S 1330APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
« CITY OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL
PE IT NO.
� 13 3 0
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS : -
SANITARY NO
APPLICATION Sum TEAL DATE
~
OWNERS NAME: PHONE:
CONTRACT OR'S NAME: LIC NO,
NIC
❑
CONTROL #
SS -
ARCHITF.CT/F.NGINEFIC LIC NO:
ADDRESS'.
-0 7
PHONE.
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELEGYPLUMB MECH
TICHNSCD CON'FRACI'OR'S DECLARATIONQTY
amrm that 1 am Becnsed ander prnviciane ofehaptor 9 (eammeneing
FidlSebtand Pudessions Code, mainly l ocatory
effect.
LichpPP1,lANCES-RESIDEN'T'IAL
Contractor
ARCHI'I'ECI"S DECLARATION
I understand my plans shall he d useus public rewsms
/N«YAY& b IAZ
-ELEC'I'121CPERMfI' FEEny
Z9W0)ofLumsion3oflheBusiness
14 �UUs
W
'Doo
4 �
7Z
�W
S~y`2OWNER-BUILDER
iAT0 0.� Q
p U
y a LL y
'A;
'ly pr
JOB DESCRIPTION
RPSIDFNTIAI;and
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RF-PIPE
❑MULTI-UNIT El STRUCTURAL
MODIFICATION
O INTERIOR 0 CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
F1r BATH REMODEUREPAIR 0 DEMOLITION
❑OTHER
�J y"
PERMIT ISSUANCEW�
PANELS
UP TO 200 AMPS
Liansul Pndcsvonnl
DECLARION
I much, affirm that I nm cxcmpt from the Contractor's Licensc Law f the
following reason. (Section 70315, Business and Prear, sioms Code: An t t
which requires t m unnstntet: alcor, Int p oi city
ucco y
quires a permi prove, Aemolish, or re air un wcfum
1i In it,': ce, also capture,tire oo,li'ardis,, "'ol"orno,f fif, o6gard ttetem
did he licensed pursa the brovisinuoul he Contractors License'L (Chapter9
201-1000AMPS
OVER 1000AMPS
SIGNS 6LBC, RICAL
SPECIAL CIRCUIT/MISC
FL, ME ME I' ER OR POLE INS
MPR IAL'
(courancima, w ith Section Toro fDivieon3of the Business and ln5fcss itis Gdepn
L q y
k Y.
ul^rn
F IL N
(..
that he is cxcmpt IhercGmn ;cod the basis for the alleged exemption. Any violation of
Section 9031.5 by any applicant race permitsobjectx the applicant
Section penalty ul'
to
not more mvn Eve M1undrcd Dollars ($SOU).
❑ Lathework, ndthestractormyemployeacwithwacd fir h (Sec. coU,B lines,
will Bothe work, mad the
rot
NEW HLUG/ADDITION 0 OHMOUTION
❑TENANT ❑FOOD SERVICE
IMPROVEMENT'
El OTHER
POWER DEV ICES
SWIMMING POOL ELLC'1'RIC
W0.
not apply m if owner of
he Contractor's Licerd, Law down apply,, an of
and PnsPoshiob Colic improves
Co s then' L rid w Luo s such
pro,cally who builds or thereat, end who docs such work hlmsclf or through
OUTLETS-SWITGIII?5-FIX 'C
own
his awn ew sided tho not iatmWN or altered for
provided that such held cname
NSW RESIIIF,NTIAI. F.LP.CTR
SQ. FT. FLO RA EA
5/SQ. FT,
tan,o
ver, the the
lthat lid noneyeafof wreve
owner-budder ill have Havimpmvemenl
r-builder will have the hurtlen of proving that he did not bdJd or Impmvc for poo-
he for
poseofrale.).
��� Oq
E]1 f theproperty, exclusivelycontracting with licensed nl I to
TOTAL.
�j v
�,9
controlthe protect (See, 0044 loursicessandPf Csd)lhContractor :f
sen g Laos due, net r,,Y to goosocir olpDo,erl, hit buildsorna,usti, theme, d
'
QTY PLUMBING PERMIT FEE,.y(
wh t of vachp,ceswthu out t,rcaleensed pt v'muo the Cont-dors
—.,- �111��a
PERMIT ISSUANCE'
`
Lecnec Lu
❑Ian em tund� c ,B&PC fe
Ow Dm is rce t
W RKER:S IIMPEN: DE ARATI
_ -
AI;FER-DRAIN & VENT- WA'III (BA)
VALUATION
6 ,.
