B 0492 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO N FRIT PLUMB NG-MECHANICABUILDING-E.LHCTRICAL PERMITNO�O ^ w
BUILDING DIVISION APPLICA L. 50001 JVL
'BUI.MNGPROJECTIDEN'I'IFIc 'r10N, O
BUILDINr1ADDRLSS: 04199-3 SANITARY NO. PLICA'T'ION SUBMITTAL DATI
� rr APer u •3 L - z,0 4b 0
OWNER'S I' ONE: CONTRACTOR'S NAME: LIC NO.
NIC CONTROhM
7kRCHIIECEC s N R: LIC NO: ADDRESS:T': PHONE: BUILIJING PERMIT TNI O❑ Consititant Fccs Paid by Applicant(Initial) BLDG EuiCf PLUMB MECx
LIC.NSED CONTR 1OR:S DECLARATION QTY. ELECTRICPLRMIT,' •FEIi 'hereby abSnn ih am licensed under provisi ns 0f Chaper 9(ommencingJOB DESCRIPTION
tionaam)ofoiv 3 oflM Rusineax emaP i nyfiad allyttylicettseis RESIDENTIAL:
IPERMITISSUANCEne effect. ❑SFDWI. ❑KITCHEN REMODEL
Lic.Y_ APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PII'fiConvenor
F,Orn RCHITECTS DEC R PANELS ❑MULTI-UNIT El SIT
Zprr�Z Tun ersun my plansshallbeusedaspub records MODIFICATION
.aZ,rQ UPT02W AMPS ❑INTERIOR El CHIMNEY REPAIR
F�1-'al Licensed Professional 201-I"AMP5 IMPROVEMENT ❑SWIMMINGPOOLS
aOWNER BUILDER OVER 1000 AMT'S ❑BATH REMODFUREPAIR LJ DEMOLITION
r� a 1 hereby affirm that I am exempt from the Connector's License Luw for the
iqS O y U following mum.(Section t0315.Businco and Professions CtNa.Any cily or county SIGNS IiLECTRICAL ❑OTHL'R
t++3
0 y which reyuircit rym
s a permm smatcl,tiller,improve,demolish,or repair any etrunure
E"LLg
prior o its issuance,also requires the applicantfor such pemnit to file a signed statement SPECIALCIRCULDMISC.
5555 }
that lie is licensed pursuant to the provisions of the Contractors License n 9Low(Chaprer9
�•StiofKKpof llivisinn3nf the Business and Professloas Cndo)or TEMP.ME'fl?R OR POLE[NST DMS MFRL
CIA
O (asmmoncingwith See
W c C that he is exempt therefrom and the hasis for the alleged exemption,Any violation of ❑NEW BLDGIADDI'I'ION 0 DHMOLITION
4•�
Section L5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES y El TENANT ❑FOODSERVICE
F
not mare than five hundred dollars(SSW 1. IMPROVEMENT SG ❑Lo the work,
Pe dructor myemntendedwithcred fm0tl(Sec.c0m,Business SWIMMING POOL F.LECTRI
F will dnthewon,and the he Contis pots Lannse Lawdoforot applyoi4,owner of [I OTHER
3 m and Professions Code:The Corrector's 1.nd w Laws such
not apply In if owner of OUTLETS-SWITC IXTUBES
property whohandso,ews,or Improves thereon and who does such work himself or through -
his own employees,provided mei such improvements ore not intended or offered for NEW RE SIDENTLOM114, SQ Pf.
cide.omar-1 told,,will have
han improvement isst el heddwithin t bond at improve
ane HQ.FT.BOOR ARCA EISA,IT.
caner-builder,will have the M1UNen of proving that he did not M1uild or improve for pur-
pose of sale.). —^/
❑ h connecting as owner of the property,am exclusively coacting wm
ith licensed comnata to O C.�7 7 O -
eanahucl the pmjG9(Sec,mN i.Business and Professions Cade)The Cminuclur's Li- - - - ;
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. " PIIUMBIN4 E FEE'
who contracts for such pmjecn with a cnmmcums)licensed pursuant n NC Comessetod 4� 2
License low. PERMIT ISSUANCE 4r, J
I am cs n oder Sec. .B& C for this reason
ALTER-DRAIN&VENT-WAfEk(PLA) VALUATION
Owner 075, ®-o e�
NKE 'S CO APF.NS 1'O F.CLAT A' YN BACK FLOW PROTECT.DEVICE.
