S 1015 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD DING-LLEC I RICAI. PF}`1MIT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SJ
1015
BUILDINC,PROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMIq'1'AL UAfE
ao6y8 Ce/erf c CIA ( V ttXl
WNER'SNAME: // PHONE,: CONT ACTOR'S NAME - LIC NO:
of r/_ y. A,. ( NIC CON'I'ROI,p
O e-vr HYQ ❑
ARCHITECIENGINEER: LIC NO: AI I3 _
Z., `s' R AUL Sia:"f JJ
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
Caz JOB DESCRIPTION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
with Section 7000)ofDivision 3ofthe Businessand Professions ode,andmylimme is RESIDENTIAL
NTIAL:
4l p `p PERMIT ISSUANCE
�UF Licenl force and 1� Lic.N o0 /�/ ❑SFDWL ❑PLUMBINRHMODEL
Q U C APPLIANCES-RFSNENTIAL ❑ADDITION [I PLUMBING RL-PIPE
F W D Cantmemr
ti a ❑MULTI-UNIT ❑STRUCTURAL
F7 ARCHITECT'S DECLARATION PANELS MODIFICATION
1 undemanJ my plans shall h used as public records
UP T0200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
r,il Imy Licensed Pndcssional 201-10MAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
Q I hereby marine that 1 am exempt from the Convector's License Law for the OVFE IIXN)AMPS
[3 BATH RF.MODIi iP M01.
g 0 a U following reason.(Section 7031.5,Business and Pndmeiam Cade:Any city m countySIGNS ELIiCTRICAL ❑OTHER
u� C which requires a permit re cansweL alter,improve,demolish.nr repair swaure
Priono its issuance,also inquires the applicant for such Permit o file aligneded statement SPECIAL CIRCUIT/MISC.
a� that he is licensed pmourattothe Provisions ofthe ConexamesLicense Law(Chapter 9 COMMERCIAL
O (commencing with Section 700(1)of Division 3 ofthe Business and Professions Coil TEMP.METER OR POLE INST.
a a o�s�y that he is exempt therefrom and the basis for the alleged exemption.Any vfamain of ❑NI7W BLDG/ADDITION ❑DEMOLRION
X so t� Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES OTENANT ❑FOOD SERVICE
not mom Nun five hundred dollars S500). IMPROVEMENT
F� ❑I,as owner ofthe property,or my employees with wages as theiranle compensation. SWIMMING POOL ELECTRIC
will do the work,and davl uaure is not intended oroffered forsde Ser,70t .Business ❑OTHER
L a and Professions Code:The ContncuMs License law does not apply to an owner of OUTLETS-SWITCHES EI%TUkIiS
property who builds or improves thereon,and who rims such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTS SQ IT
sale.If,hmveveo the building orimpromeme sold within one year ofcompletion,the SQ.FT.FLOOR AREA SISQ,PI'.
wnervbullder will have the burden of proving that he did not build or improve for par-
po u,of sale.).
❑I,as owner of the propeny,um exclusively contracting with licensed eontmctors to TOTAL: 1
on,rvcs the project(gee.70Y/.Business and Pndessiom Cale:)The Commctoh Li- - to r� s
Li-
On.law does not apply m an owner of propeny who huildsor improves thereon,and QTY. PLUMBING PERMIT F
whence Law.Touch projects with acontanor(s)licensed punuann)the Convenor's �/� O�
License Law. PERMIT ISSUANCE p
❑tum exempt undcrSes. .H&PCfar this rwsnn (., !,
ALTER-DRAIN&VENT-WATER IEA) A, VAL ION
Owner Dace
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE '
I hereby air,.under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate ofComento self-insum for Workers Comma- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCI'ION
sation,as provided for by Section 37M of the Labor Coda for the performance of the
work for which this permit is Found. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the lsMr Code,for the performance of the work for which this .it is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.CROUP AI'N
My Work`r's Compp5S99s pion Insurance artier and Policy nyymWe are'
Carrier.] u!K pT4f0•KFPolicy AJ {IZq)f 6� GAS-F.A.SYSTEMOVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASMISDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE HULLOING DIVISION RiFS _
(This session need not he completed Base Permit in forma huulreddollars(SIM) GREASF.TRAP
m less.) . PLANCHECK FEE
I cenify that in the performance ofthe work forvehich this permit is issued,l shall SEWER-SANITARY-STORM FA.200 FI'.
not employ any person in any manner so ns us become subject m the Workers'Carmen- ENERGY FEE
s� cation laws of Califamia.Date WATER BEATER WATNTIELECTR GRADING FEE
O Applicant
Z y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS I'EMOREATING SOILS FEE
a ; berome subject to the Worker's Compensation provisions of the Labor Cale,you must
a r forthwith comply with such provisions or this Permit shall M deemed revoked. WATER SERVICE
O
CON59'RUCTION LENDING AGENCY NIiW RESIDFNTIAI.PLMN, SQ,FT. PAID Dam Ncceiptk
V 0 Ihereby affirm that them is a construction Lending agency marthe performance of
the work for which this stood is issued Ser.31197.Civ.CJ
Lenders Name TOTAL:
U tenders Address BUILDING.TOTAL:
I eenify that 1 have read this application and sate Imes the above information is LDING FEE
Tan correct I agree In comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V Z building convection,and hereby anthodu representatives of this city to enter cram the
ahove-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
We)agree to save,indemnify and keep madness the City of Cupenino against
liabilities' send expenus which may in any way ammo against said City' ALTER ORADD TO MECH. PLUMBING FEE
in equenceof the ming) this pe mit.
PLICANTUkSTANDS ti ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO l0.0o0 CFM) MECHANICAL FEE
URGE RF ro
AIR HANDLING UNIT(OVER IU,IXN)CFM) CONSTRUCTION TAX
/ Signa ofApFlican Convects Date EXHAUST HOOD(WIDUC) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicunt or to..Wilding oecupantnore nr handle harromm,material If
UNIT
HBTU)
ao defined by the Cupertino Municipal fide,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,ME BTU)
Code.Section M532(a)Y
❑Yes FIN. VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant ar future building occurs,use mortared,or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit himardous air contaminants us defined by the Bay Area Air Quality Management TOTAL:
District'! BOILER-COMP(OVER 100.0(X)BTU)
❑Yes ❑Nn
I have read the haardnus materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DA
mania Health&Safety Code,Seen.M505.25533 and 25534.1 uncieaumd that if the NEW RESIDENTIAL MECH. SQ.IT,
handle,does nm currently have a tenaaWtl.it is my responsibility m notify the rccu,.t
of Ne tequiremena which must be met prior to issuance of u Certificate Of Ormind cy.
\ Owmr or serthomed agent - Data TOTAL:: ISSUED BY:
OFFICE