�
BACK FLOW PROTECT. DEVICE
Ihemby thinunderpenaltyofpr,my namof the followingdeclarations:
�
"JU�❑
TRAINS-FLOOR, ROOF, AREA, COND.
Ihaveand will mmmmOtaCerti6caenf Cnnsemmvalf-insurefor Workers Cnnipen-
sation, as provided far by Section 3900 of the Labor Code, for the performance of the
'TORIES
TYPE CONSTRUCTION
work for which thus permit is Issued.
FIXTURES-PER TRAP
0 1 have and will maintain Worker's Gimpewatlon Insurmce, as retained by Section
Tryst of the Labor Code, for the performance of the work for which thispermit is issued.
My Worker',s CarKinsetwn Insurance currier and Palmy nmaber ere.
Carrier: Po] icy So:
GAS -EA. SYSTEM-I INC.! ETS
OCC, GROUP
APN
GAS -EA.SYS TEM-OVER4(EA) AVN
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis scctianneed gat hcenntplemd INtupermit is fneunehondred della, ($100)
or less)
GREASIVINDUSTRL WASTE INTF,RCF,PTOR
RULED 1
'DIVISION Pg,$, r
GREASE TRAP
PLANCHECK FEE LA
V
SEWER-SANITARY-STORM EA. 200 IF
C z
%
I certify that in the perfortnunce of Ilia work far which this pennh is issued, l shell
not employ ary,coon in any manner ser es to become sobjea m the Workers' Conryen-
true. Laweof Califuniu. Use
Applicant
ENERGY
WATER I HEATER WNENTIELECIit
GRA OfEE
r.y h
W
NOTICE TO APPLICANT: If, after nmong This Certificate of P,senpllon, yon should
bean.. cafjectw the Workers Compensation provisions of the Labor Cuda, you oast
fotlhwith comply with such provisions or this permit shall be Jcemcd revakoJ.
WATER SYSTEM/TREATING
WATER SERVICE
SOILS -
Q
Uz
C.) C
W
CONS9'RUGTION LENDING AOENCY
Thereby affirm that lhereisaconstmction lending agency for the performmceof
the work l'or which thin pcnnit ieisaucd (Sm:.3119), Civ. C.)
PAID
Date Receipt#
NHW I<HSIDLNI'IAL PLMB. SQ.IW.
'
IF
C)
Leaders, N
'IDEAL:
OTAL:
Leader', Address
U
W
BUILDI ,FEE
1 certifythat lhave mad this application and state that the above inforreationis
MECHANICAL PERMIT FEE
to
U �
cam. t l agree in I IY with all city and county ordinances andot Iaw% relfiraig toQ7
Lr upon lM1e
buildingconstruction. and hereby authorize o[n-n�tye nn
SEISMIC FEE
V PERMIT ISSUANCE
ELECTRIC PE
above-menioned property lonnspection pom,i
(We) agree to save, indetnday and keep harmless the City of Cupertino against
ALTEI2012 ADIJ'ID MECH.
PLUMBING FEE
Iizbilitme.judgmen6,c... orad espemes which mayartay wuyuccrue aga cel said City
onnequence of the granting of this permit,
AIIt HANDLING UNIT CTO 10,000 CPM)
-
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
STURP GU,ATIO X -
MECHANICAL FEE
AIR HANDLING UNI 'C(OVER 10,000 CPM)
CONSTRUCTION Te
�l
Slgnaum of ApptunlCc.hmcwr Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION P.
HEATING UNIT HO 100,0011 BTU)
Will the applicant or future building anapvm store or handle hazardous matrrial
to defined by the Cupertino Municipal Gme, Chapter 9. 12, and the Hedur and Safety
HEATING UNIT (OVER 100,0011 BTU)
PAID
Date Receipt#
Code, Section 25532nd?
❑Yee %No
Will the appliamt or future buildingocapam rose eyripmemor desire, which
mit heramoue m Air Quality Manageen
air conmiaanls ac defined by the Bay Ama m t
District,
E] Yes 5(N.
VENTILATION PAN (SINGLE RPSID)
- ,
BOILERCOMP(3IIP OR IOo000 IF[ Of
TOTAI
BOILER - COMP (OVER 100,003 BTU)
AIR CON DI'I'ION HR
I have read the hazardous mamritJs mquirements under Chapter 6, 95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MSCII. SQ. Pf.,
htmiagdoesHealth &Safety Code, Sections 25505, it May end 2. itch to mad, ad thatifthe
frunce
tha;d the
building does not currct tions 2 505, May anpoaeibl4. 1 understand
of gatrenents a prior witoon"sofa Cetilic to of Oce
rc� f- use
ISSUED RY'
UWVf OV anthill at Dam
TOTAL:
OFFICE