S 0546 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EkRCPRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 0546
BUILDING PROJECTIDEN1'IF'ICA'I'ION
DILDI NGADUNESS: SANITARY NO. APPIACADON SUBMI'ITALDAI'I
Me
. V iR5 NAME:MEN HONE: _kfkAJCIOH'S NAME LIC NO: � #g N/C ONBOI"Oet- U
I AR HITECT/ENGINIiER: LIC NO: ADDRESS: ❑
CONTACT:
PHONE, BUILDING PERMIT INFO
❑ CnnsDheSt Fees Paid by Applicant(Initial) BLDG li ' PLUMB MECH
LICENSED CONTRACTORS DECIARA'TION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed rude(erosions of Chapter 9 0mmmearmg JOB DESCRIPTION
aZ with Section 7000)of D'm'ninu 3.1 he Bt,inesund Prof sinm Code,rndmy lice:..I," RESIDENTIAL,
WOO I'IiRMi'1'ISSUANCE1-w. Tulle forceandelfmt. ❑SFDWI. C1 KITCHEN REMODELaUV
License Class Lic.p APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PINI:
Z LL: Date COmmclor
ARCHITECTN DECLARATION PANELS ODIFl❑MULTI-UNIT' ❑MODIFICA'O(JN
UNAI.
Z O�to
Z mm
umJcnd my plan.shall he nmA user prM1reo
lic crds
OZ-+0 UI"1'02IXIAMI'5 0IN'I'IiR10R ❑CHIMNIiY It GPAIR
fa_n F-W Licensed Pndessional 2III-ICMAMPS IMPROVEMENT C]SWIMMINGPOOIS
OWNER-BUILDER DECLARATION OVER IEBOAMI•S ❑BATH REMODEL/RF.PAIR [I DEMOLITION
OC W Q I hereby affirm that 1 am exempt from the Contractor.License Law for the
CiyS O Y U following Tusnn.(Section 7031.5,Busincs,and Pct ta,,ioa,Code,Any city or count, SIGNS ELEC'IBICAL ❑OTHER
which m tura,a permit m mnnruct,ohms Improve,Jcnmlim,or repvir any slmcwre
< pro onnin ixxamer'.1n megrim,the applicant for such permit in file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions ofthe Commences License Law(Chapter 9 COMMERCIAL:
l+�i°C0�0 (commencing with Section 7")of Division 3 oRhe Business and Professions G:ddnr TEMP.METER OR POLE INST.
C.A.ey� that he is exempt therefrom and the halo,for the alleged exemption Any violation of [I NEW BhUGIADUITION ❑DEM1t01,1'I'IUN
W or Section 7031.5 by any applicant lion permit subjects lacapplicant loo civil penally of PUWIiR DIiV'Co.." ❑'I'13NANT ❑I-'OLD SERVICE
E-ZY ammo,than Eve hundred dollars 0I51101. IM1'ROVEMEN'I`
�SQp n Las Owner of the property,or my employees with to a%their role compensation. SWIMMING POOL ELECTRIC
F• will Jo the work,and the nmetme is not intended uroRcmd for sale(See7(W.Business OTHER
0..3 mand Professions Qde:The Contramors License Law Jtes nm apply m an owner of OUTLETS-SWITCHES-IBX'f11RE5
pmpeny who build,of impowe,themon.and who)docs such work hnnsclfor through !' h
his own employees.provided that such improvement.arc not intended of offered for NEW RESIUEN'I'IAL ELECI'R 'I'.
sale.IL how,,,the bWild ingmimpr,crarm Raold with in one yea vl 0...1-ion.the SQ FT.Iq.l1OR AREA SISQFlt
,
menerbuilder will have the Wadan of proving that he did not build m improve for put- UG 12 %CU
pose of sale.).
