B 0111 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICA], PIIRMU NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAh SOOOI .B '$,0111
BUILDING PROJECT IDENN
'FIPICATIO
IfU11.OIN 1ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
Q Iv 13C�1G(/ D
O/WNER'S NAMB: PHONE: CONTRACTOR'S NAME: LIC NO'.
N/C CONfRO'#
ARCH]'I'ECTENGINEER: LIC NO: ADDRESS:
CON'TAC'T: PRONE: BUILDING PERMIT INFO
S(�ry� X050 ❑ Consultant re.Paid h Applicant Initial
RWiffL =�- 36-/ - IZLiY nn (Initial) IIEl ELECT PEE] MECH
LICENSED CONTRACTOR'S DECLARATION Q'�' ELECTRIC PERMIT' PEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OQZ with Section V000)of Dickie Sof the Business and Professions Cale,and my license is
O i PERMITISSUANCE RESIDENTIAL:
F W� n full force and effect ❑SFDWL ❑KITCHEN REMODEL.
MI."eme Class Lic.p AI'I'LIANCES-RESIDENTIAL.
FF ul Dam ConBalle, ❑AUDITION El PLUMBING RE-PIPE
NDN ARCHI'I'HCPS DECLARATION ❑MULTI-UNIT ❑STRUCfURAL
F I'ANI:I.S
OOHZ understand my plans shall used as public.eco ds MODIFICATION
O" M lll'TO NX)AMPS ❑INTERIOR C1 Cl EMNEY REPAIR
F=:'; Licensed Professional 201-1000AMPS IMPROVEMENT IMMING POOLS
g Yg,' OWNER-BUILDER DECLARATION OyIiR IINXIAMPS ❑BATH REM1fODEf/REPAIR i)W, 1.ITIQN
C Q 1 hereby affrnn thm 1 nm enempt from the Cnntruetnr's Littnu Law for the
�L a U tidlowing mason.(Section 7831.5,Hmines,and Professions Code Any city m county SIGNS ELECTRICAL ❑OTHER
F f"' which requires a permit to construct,alter,improve,demolish,or repair any svucmre
rt _
prioo its issuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUIT/MISC.
} thm he in licensed personae the prckians of the Contractor's license Low(Chapter9
(Inboldring with Swlinn7000)ol'Division 3 of the Businessand Professions Crete)or TEM H METE R OR POLE INSL COMMF.RCIAI:
d y o of mut he Is exempt therefrom and the hast.,far the alleged exmnn ion.Any violation of ❑NEW BLDG/ADDITION 1:1 DEMOLITION
iLLfl n INy Section 9031.5 by any applicant for v pcnnit sugmts the vpplicam too civil penalty of POWER DEVICES
FZy not mote than ave hundred dollars(ESgB. ❑'rl?NANT FOOD SERVICE
=Q I,asnwnerofthepropctry or my employees with wages as theirsolen,mpens:aion, SWIMMING POOL ELECTRIC IMPROVEMENT
F�.FC i Jnthewmk,and theswcwrcisnot intended or offered for wle(See.]W4,Business ❑0'rHER
W _ snit I'mfessfons Code:The Contractor's Licence Law does not apply to an owner of OUTLETS-SWITCHES-I`VCR UI
0'3 popery who builds or improves thereon,and who does such work himself or through
hlx n employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ I7.
