S 3818APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
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BUILDING . ELECTRICAL
BIAG [LE PLUMB MECH
PERMIT NO.
BUILDING. DIVISION
APPLICATION/PERMIT
PLUMBING. -MECHANICAL
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'h�i'4`Tf,J?OBUILDING PROJECT IDEN9'IPICATIONIGI: t.17S', it
I'ERMI'P ISS( 1ANCE r
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BUILDINGADDRESS:
PANELS
UPT0200AMPS LC sli
Lircnsul Pmfic"knnl
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following ries on.(Section ]Ilii 5. Business and 11rofe,din I, Cud, Any city nr county
which requires a permit to construct, alter. improve, demolish, or repair any structure
Foot,, it, iesuuncr, also reoryireemheappfaem fmsuch permit,, Elevsignedsm¢mcm
that he is licensed pursuant it) the provi.cionsofthe Convector's license Law (Chapter 9
(commencing with Section 70110) of Division 3 ofthe Business and Professions Code)Or
that he is exempt therefrom and the basis for the alleged exemption. Any vinlmion nt
SANITARYNO.
APPLICArIONSURMI'ITALDATI;
SIGNS ELECTRICAL.
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
29
OWNS NAME:
PHONE:CONI'RACTOR'SNAME:
I.IC NO',
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RCHITECT GJNEBR: _ LIC NO:
ADDRESS: _ a _
OFFICE
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❑ Consultant Fees Paid by Applio:Ent(Initial)
BIAG [LE PLUMB MECH
LICENSED CON FRACTORS DECLARATIONQTY
I hereby alarm that l am l censed a da p f Chapter 9 (commen g
If Serton 7000) of Dm sir 3ofth, Business and Pr fessrm CwlenW my Ter
'n fall rce and effect.
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Liccncc Class LiCM �
Ilam 'fS S ¢ontramor
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JOB DESCRIPTION
�RESIDENTIAL;v
❑ SFUWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
[0 INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑BATH REMODEIJREPAIR El DEMOLITION
El MITER
I'ERMI'P ISS( 1ANCE r
gpPLIANCES-RESIDENTIAL
ARCHITECTS DECLARATIO
I understand my plans shall he used is public ree,,rdc
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PANELS
UPT0200AMPS LC sli
Lircnsul Pmfic"knnl
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following ries on.(Section ]Ilii 5. Business and 11rofe,din I, Cud, Any city nr county
which requires a permit to construct, alter. improve, demolish, or repair any structure
Foot,, it, iesuuncr, also reoryireemheappfaem fmsuch permit,, Elevsignedsm¢mcm
that he is licensed pursuant it) the provi.cionsofthe Convector's license Law (Chapter 9
(commencing with Section 70110) of Division 3 ofthe Business and Professions Code)Or
that he is exempt therefrom and the basis for the alleged exemption. Any vinlmion nt
201-100 AMPS
OVER 10010 AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
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Section 7031.5 by any applicant fora permitsublest, the applicamme civil peO.Ity,,f
ern more than live hundred hot... ($500).
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will Jcthew,ak,eadhextmmure lin,,tiofferdadmIfRemd frsole (SwJ014. Business
and Professions Code: The Certitudes License Law docs not apply m an .,net of
property who builds or improves thereon, and who dtwa such work himself or through
his own employee,, pnrvlded Thal such improvenmms are non Intendcd m oRured for
sale If howevec. the huddingurouproveracra is sold wiffirrione yearocompleirm, the
wriner-hrilder willh the burden fpr vngthat M1 I'J notlt Id or moprosefor p
POWER DEVICES
OT'ENANT ❑FOODSERVICE
❑OTHER
SWIMMING POOL ELECTRIC
" OU111I.I TS-SWITCIIF,S-PI%TUBES
NEW RESIDENTIAL. HLECTR SQ pT
F77PEGGR,AJ{EA
to Pf,
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❑I Ithe p Any exclusivelycontracting'thlc dcommands t
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comfort N t (S 70iD li d f t C de TI Contractor
P j )t
cense) d t h mm fp pony h builds improves art d
who t c f hp 'h lh ueonva mrtcll ee ssul puree amt theC mtruct r:
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QTY ' PLUMBING PERMIT' (, ,PEE'•
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PERMIT ISSUANCE
Did, Us,
I nm exempt under Sec B & P C for this reason
Owner Dae
ALTER - DRAIN&VENT-WA'I'IiR (1iA)
-` (�— VAIAAT'ION
WORKER S COMPENSATION DECLARATION
BACK PLOW NICE OCT. DEVICE
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1 hereby affirm under penalty of perjury one of the following declarations:
I huvc and will maintain it Craft Fettle of Consent toslf-imnre for Worker's Compen-
cation, its provided far by Section 37M of the Labor Code, fur the poefmarair. a of the
winds for which this permit is issued.
