00020031 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Iftooa 00 3
CITY OBCUPERTINO BUILDING-ELECT RICAL PHRMI I'
BUILDING DIVISION APPLICATION/PERMIT PEGSIBING-MECHANICAL S0001
BUILDING PROJECT IIIEN'I'IFICAT]ON \I
N�ILDING ADDRESS: SANI'IAItY NO. N'I'LICAI'ION SI111MI'I'IAh UA'I
oa6l2 GRP D/2
')WNER:S NAMIi: P110NG: O CONTRACTI<:S NAMIi' TIC No:
yLL13 f �N rM,tOT y$-8346 i r 6 torr ahvrkDl.N
CHITECT/ENGINIZER:Al 14 LIC NO', ADDRESS310 NfOe PQM T ❑
CONTAC': PHONE: f3U H.DING I'EHMIT INFO
❑ Consultant Fccs Paid by Applicant(Initial) BLDG ELECT PLLJMIVI SUCH
LICENSED CON TRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE J013 DESCRIPTION
1 hereby afftm tem 1 am licensed ands,pmvoinss of Chapter 9 fenimncncing
OCZ with Section7000)ofDivision 3of,he Bast nes.and profe..inns Cous.many license is RESIDENTIAL:
PI[RMI'I'ISSUANCE00 in full franc unJ ctlbut. ❑SPDWh ❑KI'IY:11EN RIiMODIiI.
aUV License Class Lica APPLIANCES-RESIDENTIAL ❑ADDH'ION ❑PLUMBING RI:I'IIE
E.Z W Date-Conm¢mr
Snag. ❑n1ULTI-UNIT ❑SI'RUCIFRAI,
ARCHITECTS DECLARATION
FSH PANELS MODIPICA'I'IUN
O Z 1=`- l understand my plans shall be used as Public mends UP 10 200AMPS
❑IN'1'IikIOR El CHIMNEY REPAIR�4,r'.W Licensed Professional 201-HXIBAMPS ..�IMPROVEMEN'I' [D SWIMMING POOLS
OWNER-BUILDER DECLARATION _ UVIik I(XXIAMI'5 r[V tiAl'It RCMODIiIJRI;PA1R �UIiM01,1'l lON
W eel 6 I hereby affirm that I am exempt from the Conformers,License Law Int the �#
O G O following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECI'RICA], LI YI III?k
Y131L e` which requires a permit to mmstmct,alter,improve,demolish,or repair any structure
F"NCara; prior mu,i...gave..1o,requires the applicant for.such Permit it)file a signed statement SPECIAL CIRCU l 1'/MISC.
�y)Y that he is licensed pursuant,the pnwraom of the Commuters Lice-,Law(Chapnr4 COMMERCIAL:
al (commencing(commencing with Section 7000)of Division 3 ofthe Business and Professions Crede)or TIiMP.METER OR VOLE INST.
a E c C that he is exempt therefrom and the basis for the alleged exemption.Any violation at [:1NEW BLDG/ADDITION ❑DIiMOhI'1'[ON
W III m Section 7031.5 by any applicant for v permit subject,the applicant o a civil penalty of POWER DEVICES ❑TENANq' E3 pool)SERVICE
not more than five hundred dollars(5500). IMPROVEMENT
=0 0 T,vioxmcrofthe Tenpin,or my employees with way,,a,their sole emopemmion, SWIMMING POOL ELECTRIC
F- will Jo the work.anomorumere is Batintended.....noted female lSce.]OW,Business ❑OTHI?k
W 3 m and Professions Code:The Contractor's License law does not apply to an owner of OIITLGI'S-SWITCI{Ii5-PIXY
pmfcrty who build,or improve.Immo..,end who does such work himself or through
his non employees,provided that such impmvmscnts ate not intended or offered for NEW RISSIDHSTIAL ELECfR S b
one.IL hnweveg.he buildingar improvement i,s..ld withiumm ycaraf,ompE1ion.the "�SQ'IT\11:OOR ARIir��—� USQ.1'I'.
