B 0637 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LF=RICAI, PERlstll'NO. ^ ^
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. o/Vlpl FS 'LJ-SµJ.Soj•~li
BUILDING PROJECT IDENTIFICATION Otls9'f 1J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL UAfI
30111°+ ar Z .nj
OWNER'S NAME: ` PH E: CONTRACTOR'S NAME: LIC NO'.
6 1._` NIC �JCONTROLp
uh Cy
4�QiiT CF/ENGINEER: LIC NO: ADDRESS: ❑ 1
CONTACT. PHONE: BUILDING PERMITINFO -
GtKk I r ueTd 04 0-6) ❑ Consultant Fees Paid by Applicant(initial) BLDfr ELS PLUMB MEC
LIC�ENNSSEEDD CONTRACTORS DECLARATION 0 1 QTY ELECTRIC PERMIT FEE
1.'�"
I hereby affirm Nal l am licensed under provisions of Chapter 9(Commencing JOB DESCRIPTION '
oaZ with Section 700pofDivision 3ofthe Business nd Professions Code, it my license is R Slp NTIAI:
V{s4�0 0 p PERMIT ISSUANCE
F-,P in full force and oRcct. V ❑SFDWL ❑KITCHEN REMODEL
1UU License Class Lic.N APPLIANCES-RESIDENTIAL ❑ DI511'@�� UMBING -PIPE:
11....Z W Date Can lmdn
ms6y ❑.f LI-UNIT S U
=ar ARCHITECT-S DECLARATION PANELS f-
Z�tr�'� lundcrstand my plans shallhuxd vs public records UP'10203 AMPS ODIFI A N
OZ,.Q ❑I TOR ❑GHIMNI PAIR
FM�tal Licensed Professional 2014"AMPS P VIW ( iM OLS
y ; OWNER-BUILDER DECLARATION OVER I"AMPS ❑ A RE�(�ilR A {OL
K 6 I hereby efrm that I am exempt tram the Contractor's License Law for the
iy5 C 1 U Ibllowing reovon.(Section 7031.5.Business and Profusions Code:Any city or county SIGNS ELECTRICAL. ❑ ER
1+13 u y which requires v peont m construct.cher,improve.demolish,or reso
pair y structure
=0I Frnt.asiumose.ilmrequiresdeapiliventfarsuchPernittofileasigedsmmment SPECIAL CIRCUIT/MISC. V
Mthat he is licensed pursuant to the previsions of the Commences License Law(Chapter 9
Qf (commencing with Seninn 9m0)of Uivision3 ofthe Business vnA l'rofessionx Gmde)or TEMP.METER OR POLE INST.
a ly o that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
YXl Y•
Section 7011.1 by any applicant for a permit subjects the applicant no a civil penalty of POWER DEVICES ❑TENANT. El FOOD SERVICE
QN not more Nva five hundred dollars($5100). IMPROVEMENT
❑1,as owner of the propeny,or my employees with wages as their sole compensanion, SWIMMING POOL ELECTRIC
will do me work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHfiR
{yI^� and Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-F " R -
property who builds or improves Nemo,out who does such work himself or through
his own employees,provided that such improvements ere not intended or offered for NEW RESIDENTIAL ELEELOX SQ Fr.
sale.IL however,the building or improvement is sold within one year m completion,the SQ.FT.FLOOR ARTA §ISQ.14.
"Ar owner-builder will have the burden of Forcing Nat he did not build or improve for put.
pose of.mle.1.
