S 1143APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL
� CITY ON CUPRRTINO
BUILDING DIVISION APPLICATION/PERMIT
PEN ONLY
MECHANICAL.
1143
OFFICE
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ARCIIITECf/ENGINEER: LIC O:
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❑ Consultant Fees Paid by Applicant(Initial)
BUILDING PHRMIT INFO
BLDG eLecr rl.umu E
❑
pay
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LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of chapter 9 (commencing
�iJ� 7 Care.
in ini fall fi�ltisnd effe,Ci`,13Oo[the Lesiness andh�ndcvi C:xle. undm tleenmia
Dam—���Comrednr
ARCHITECTS DECLARATION
I understand my Plans that 6e uxedts Public records
QTY. HLECFRIC PERMIT FEE
JOB DESCRI ION
RESIDENTIAL
❑ SIDE ❑KI'I'CIICN RF.MODIeI.
❑ADDITION ❑I'LUMNING RGPIPE
❑ MULTI -UNIT ❑ STRUCTURAL
MODIFICATIONOZ—Q ❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
iNttAL
nl'PLIANCrUA RESIDENTIAL
I'ANI!IS
UPT02IXl AMPS
Licensed Professional
2111-INX)AMI'S
966'' Q
JLy w U
OWNER -BUILDER DECLARATION
1 hereby from that I am exempt from the Com urinous License Law for the
following masa.. (Section 7031.5, Business and Professions Cold Any city no county
❑BATH RF.MOUEIJRF.PAIR DEMOLITION
❑ OTHER
OVIiµ HXXIAMPg
SIGNS ELECTRICAL
F�Oyr3
y
C d£
w o C
W
m
F Z i
SI
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W
which requires a Permit to construct, alter, improve, Mmolish, or repair any structure
prior m its issuance. also requires the applicant lmsuch perminn filo a signed statement
that ho is llecnsei pmmnd to the,reeki esof life Contractor's license Law (Chapter 9
(commencing with Saninn 7000) of Ui me.3Ill' Om ipomeas and Packs....... Codc)or
❑uu he ix exempt Ihciefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects tha applicunl to a civil penalty of
not marc than five hundred dollars(3500).
OLasill he owner k. the pmpeactur myemntended withwages rstheir soleale(Sec. compensation,
Business
will ProfesionsCde: not Licensnrnllined wdosnol apply to
and Professions ha Code: The Containers License Is Idesstnsnmapplytolf owner of
his o ny who build, or improves thereon, ass who rasa mph work himself ff through
his own employees.flue provides that such mentis seed thin not intended or offered far
sale. IL however, the huilJing orimprovemem is sold within one year of n:mpinion, the
SPECIAL CIRCUIT/MISC.
TEMP. Mh I'Elt OR POLE INS'('.
COMMERCIAL;
EINEW BLDG/ADDITION ❑ DEMOIXI ION
❑TENANT ❑FOOD513RVICIi
IMI'HOVF.MENT
[]OTHER
POWER DEVICES
SWIMMING Iv)OLBLECTNIC
ODTLLTfS-SWI'(C111i5-PoXTUN
NEW NISIUIiNT1Ah ELEGfR
SQ. 17. FLOOR ARCA
USQ. FT.
ser -builder will have the bufden of proving that he did not build or improve for put -
qac If salcJ.
❑ 1, as owner of the property, am exclusively contracting with licensed contractors m
T L:
i-
construct the protect (Sec 0044, Business and Professions Cadc:) the Contractors Li-
initiatives thereon,and
c se,Law does not apply to an owner of property who hudds or innpro
came,
whit contracts for. such prolene with a comr:acmgel licensed parsuaut to the province.
MI
QTY. PLUMBINGPERT
PAI
PERMIT ISSUANCE
License Law.
Ll 1 am exempt under Sec. . 116 P C for this reason
D
),.
Owner Date
ALI'E IR - DRAIN 6 VBN'I'-WATER (EA)N
I Ilys'I'IQN
1
BACK FLOW PI GI'ECT. DEVICE
WORKER'S COMPENSATION DIiCLARA'I'ION
herchy land under penalty of penury one of the following declarations:
A
D
C�
(huve and will maintain aCertificamof Consenl lneelf-inmrefor Wodcr's Compen-
come, as provided for by Section 37W of the Labor Care, for the performance of the
work for which this permit i. issued.
