S 0495 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUMBING-MEC" ANICA, rERMrr No
BUILDING DIVISION APPLICATIONIPERMPr PING R OJECT:CIIANIFIC
BUILDING PROJECT IDI:N'1'IN'ICATION,
SANITARY NO.J\ AI'I'LICAI'IUN SUIIMI'fl'N.❑A'I'L
BUI DINGIIRF.SS: ^� Pt '
OW E: DL: C N'AACfOR'S NAll LIC No. `�
\I l 1 � NIC C)N'I ItULX
FR:S NAM
16 ARCHITECT/ENGINEER: LIC NO: 1) RGSS: ElCONTACT: PHONE; SE HIIILDING P17RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG 2I.IiC'1PLUMB MLieU
LICENSED CONTRACTOR'S DECLARATION QTY ELU'CT'RICPHRMIT PLL JON DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
lit with SeeticaT"Bof Division 3afthe Businessland PndcWtva,Code.audit,,licensed PFAMITISSUANCE ReSIDENTIAI:
CIE+ in full force and eff EISFDWIL ❑KI'I'CII I7N REMODEL
Q,UU Licen cCl�. LICk APPI.I ANCES-RES I DEN I IA I. ❑ADDITION ❑PLUMBING Nil Pill
Z a Date Convector
G ARCHITECTS DECL PION PANELS ❑MUI:I'I-UNIT' ❑S'IRl1CTURAI.
MODIPICA'TION
F,ym I understand my plans shallhnsed b,tiblic records
5Z`3 UPT0200AMPS
f:m, Licensed Promoional 201-1000AMPS ❑IMPROVE ❑SWIMMING
REPAIR
..l IMPROVEMENT SWIMMING I'OOIS
OWNER-BUILDER DECLARATION OVER IlNX)AMPS ❑RATH REMODFLARHPAll ❑DFM'LI'FIGS
1 hereby affirm Not I am exempt from the Contractor's Licema Law for the _
O V following reason.(Section 9031.5,Business and Profession,Code',An I t ❑OTIIEIi
ip5.. A.,citySIGNS F,LECfRICAI. I
1++3 0y which requires n Benoit m construct,alcor,improve,demolish, file
repair any odamem
F��6 thea hesTrened!toraintanhetheapplicanl for such Contractor,
SPIiC1A1,CIRCUII'IMISC.
tom he is lila,wit pScene.7")provisions of the a Broin,x nd Probnsees
esw(Chapter 9 COMMERCIAL:
W
'bar
he
ixemith Sectioen ad he
Wais fee of theeged exurndon.An vilation of 'fHMP.METI[N OR POLE INST. N RW
Ivy a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑TFN BLOOM DDI'I'I(1N ❑FOODDHMOILI
SERVICE
�YEI ti not
Section7031.5thus by any hundred
doll ,($50rmit subjects the applicant mncivil pcnulty of POWER DEVICES ❑IMPROV FOOD SGRVICIi
not more than fivehundred dollna fESW). IMI'ROVI?,M F:N'I'
=O ❑I,as owner of the propeny.nr myemployees with wages us Heir sole compensminn, SWIMMING POLL ELECTRIC
=o will do the work,and the structure is not intended oraffered for sale(See.]OM,Business ❑OTIIHR
Wim and Professions Code:The Cnmmtvor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered Jar NEW RESIDENTIAL ELECTR
d Le sale.If,however,the building or improvement is sold within one year ofenntpletim,the SQ.I'I'.FLOOR AREA SISQ.IT.
caner-builder will have the human of proving that he did not build or improve for pur,
pore of sale.). TOTAL:
�1,as owner of the property.am exclusively contracting with licensed contractors m
mnsuuct the project(Sec.]044.Business and Professions Code)The Contractor's I.i-
n
seLow does nor apply loan,ownerofpropenywho WilJNmusprovesthereon.and QTY. PLUMBING PERMIT
who contracts for such projects with o contractors)licensed pursuant o the Confactorx CE7` TL1
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VA UT'V
Owner Date Q,�
WORKER'S COMPENSATION DECLARATION BACK ROW PROIlCI'.DEVICE
• have
and will
under Certify of e of Corury ncoftheinsure for decWorker's
or
❑ as and will for bynection3M of the Labor Code.surefar Wmknrace of the
DRAINS-FLOOR,ROOF.AREA,COND, 'I'YI'li C( SIRUCI'101
Marc.on.as provided for Form'
Section 3]00 of the Labor Code.for One performance of the
work for which this pannii is issued. FIXTURES-PER TRAY
IN",have and will maintain Workels Compensation Insurance,as rcquiretl by Section
of th�ejlsbnr Coded,for Jthe performance of the work for which this per�m�it ips issued. GAS-EA.SYSTY:M-I INC.40UTLE'TS OCC.GROUI' AI'N
MyWCame�r / �' �3_L V IcY No.: t Yd_d2�2 GAS'-EA.SYSTEM-OVER 4(HA)
CERTIFICATE OF EXEMPTION FROM W RKERS' GREASM%NDIISTRL WAS IE.INTERCEPTOR
COMPENSATION INSURANCE IIUILDINO DIVISION PliliS
(ThisscrummeeesdambecompleteJ if Ne permit is for one hundred dollars(Elfl01 GREASETRAI'
or less.) 1'LANCIIIiCK FEE
I certify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-S MRM EA.200 FT.
not employ any person in any manner so as to become subjecto the Workers'Compier- ENERGY FEE
Z one.Laws of California.Data WATER HEATER W/VIiNT/F.LECTR
Compiler-
0 GRADING PER
Applicant
F-t i NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IREATINC
F , become subject to the Worker,Compensation provision,of the Labor Care,you must soils FEE
La3I ora forthwith comply withsuch provisions or this permit shill flat deemed revoked. WATER SERVICE
Q
G CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. I'ND .(a kecci X
V O Ihureby affirm Nm Nem is econstructinn lending agency 6nhe performance of
V. Ne work for which this permit is issued(Sec.309],Civ.C.)
O U Lenders Name IYYTAL. 01AI.:
r LkI Lenders Address
y 1 certify Nat I have read his application and state that the above infommtion is BUILDING ITE
tFi l)) rubber,l agreem comply with all cityand county ordinance,and are law,Malaga, QTY MECHANICAL PERMIT FEC SEISMIC Illi
V Z building constmction,and hereby amhori,sa representatives of thin city to enter upon the
above-mmmerad propeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC Igili
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECIL PLUMBING FEC
in corse,conce of the granting of Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'('I'O 10.(XX)CFM) MECHANICAL.Bili
SOU ^LAnatCon,u 111'I/PO1
,„' p r� AIR HANDLING UNIT(OVER 10,00)(CFM) CONSTRUCTION TAX
g w ApplicaMContmnor Dine EXHAUST HOOD IW/DUCT) HOUSING MI'TIGAT'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle hazardous material HEATING UNIT CTO I FLOW BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safery
Code.Section 25532(x)? HEAT)NO UNIT(OVER 100.000 BTU)
El Yet, ❑No VENTILATION PANS INGLE RE.CID) PAID
Ilam Remipt X
Will the applicant or future building occupant use equipment or devices which BOILER-COMP CUP OR 1(X1,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL; f Lfu
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
I have read the havardnus nmterials requirements under Chip.,6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cork,Section,25505.B533 and 25534.1 unicameral that if the NEW RESIDENTIAL MECH. SQ,FT.
building does not currently have a tenant that it is my responsibility no notify the compact I
of the requireniems which must be mer prior m issuance of a Certificate of Occupancy.
Owner or authorised a gent - Data TOTAL L49ISSUED BY:
OFFICE