B 0348 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY
CITY OF CUPERTINO t BUILDING-ELECTRICAL _ PERMI O00348 0 3 4 8
' BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAI. p i
BUILDING PROJECT IDENTIFICATION POOO1 J
BUILD NG ADDRESS - SANITARY NO. APPLICATION SUBMITIAL DATI
2
00 DU 1000 74VCNUF.
OWN•R" iqfpp .. ^ �/ PHONE: CONTRACTOR'S NAME: - - LIC NO:
r( __yEE� TL ` C,' N/C CONIROL#
ADD •SZ { o9 I E] t
CONTACT: PHONE: UILDING PERMIT INFO
�" ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT, PL M MECH
rio
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMITi • t iE
I hereby ativm th t I n 11 n. d oder p vis' m f Ch'Pter 9(c.mmen ng _ JOB DESCRIPTION
®aZth wiSwn.n 78118)o[D"xmn3nf the Bus ns and Pm[evs en:Cale,and my lia.n
� In full force and t,ERMIT ISSUANCE
�U UW.WClass Lic.# ElKITCHEN REMODEL
Dam Contractor PPLIANCES-RESIDENL. ADDITTIAWI.ION• - El PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS [I MULTI-UNIT ❑STRUCTURAL
Z O h z I understand my plans shall be used as public records - - MODIFICATION
'OZ.- 1 ' UP102MAMPS
F N, W Liernacd Professional - - - El INTERIOR •❑CHIMNEY REPAIR
201-IMOAMPS IMPROVEMENT SWIMMING POOLS
WIOWNER-BUILDER DECLARATION OVER IOOOAMPS
tpL I hi of irm that I am embumnrLice
exempt ore the Cans Licensee Law for the El BATH REMODEWREPAIR (]DEMOLI'T'ION
i0.0.iyy� W U following reason(Section 7031.5,Business and Professions Cede:Any city treasury SIG)JLELECTRICAL ❑OTHER
n+�O h which requires a Permit en amshuct,alter,improve,demolish,or repair any stmemre
yy-1¢ poor,its issuance,also requires theapplicant for such permit to file a signed statement SPECIALIT/MISC.
w+`a that be is licensed pursuant to the provisions ofthe Cumecl.re License how(Chapter 9
(ooramaeing with Seen.,,70 )of Division 3 efthe Biomass it Refeesions CedOire FTER .INS'f. COMMERCIAL'
G W m a that he is exempt therefrom and the basis far the alleged', prior.Any ,icli r as of El NEW BLDG/ADDITION El DEMOLITION
iC W Section 7031.5 by nny applicant for a permit suhie<tx the applicant mea civil penalty of POW ER D '
re
�..y not mothan five hundred dollars($500). ❑TENANT ❑FOOD SERVICE,
� +,d i,as owncrofthe t,orm to sea with we os ss thni,sole enc ensatlnn, SWIMMING POOLE IC IMPROVEMENT
Q.Q propery Yemv Y 6 P
will do the work,and the stmeturc is net lnendmd.r.Rered historic(Sec.9044,RosinessDOTTERand Professions Code:The Contractormv
's License Law does not upply to as ner of OU _ S-FTLETS IX' S
pmperty who build,in improves thereat,and who does such work himself in through
his own employees,provided that such improve ncom am not intendad or offered for NEW RESIDENTIAL e SQ Fh
sale,If,however,the building.,inaprovion is sold withinone yearufamrplecon,the SQ.FT.FLOOR AREA $/SQ.F.
nenobuilder will have the burden of proving that he did not build or improve for puo- '
pnve f, le). 411 -'
1 a..,car of the property.a.eveltowel,contracting with licensed.ed c men m
cotheproject(S 7044 Business and P f :' s Curb:)Th C t t L
f property theond QTPLUMBING
G PHRMrITt FEE .
c s L des t apply JG
who contracts for such p1 sits with a conventions)licensed porsaabuo the Contmmt n •
License L.
w CcDmakI��1_�='
E]ILate...
aexempt under Sec. ,❑&P C for this moroPERMIT ISSUANCE n -
ALTER-DRAIN&VENT-WAI' A)
Dale - VAT
ser WORKER'S COMPENSATION DECLARATION I{p'Dy
HACK PLOW PROTECT.DEVI � I I_
have
and willt.