DRAINS- FLOOR, ROOF, AREA, GOND.STONI
,g Uf-L/)
TYPE CONSTRUCTION
IOU
FIXTURE4 - ITER TRAP
❑ 1 have and will maintain Walkers Compensation Insurance, as required by Section
3700 of the lao,C,Ctjd�e4.for the performanre o(thc work( M1this pcmhit is issued
My
''iY
Carrier:re?JC:^ V ace came volley NiY
OCC. GROUP
MIN
GAS - I SA. SYSTEM. I INC. 4 OUTLETS
GAS- EA. SYSTEM OVER 4 TA)
GRI!ASI%INUUS'1'NI. WASTE INTERCEPTOR
CGRTIFIC OE EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FI!ILq
(T his section need not be completed if the permit is Lu mm hundred dollars(S1 W)
tor Iwa.l
GREASE TRAP
I'LANCHECK ITS.
I certify that in thepentormance nfthm work for which ild,unnd is issued.(shall
nm wnPlny any parson in any manner sit us m hoconm antlers m the Workers' Comped-
SEWER-SANT"fARY-STORM EA. 200 FI.
ENERGYFEE
WATER HIHNI'UR W/VENT/HICCTR
ZAppl
.Zs ti
a 7
� Z
LJ
P.
Fh
V z
cation laws of Califomin. Dnto
lent, t
GRADING PEE
NOTICE TO APPLICANT: If, after making this Cen t earn n1Elmaidien, you humid
become subject ,o the Worker's Compensation provisions of the Labor Calc, you must
forthwith comply with such .... ione, or this permen lu ll he deentedoe,oked.
CONSTRUCTION LENDINGAGENCY
rwhich nnthat thereis.ad(Sedionle, Cis, agency limhePerformance of
I far
the work fur which this permit is issued (Sec. 3fY97. Civ. CJ
lender's Name
WAHi, SYS'I'HM/fIt BATING
WATER SERVICE
SOILS FEE
PAID
Date Receipt X
NEW RISIDIiMIAL YLMB, gQ. Ff"
A. 10 1.:
L.endeex AdArees
TOTAL:
BUILDING FEE
1 cenify that 1 have read this application and state that the above information is
correct. l agree to comply with all city and comfy onllnances and state laws relating to
huildinglaentraction, and hereby authorize mpesentativex ofthis city menverugm the
QTY. MECHANICAL PERMIT EVE
SEISMIC FEE
PHRMIT ISSUANCE
I I.ECfR1
ohne-mentioned Property for impaction parne'es.
IW ng ce m xnse, indemnify and keep hurmles.. the City of Cupertino against
liahllitie J. mnte, costs and expenses which may in anyway aceme ugairderid City
in con yup cnf 0c gen' ofthis per 't.
the
ALTER OR ADD TO MECH.
PLUMBING PEE
AIN HANDLING UN if (TO I(1,(IfX) CFM)
MECIIANICAI.
'
APP( ;A f UN DS N ILL COMPLY WITH ALL NON -POINT
SOI Cl BUD] I
AIRIiANDLINGUNI'I'(OVER I0,000CFM)
CONSTRUCT L TAX
_/I � G 6
`
EXHAUST ]JULD (W/DUCT)
HOI151NC Nr IGATION PBG
Signature nl ApplicenOCon ne r Dam
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNI I'fro 1 00.0(i B' I' Of
Will the applicant or future building occupant. store or handle humorous material
u defined by the Cupenina Municipal Cale, Chapmr 9.12, end the Health and Safety
Code. Section 25532nd?—/
❑Yes IMfN'O
Wil I dth, applicant orfumre building by lementme ., Air. Qu urdeviceswhich
emit hazardous air contaminants as defined by the Hoy Amo Air Quality Management
Di... cll/
❑ Yee VTR
PAID
Date Benet"g
HEATING UNIT (OVER BX).0X) BTU)
VEs1HLA'I'[ON PAN (SINGLE RESID)
BOILER-COMP(3HPOR 100,000BTU)
'fOTAI :
BOILER-COMP(OVER 1,00OBTU)
AIR CONDI'IIONIiR
- el nd lite holadous mmennLs is under Cha lief 6.95of the Cali-
requirenw
I'O'S'.
ISS DATIi
NEW RESIDENTIAL M17 U. SQ. ET
name e 11 I,b Sufuy Cn�Ip, Sections 305, 2.5.539 and 25534, 1 mrerstand that if the
huilJin An (n Iy �nve Whot it is myrC ponnibility In nmify theoecupam
of lib 'v rcmt h fj nusta et priori isnuuntt ol'u Ccn7act �nc
TOTAL:
ISSUED BY:
Ow cr nr uuthnrireJ agent Date
OFFICE