I,a,owner of the pmpeny,am emluslvely contracting with licensed cmaract rs In 7
msauct the project(San.7044,Bmin%,and Pmmoo,ioro .I:I'1'he Contractor's I. Gr VVr
cense law does not apply to an ownerof
pmpeny who builds or improves thereon.and QTY. PLUMBING PERMIT 117E I_ tN oINU
whoconwcts for mch projects with a etmasitan%)licensed purwanun the Contractor's
Licenm Law. PERMIT ISSUANCE
❑ I:un exempt under Sec. .H K P C for this mason
N ,. ACI'ITR-DRAIN.@VENT-WAI'ITR(EAI VALE/A PION
WORKER'S COMPENSATION DECLARATION t F BACK MOW PROTECT DEVICE
1 hereby affirm under Penalty of territory one of the following dcclafations:
r7 I have and will maintain a Carifcnte of Commot to self-imam for Worker's Compen- DRAINS-FLUOR.ROOF ARBA.COND. ST(JRIES TYPE CONSTRUCfIOI
mlien,ns provided far by Section 3781 of the Luton Code,f r the pmrfurnianlr of the
work for which this tearer is issued. FIXTURES-PER 1'RAP
I have and will maintain worker's Compensation Insurance,as myulfed by Section
37M ofthe Leir-Coo for the pedonnance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OU EIS OCC GROUP APN
My Worker's Compemmion Insurance carrier and Policy number arc: r
Currier: Policy No.: GAS-EA.SYS'I HM-OVER 4(HA) \V/w
CEIGJF[CATE OF L'XEMM ION FROM WOR KERSGREASEJIN DU5'TRL WASTE IN'I ERCEITON
COMPENSATION INSURANCE ILLI IN DIVISION 'EES
(Thissectimi need makenontlewrifNepemtit is formchaddradd.U.,($100) GREASETRAP
or lett) FIANCE' , 19Th
I certify that in the Fcdonnance ofthe work for which this permit I%issued.I%hall SEWER-SANI'T'ARY-STORM ITA.200 ITT
not employ any person In any remove, o os to bes,m a Object to due Workers Compen- I:NIi YE
Z .cation law,of C.1dun ia.Data WATER HEAT ITR WNENTIELEC R
zp Applicant Of 1':1'
h NOfICETO APPLICANT:!f,ager making this Certificate of Exemption,you should NATER SYSTEM?BEATING SOILS FEE
abecome subject m the Workers Compensation provisions of the Luton Code,you must
[21 forthwith comply with such pnwisinn,or this permit shall be trained revoked. WATER SERVICE
PAID
�z CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLA1H, SQ.IT. Done Receipt
U O (hereby affirm In.the.isaronamemon lending agency finite pedommnce of
" . the work far which this permit is issued(Sec.3097.Civ.C.) -Noto TOTAL:
C) U L,dcrn Name
fender's Address 'I(YI'N.:
a
1 Tandy that 1 have real this to,hemum and same that he Nice information is IIUILI Llai
F Z correctlonstrma:mplyherchydtyand coumynminanresuis surto lmnt,,.mining m QTY. MECHANICAL PERMIT PEE SEISMIC FEE
U z building cunstmctinn,and hereby umhnrixe retresenmtivcs of this city to enter ugmthe
abu cc.oc,namid p,,,,a,for Inspection purpmes. 1-17RMIT ISSUANCE IThECI RIC Flili
(we'
agme In%use,indemnify wad keep hunnle,s the Clly of Cupertino againd
habilitiex,judgments.coots and expoo which may in any way acerae agaim(said City ALTER OR ADD'1'0 MECIL PLUMBING FEE
in consequence of the granting dthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.I0p CFM) MECIIANICAL IIiIi
SOURCE REGULATIONS. /
/�iI � �N�U AIR HANDLING UNIT(OVIiR I(I,INIOCFMI CUNSTRUCI'ION'TAX
-6/ a 7
Signmum nfApPlicuHA7A DO —TIaT EXlIAUST HOOU(W/UUCI'I HUIJSING MI'1'IGAIION FEI3
HAIARu�US MATERIALS DISCLOSURE
Will the applicantor future building accum,5mmpnOhm or handle haraNnm material HEATING UNI"f(TO 000,0110 BTU)
as IT by the Cupertino Municipal Code,Chapter 9.12 and the Health anti Safety
lnIIIiAfING UNIT(OVER INL(NNI B'TIl)
CWu.Sed029532007
(]Vere Fl No VENTILATION FAN(SINGLE RESID) PAID
Doc Receipt M
Will the applicant or future building occupant use equipment Or devices which BOILER-COMP @HP OR 100,40 BTU)
Train harallous air cnnwmiand%a%Jdincd by the Bay Area Air Quality Management '1 OTAL:
L
BOIhGR-C(IMI'(OVBR IINI,(NXIBTU)
❑Nn
mad the hamtdous material,re umann ,under Chapterfi95 of the Cali- AIH CONOII'IUNT:R ISSUANCIDATE
&Safety Code,Section,25505,25533:rad 25534.1 understand that if the NITW RESIDENT IAL MECH, SQ,IT.
not...randyhweurunout,Inot it in my re, umibilaymnotify thoaecunlnttenh which mol he mel prion nc icm mor mf a Coa heath of OccalmwY
....agent Date Tmnl: ISSUED 11OFFICE