Certificate
ofCper,oueneo xW-inhawing orker s Co 1'-AVl
❑.,W mmol, fare Sc Corti 37M of Chowan rCod.far the Workers Compeo- DRAINS-FLOOR,ROOF,AREA,CO STOItIP.S T D ONSTRUCt'ION
work,uv provided for by Section 3]00 of the Labor Cede,for the performance of the OCT L �gge
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will odintaine,for Wmkeor ante of
fsthew Insurance,which rcqulmd by Seeder _
My0 ol theWorkr Labor Cede,fonthsurancrt catcer athe work(numbrare permit is issued. GAS-EA.9Y9'1'EM-I INCA OUTLETS OCC.CROUP APN
MyWorku's Compensation Insurance carrier Policy number are:
Carries• Policy Na: GAS-BA.SYSTP.M-OVER 4(EA)
CERTIFICATEOMPE SATI TION NINSURAN WORKERS' GREASEANDUSTRL WASTE INTERCEPTOR
CAMPBNlawalH INSURANCE BUILDING DIVISION .S
(Thio seetlnn nee)na bewmplctedifthepermit is foronehundred dollars($1110) GREASETRAP or lees.) PLANCHL PGE C 3
I certify that in theperformance
man nceof stoworkbecome
for which this Permit is issued,I ehv11 t�
10,
not employ any person in any manner so as to became subject to the Wodax'Compem 9BWPA-SAN ITARY-STORM EA:200 FT ENER04
,Z Whom Laws of California.Date Q
z O Applicant- 1 WATER HEALER WIVGNT/ELECfR GRA2NME
rt'"p NOTICE TO APPLICANT:If,after ranking this Certificate of Exemption,you should WATER SYSTEMlIREATING
abecome subject to the Worker's Compensation provisions of the Labor Code,you must _ SOIL E
411 forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDP.NTIAI.PLM. SQ.FT. PAID
U work
rwhich vnpe them ieaed(See30lending agency for the performance of Dvte Receipt#
the work for which this permit is issued(Sou.3097,Civ.CJ
U Lender's Name _ _ FT T TAI.:
Lender's Address - T A.:
I simply that 1 have revel this application and sem that the above infsmnulion is BUILDING FE �'�
III contract.I agree m comply with all city and county ordinances and state Tawe relating m QTY.• MECHANICAL PERMIT f 'FEE.
U building constmetiogand hereby authenze mpremreads,a of this city to aberration the .i - SEISMICP
above-mentioned property for inspection purpose,. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against FILE
liabilities,ryrmeoft,seen andexpenseswhich may in any way acmeagainst said City
l- ALTER OR ADD TO MECH.
in comequence of the granting of this permit. - PLU+^Ff A
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(TO 10.000 CPM)
SOURCE REGULATIONS. MECHANIC I.PEE `
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTI X
Signature of Applicabt/ConRDO Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGAT12 FEE
HAZARDOB$MATERIALS DISCLOSURE
Wiil y 0n,Coperanr furore Municipal
Code,Cham.vmm2,and t e Health
Sat ty HEATING UNIT(TO 100,000BIO) ,
as defined io the Cutieninn Municipal Cadq Chapter 9.12,and the Health and Safety
'
Code,Section 2.5532(a)7 HEATING UNIT(OVER 100,000 BTU)
1
Fl Yes ❑Nn PAID
VENTILATION PAN(SINGLE RESID)
Dec Receiptp
Will the app onta manesor as
by
nt use Bay Area
Air
mlity or Maceswhich BOILER-COME DIE OR 100,001 BTU)
emit hazardous air contaminants as defi.eA by the Bay Area Air Quality Mvnagement tJ,
,Dielnaf!
❑Yes E]No BOILER-COMP(OVER 1011,0011 BTU)
t
I have read the hazvdnus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
humin Health&Safety Code,Sections 25505,25533 and 25534.I understand that time NEW RESIDENTIAL MECH. SQ,Pr.
building does not nmradly have errant,that it is my responsibility to notify the occupant
of the requirements which must be met prorto issuance of a Certificate of Occupancy.
IN An
Owner orambnnzed agent DoeL' - ISSUEDBY
OFFICE