I Inner, nd typf pend f olhavin deciamtinare
'0 Ihave a t r E3se4 vent oself-insure6gWerkers Coni DRAINS-MOOR,ROOF,AREA,COND. STORIES 'TYPE CONSTRUCT ION
scion v dad for by Section 3700 of the Labor Cade,for the performance of the
work er sh this.....it is issued. FIXTURES-P17R'I'RAP
I have o will motion Workers Compensation Insurance,as iequinal by Section
3900 uflhe bar Code,for the performance ofihe work for which this permit is issued. GAS-EA.SYSTEM-[INC.4 OUTLETS OCC.GROUP APN
My Workers asmion Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEJINDUSTRL WASTE INTERCEVI'OR
'BUILDING DIVISION FEES
(lbisseetion need not he completed if the pbi is Toren.hundred dollars($100) GREeASETRAP
or less.) PLANCIiEC .F. �-
I certify that in the performance of the work for which this permit is issued.[shall
SEWER-SANITARY-STORM CA. FT.
not employ any person in any manner so as w become subject the WorkerA Campen- ENF.RG
Z cation Laws of California.Date WATER HEATER WNENTIELECI'R
y� OA,hclinl I GRA A
s7 ` NOTICE TO APPLICANT..If.after making this Certificate of Exemption,you should WATER SYS'r1iM/fREATING
a , become subject in the Worker's Compensalhat provisions of,he labor Cede,you mud SOILS
W
forthwith comply with such provisions or this permit shall the descried revoked. WATER SERVICE
{pp❑y..
CONSTRUCTION a TTONLENDING
ngAGENCY
agency
NEW RESIDENTIAL PLMH. SQ.Trp PAID
U0 I let which thilh a there isaconsrut.30 lending agency for the performance of
- Date Receipt It
Othe workbe,I'ur which this permit is asued(Sec.909],Civ.CJ
1••' 4nJere Name TOTAL:
lU Lcndcrs Address TOTA
I certify that 1 have read this application and sure that the above information is - BUILDING FE �-
IZI correct.l agree to comply with all city and county ordinances and sure[awa relating to QTY. •, MECHANICAL,PERMIT FEli
V building construction,and horsey annual in.....anutives of this city to enter upnn,he SEISMIC •7 -
above.menBroad property for inspection purposes. PERMIT ISSUANCE e . /
(We)x me to save,indemnify and keep harmless the City of Cupertino against ELECI'kl EE y'
liabilities,jud rnts,rons and expenses which may in any way venue againd said Ciry ALTER OR ADD TO MECH.
nsequ f the granting of this Pe 't. PLUM GFEE
APPLIC NR DERSTANDS AN .i.COMPLY WITH ALL ON-P INT AIR HANDLING UNIT(TO 10.000CPM)
MHCHANI'AUFEIi
SOUR( iRF LA,
Ul�
AIR HANDLING UNIT RI,(MCFM) CONSTRUCTION TAX L'j
Signawrc0 App nJCon a EXHAUST HOOD OMMUCD
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FF.F.
Will the applicant or future building necupinldore or handle hazardous material HEATING UNIT U 0100.000 LOU)
as Code
by the Cupertino Municipal Code,Chapter 9.12,and the Heath and Hafmy h
Cotle,Sullinn 25532(v)4 `' � � HEATING UNIT(OVER 100,001 BTU[
❑Yes [jNo _ t
VENTILATION PAN(SINGLE kFSIO) PAID
Dam Receipt it
Widen,air omationdo tare building by the B Arco
Air
Management
BOILER-COMP QHP OR 1(X1,(1(10 BTU)
'mit hawNnus air cnnmminantc.ae Jelined by the gay Arcn Air Quality Munagemem TOTAL
District? cI/7-J'/'s-,-_ BOILER-COME(OVER 101.000 Bru)
❑Vea
1 hav Ne hawdnus mareriWs requirements under Chapter 6.95 of rhe Cali- AIR CONDITIONER ISSUANCE DATE
Temic He th S fery Csde.Scnions 25505, 33 and 25534.1 un emrand Lha f rhe NEW RESIDENTIAL MECH. SQ.FE
building ,eu tum hxvealcnanMha myrespnnadi Troy'. By the cupam
ofabe r airs seat he a 0f n Cent v
Owner in
uu.r.a.i droant am TOTAL:IF ISSUED BY:
OFFICE