er-builder will have the burden of proving Nat he did not build or improve for pur- I hi \ I_I
par of sale.). O, !—`-111
0(�s.a,owner or me properly,am exclusively contracting with licensed contractors m
`1ilr rum,he project(See,y0.W,Business and Prom"i..m CoAe)The Comemou"Li- QOoo
se Law does nm apply to an ownerof prepeny,who builds or improves thcrcun.and QTY. PLUMBING PERMIT P:. FEB L
who contracts for such projectswith a comtmctur(m)Iieensul pursuant to the Contractor's
License law. PERMIT ISSUANCE
]am exempt under Sec. .B&P C for this reason
A.'wour D ALTER-DRAIN&VENT'-WATER(IIA) `/ VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE J ��
1 hereby aRren under penalty of perjury one of the following declamations
❑I have and will maintain a Cmufeam of Consctn toself-insure for Wicker's Compen- DRAINS-FLOOR,ROORAREA,COND. S'IoRI.; 'rYPECONSI'RUCHO
nonan,es provided for by Section 3II0 of the Wbnr Cola for the performance of the
work for which this psonil is issued. NXTURGS-PER TRAP
❑1 have and will maintain Workers Compensation Imuran,as respond!by Section
3700a the Labor Code,for the perfnmmnce of the work for which this permit is issued. GAS-EA.SYSTEM
INC.iOUTIJTS (A'C.GROUP AI'N
My Workers Compensation Insurance carrier and Policy number:ue:
Cartier: Policy Na: GAS-CA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTE INTERCHVInR
COMPENSATION INSURANCE BUILDING DIVISION IgiliS
Ofiis section need not be completed none Permit is for one hundred dollars I$i00) GREASETRAP
I or tented VIANCIIIiCK IEE
I certify that in the performance ofthe work for which this pmmit is issued.I shall SEWER-SANITARY-STORM EA.2W FIL
not employ any seems in any manner wt res,lecame subject to the Workers'Compere- T:M1'IikGY RIE
Z nation laws of California.Date W'AT'ER HEATER W/VENUELECTR GRADING PER
C.I.I.-
0 0 Applicant i
red+ NOTICE TO APPLICANT:If,of r,making this C,rtifirme of Exemption,you should WATER SYSTEM/TREA'TING SUES FIJI
a > Iwcome subject m the Worker,Compensation provision,of the labor Code,yob must
forthwith comply withmvch provisions ar Min permit shall W deemed revoked. WATER SERVICE
PAID
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Yen Dam Remipl4
(.7 0 1 hereby affirm that bere m
is a cowction lending agency for surfonm
nme,of
V. the work for which Ibis p,mut is issued OSec.3097,Civ.CJ
1-' IUTAI.
Lenders Name
V Lenders Address 'rOTAh:
;t- PW. 1 certify tbar 1 have read this npplicmion and mart,that the above information is BUILDING FEE
F' V) seam.l agree comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
rosea. SEISMIC PER
U ,Z Wildimgconsnucton.andhenhytenhomc mpresenuuv,s of thiscitymemerurym the
ran,e-mentioned propefy for im ectu n purposes. PERMIT ISSUANCE ELECTRIC PER
(We)agree to save,indemnify and keep hanaless the City of Cupertino against
liabilities.judgment.costs and expenses which may in any way accme against said City ALTER OR ADD TO MECI I. PLUMBING Iq!E
to consequence of the granting of this permit.
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00CFM1 MECHANICAL FEE
SOtRCE REGULATION
AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTION TAX
Signature..ApplicaMContecmr Date EXHAUSTHOOD DoIDUC) ROUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hiafkats motafel HEATING UNIT CIX)10d.00 BTU)
a,defined by the Cupertino,Municipal Code.Cbapmr 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)Section 25532(x)7
❑Yes VENTILATION FAN(SINGLE R[.SIDI PAID
one RcttiptN
Will the applicant or future Wilding occupant use equipment or devices which BOILER (3111'OR 10.00 BTU)
emit hazardous air contaminant,am def ml by the Bay Area Air Quality Management IDEAL:
District! Yes �� BOILER-CHMP(OVER 100.00011'FID❑
I have read the Enormous materialsrequimt,under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DAT I3
forma Region&Safety Cod,.e.urSections 25505,toraymrd2553J.1uM,nyth Lhaif the NEW RESIDENTIAL MT:CH. SQ.17.
buildingdoes ern cu,mntly have a tenant.Wt,it ix my resrymsibiliry m notify the oesupam
of a/irem,ntswhichm i priorm issumtcc oft Ccnifcau�f cu.;oey.
s
'wnerorau edvgent Date TOTAL: ISSUED BY:
OFFICE