❑1,as owner of the properry,am exclusively contracting with licensed comacmrs tu
nnstruct the project(Sec.70,14,Business and Professions -n lco The Contactors LL-
ssLaw does not apply u,an owner of property who builds or impnwes therron,and QTY. PLUMBING PERMIT F
who contracts for such projects with a communist licensed pursuant to the Commemes
License Law, PERMIT ISSUANCE'
❑ I um exempt under Sec. ,B&P C for this reamn
AL'I ER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dom
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO ECT.DEVICE
iI hereby nation under Penalty of pcpury bar, of the folhwing declarations: O
^' ❑1haveund will maiominuCerhiceteof Consem mself-insure fm Wmkcr's Compel- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTIDI
sation,as provided for by Section 391111 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PF.R TRAP
❑I have and will maintain Workeea Compensation Insurance,as required by Section
3903 of the debar Cade.for the performance oDhe work for which this permit is issued. GAS-EA.SYSTFM-1 INC.40IITLETg OCC.GROUP APN
My Workers 4, person,M1l sumnce curio and Policy n t
Y'1C�� Policy No
'Larrier ) .: GAS-LA.SYS'1'EM-OVER 4EA)
CERTIFICATE OF EXEMPTION PROM WORKERS' GRGSF%INDUSTRL WASTF.INTE CEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe permit is forone hundred dollms(SIM) GREASE*1 PLANCHGCK FE
or Tessa E
I really that in the performance ofthe work forwhich this permit is issued,Ishan SEWER-SANITARY-S FA.20(1 FT.
am employ any person in any manner so as m become subject m the Workers Compen- ENERGY FEE
z ration Laws of Califumin.Date WATER HEATER W/VENT E R
O GRADING FEE
7 Applicant
❑ NOTICE TO APPLICANT:IL Cmi making this Certificate of Exemption,you should WATER SYSTEM/IRGTING
rn SOILS 1mE
F become subject tome workers Coons or is runic hal of the Inbar cake.you mast
LaF1�
forthwith comply with such provisions or his pcmlit shall be deemed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDEMI'IAL PLMIf. FT PAID
L)QI herehyaRmm insatiateisu constructionlendingagency for the performance of ReceipnN
F the work fur which his Fermin is issued(See.31197,Ci,C.) TOTAL:
ULender's Name
Linares Address TOTAL: Zis
4 1 terrify thm 1 have read this application and slate the,the above information is BUILDI FEE
.�.t
VI cared.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEEL.
^
L> G holding construction,and hereby authorize represemmives ofthis tiny to enter upon the V
idowe-mentioned property for inspection purposes, PERMIT ISSUANCE
(WO agree to save,indemnity and keep hamdess the City of Cupertino against ELECT RIC FEE
liabilities,jud em. crus and expenses which may in any way accrue against mid City ALDER OR ADD TO MECH. PLUMBING FEE
inconsequen of granting of his permit.
APPLICA U ERSTANDS AND 'ILL COMPLY Will ALL NON-POINT AIR HANDLI NO UNIT 111,000 CFM) MECHANICAL FEE
SOUR r .ATlffte..
AIR HANDLING UNIT(OVER 10.0110 CIM) CONSTRUCTION TAX
Signat ApplicannContacmr Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thexpplicam or future building occupant score or handle hexurdcus matefiul HUAI ING UNIT TO 103,100 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25533(a)9 HEATING UNIT(OVER[(In"BTU)
❑Yes HNo V FNI'ILATION PAN(SINGLE RESID) PAID
Dam Receipt p
Will the applicant or future building accupann use equipment or devices which
SMfiLardcn,air communities as defined by the Bay Area Air Quality Management BOILER-GUX1P(3HP OR 100.0100 BTU)
TOl'AI.:
r Drsara! BOILER-COMP(OVER Val"BTU)
E]Yea 8R
I have read Ne humrtom uctrials retaimmencs under Chapter 6,95of Ne Cali- AIN CONDITIONER ISSUANCE DATE
firman Health&Safe C Seroma 25505,255J and 255th.I understand that if the NEW RESIDENTIAL MECH. SQ.ET. C ^Q
huildingdi nate m vets mnnnL that it is t respansihi'y to notify the occupant s s� r
of me ratio an
en be map eof.0 eof ccupancy. ✓✓✓
Owner or vac agent Date TOTAL ISSUED BY:
OFFICE