I`Cfthis ream.
AI:FIiR—BRAIN.@ VENT—WATI[R ICA) VALUATION
( \ 74 Atj
WORKERS COMPATION DECLARATION
'D BACK FLOW PROTECT DEVICEECEI ED
Ihereby ff d pchy Ant ) ry onef the Following dI 'fs
I have and w TO maintain 4 Ceti fit f COFOma to setf' Worker COmmo.n DRAINS FLOOR,ROOF,AREA.CONIS'1'O IES TOT
YPECONST CUT
rat :p "ddfnbyS I 191X1 it WeLab rCode, r1hoper fit-ria eofthe NOV 1997 CITY Ur URENTIN(�
wort.for which this permit is Issued II%I URCS PFR TRAP
C]1 have and will maintain Worker'x Compvnmlion Insurance,as required by Section
3700ofthe Line,Cal for he perfiaronce of the work for which this permit is issued. GAS—ITA.SYSTEM-I INC.4 OUTI., OCC. OUP APN
My Workers Compensation Insurance carrier and Policy number art:
Carrier: Policy No.: GAS—EA.SYSTEM-0V OVER 4(EN
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COVIPENSATION INSURANCE BUILDING DIVISION.FEES
(Thn.timn need nuthccomplmcd iftheprtmit is foromu hundred dollars($100)
GREASE TROP
PLANCHECK FEE
Lxs.)
I ten' uColo'cll SIIWCR—SANITARY—STORM EA.21X1 FP.
Ify that m the peroinnwnwof the fnrwhich this penult is lax
not employ any memon in any murmur sit Its In become xuhjml to the Workers'Conlmmr IiNIiRGY IPP.
Z svtion Laws of Cabo mar Date WATER 1112ATER W/VENU AlLECTR GRADING IEE
z O Applicant - )
NOTICE TO APPLICANT:If,afar making this Cmnifcme of Exemptim.you should WATER SYSTEM/TREATING SOILS FEE
F�00 became subject 1.the Worker.Compen'auon pmviximns of the Jaber Rde,you roue
Forthwith comply with such petwWons or this permit shall evoked. WATER 513RVICE
Q
CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL PL\10. SQ.Flt PAIR Dae Hettipt N
VQ I hereby affirm that(here is a emeamnlnm leading agency for the performance of
the work for which this permit is issue](Sec.3(19].Civ.Cd
1.14 1"' Lenders Name TOTAh:
Ll I<nders Address TO'I'AI:
aI eruify met 1 have read On,application and'late 111111 the abate I ula ani fan Is BUILDING ITE
tai V) corneal agrvca comply with all city and termly ordinances and sate I.wx minting, QTY, MECHANICAL.PERMIT FEE - SEISMIC IEE
U Z frolding,mOtmirdic and herehyvwhorixe representatives ofthla'fly tocnter ummnthe
abevomenlloned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
100111 agree,one.indeinnifv and keep harral¢e the City of Cuperimn against
lialiities.judgmems.costs and expenses which may in any way acerve against said City ALLIiR OR ADD TO MECH, PLUMBING FEE
in cam.aquence of the granting of this memtit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AMI.NON-POINT AIR DANDLING UNIT(TO 10.0110 CFMI MECHANICAL ITE
SOURCE REGULATIONS
a
AN 1\/2b/g7 AIR HANDLING UNIT(OVER 1410X)CFMI CONSTRUCTION TAX
Signuwre Ofmnor pale 1!%IIA UST HOD,IWNUCI) HOUSING MI'TICATION IIoI?
I IAZARDOUS A'FERIALS DISCLOSURE.
Will the applicant orl'umm holdingeccupmn aorcer handle M1m,vNous material HEATING UNIT TO 100,000B'ITl)
ax dcoi.al by the Cameroon Municipal Cade.Chapter 9.12,and the Health and Safety HEATING UNI]'(OVER 1101,10X1 itI'U)
Code.Section 255320)'1 el-11
!
❑Yes ""'' VENTILALION FAN(SINGLE RUTS IDI PAIDI -6�—
re He,ciplk
r Kill the applicant or future building occupant use equipment or d,vicas which HOILIiR—COMP(3HP OR 100.(0X)tl'TUI
1 emit haaardouo air contaminants ax defined by the Bay Area Air Quality Management TOTAL
\
District? BOILER—COMP(OVER 100,000 BTU) _
❑Yes �m
AIRCONDIHONER ISSUANCE DATE
I b'avc read the lcon"lmus nculan is agractor."under Chapter 695 of 0c Call-
fo un Health&Sued,Codec Sections 255115.25533 and 255]4.11 taslmld Ihal if the NEW RESIDENTIAL MECIL SQ.Ff.
building dxs not currently have u(emme,that it is my ado n...hility crudity the oecupatt
of tl oat which Oct prinrmismnna of Cenlfcate ml lkcu icy.
172
r uNoriml agent 1 Date TOTAL] ISSUED FC.ner A
OFFICE