DRAINS- FLOOR, ROOF, AREA. CONE
STORIES
TYPE CONSTRUCTION
FIXTURES - PER TRAP
8 1 have end will mommum Worker's Com,amOodon Insurance, as required by Srctlon
3700,,Gibe Labor Code,fords, performance ofthe work forwhichtbis permit is issued.
OCCGROUP
ANN
GAS -L'A. SYSTEM -1 INC.4 GULLETS
My Worker's C npereadnn In yI carrier and Policy mmobcr m
Cartier: �e.(pe ace mm Policy Nn. LIG -Z
GAS-EA.SYSTIiM-OVI:R4(HA)
CEI1'1'IFICATE OF EXEMPTION FROM WORKERS'
COMPIiNSAI'ION INSURANCE
ORE, SFIINDI1STItL WASTE INTERCEPTOR
_Ii111LDING DNISIAN'Fk!6S
This section need not be completed if No permit is (Drone hundreddollam($I(p)
or nese,
GRHASP. TRAP
PLANCHECK FEE
I comity that in the performance ofthe work for which this permit is issued, l shall
not employ any person in any manner so its to hecome xubjeel m the Waders' Cmm,bn-
SEWER - SANITARY - STORM EA. 200 FP.
ENERGY FEE
WATER HEATER WNFINT/ELECTR
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G Zhuildng
cation L x's of California. Done
Appllcam
GRADING LIFE
NOTICE TO APPLICANT: If, alter making nits Cenilicate of Exemption, you should
become subject to the Workers Cumpemation previsions of the Labor Code, you must
limhwith comply with such provisions or this Of mil shall he deenned revoked.
CONSTRUCTION LENT] INGnGF.NCY
l forwhictinn lhanhereissued(See constructionlendingagency for the performance of
the work for wM1ich this permit Is issued ISec. IINJ. Civ. CJ
Lend ry
WATI7R SYS LUNG REAL ING
SOILS PEE
WAI Fit SERVICE
PAID
Dm Receipt #
NBW RESIUfiNT1AL PLMB. SQ. Pf.
TOTAL:
Lend AJJ
TOTAL
BUILDI FILE
I Ifythtll - dll'-pl l' m d r trade chrse mfmmat '.
coned g t ply th II tyand < my rd andamte laws renal gl
eonsmtcion and hereby atlh rive mpesentetves of this city to enter upon the
MIT 77. 3r
TY._" ANICAI IPI?Rf t1`'t FEE{'r`
Q MECDrr r. ��ll. I':
SEISMICFEE
PERMIT ISSUANCE
CLENP iE
abme-memi,,ned pmFerry It,, i eopec ion purposes.
(We) agree ,, save. Indemnify and keep hamdess the City of Cupertino against
ALTER OR ADD' 1'0 MECH.
PLUMBIN FEF.
Ilubilhice.judgerenn, casts and expenses which may in any wiry account against said City
in nuquence of the g. n d,,,f liras permit.
AIR HANDLING UNIT (TO 10,000071)
MECHAN CAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIOIJS.
AIR HANDLING UNIT (OVER I Boost CFM)
CONST CION TAX
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EXHAUST HOOD(WMUCO
HOUSIN ITIGAEION FEE
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Signature,, p icam/Commem Date
I IAZARDOUS MAI'ERIAI.S DISCLOSURE
HEA'L'ING UNIT(')O IW,ms) RTU)
'Vill the applicant or future building aeronaut store or handle hazardous maenad
I,, donned by line Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 25532(a)? -
HEATING UNIT (OVER 00,I0Im BTU)
❑Yes F7 No
PAID
Date Receipt
-
VENI'ILATION FAN (SINGLE HF.SID)
Will the applicant or future building occupant use equipment or devices which
emit hazardous air oulaminamB ns dofiaed by mho Buy Arun Air Qumhy Munagemenn
Desmon?
❑Yes LI No,
BOILER -COMP OHP OR 100,100 BTU)
OTE.:
BOILER-COMP(OVF.R Lfq.fgA9 BI'U)
AIR CONDITIONER
1 have read the hueardous materials requirements under Chapter 6.95 of the Cali-
term. Health & Safety Code, Sections 25505, 2553] and 25534. 1 understand toed the
buildingdoeranotcunend have a menam, that it is my responsibility to notify the rcrupem
ISSUANCE, D
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NEW RESIIIEN PIAL MECH. SQ. IT
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ofhcrega t test act nnis.,uam'c,,l a Ccni fi,creof Owupancy
�net.w
�_s9-5S
nerd,- In, ioeir l / Dat?
TOTAL:
ISSUED BY:
OFFICE