zoic.IL however.the building or improvement is sold within one year mf completion me SQ.F,FLOOR ARBA USQ.FE
ncr-lmi later will have the burden of proving that he did not builder improve for par-
eofJ. T(
easier,of the pn,perty, to exulusivaly wmmeting calm licensor cunuucmrs tr
-tm l the project(Seo.]044,business and Professions Cone:)The Con..... a
cease
does not apply tarn owner of property who builds or improves themon.and QTY. PLUMBING PERM IT FEE
who cantmds for such projects with v cotnmaiind licensed p...unit m the Contmetor's
License Law. PERMrr ISSUANCE
to sem a ,B&PCfnr this rca n
Date ALTER-DRAIN&VENT-WATER(.A) VALUATION
WO tKER'S COMI DECLARATION HACK PLOW PROTECT.DEVICE
mhy affirm under penalryo pl lury ane of the following dslvmtimns:
❑1 loorind will maiamina Cerificalcrf Consent mself-in sure for Worker's Cout DRAINS-FLOOR,ROOF,AREA,COIN D. STORIES 'I'VI'E CONS'I'kUC'I'ION
oninn,as provided for by Section 39(X1 of the Labor Cade,for the pe01 m amar of the
work lot which thlc pcnnit is issued. FIXTIt R ES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,rax required by Section
3718 of the Lahr Code.for the perlgnormace of the work for which this permit is issued, GAS-IiA.SYSTEMA INC.4011T'IAHS
OCC.GROUP APN
My WorkeCs Compensation Insurunec comer and Policy nate#ere:
Carrier: Policy Na.: GAS-IiA.SYSTEM-OVER Y IRA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GRHASIEBNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION TEES
(This section need not he completed ifthe Permit is forms hundred dollars(SIM)
or less.) GR17ASE'E RAP PLANCHECK FEE
I certify that in the pgrfnrmanc.of the work for widening lwnnit is issued,Ishsll SIiWtlR-SANITARY-STORM EA.21X1 Fr.
not employ any person In any manner so as m become subject to the Workers'Compen- IfNIiRGY FEE
O Z art ion Laws of Califnmir.Dam WATER IHiA'IER WIVtlNI'/HhIiC'I It
y C) Applicant I GRADING FEE
q V) NOTICE TO APPLICANT.IL after nmking this Certificate of Exctnption,you should WA'fliR SVSTEMI'1'REATING
a , become subject to the Worked.,Com,ca,oro provisions of the Lalmr Calc,you must SOILS ETH
forthwith comply with such provisions or permft shall be deemed revoked. WATER SERVICE s
star0
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB, PAID
UO 1brod,yieffirm Rotation,is.enotruclom lendingagency fore,fiefonnanceor ate Receipt#
the work for which this permit is issued(Sec.309],Civ.C.) a•s
0 U Lender's Name '1'OTA L:
a' W I.cnrtcr's Address 'TOTAL: v
I certify that I have read this application and state that the above information is - HDI DING HE
.E".t (ai) corm.I agree memmply with all airy sort eoamry ordbumeea Iron arum I,Iwx mlmh,g m QTY. MECHANICAL PERMIT FEE
UZ budding amsnation,and hereby armhmrize reprosentmivesofthisdtytoemernpm,the SHIS ICFBB
must,mentioned property for in.Nrcdlon purposes. PERMIT ISSUANCE.
(We)agree to save,Indemnify sort keep hmmlele the City of Caperinr against H110EN1
liabilities,judgments,coasand expenses which may in anywayvttme against said Ci ALTER OR ADD TO MECH.
in asequence of the granting of this pcmtit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('r0 IQ(X18 CPM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER IBlgU CFM) CONS1'RUCTION TAX
Signamate of ApplicanVCmnmeta Dam EXIT RUST HOOD(WMUC) HOUSING MITIGATION IPC
HAZARDOUS MATERIALS DISCLOSURE
Will,he vpplicam or litnrc building occupant smrc or on he huzurtlrus material I IHAIINO UNIT(TO 100,000 BTU)
m delined by the Cupertino Maniclpul Come,Chapter 9.12,soil the Health nod Safety
Code,Section 25532(x)? 11EADNC,UNIT(OVER 100,000 BTU)
E]yes F-]No VQN-FIlAT10N FAN(SINGLE]ZEST])) PAID
Will thea applicant or future brildin Date Rcccipt It
pp building, the Bay
aAir usury Management
BOILER-COMPDHPOR 100jil BTU
crud hazardous air renominates as deOnM by the Bay Arca Air Quality Alunagement 1
Uismcq / 0 TOl'A
[_1 yes ❑Nn BOILER-COMP(OVER I00,00011'I'U)
I have read the hazardous mmerin,mruinmms un der Chapter 695of the Cali- AIRCONDITIONER
1 p ISSUANCE DATE
Ibmin Health&Safety Code,Semon,25585,25533 and 25534.1 undertund that ff that NEW RESIDEN'IIIAL MECH. SQ,IT.
r r (]
hnilAing Jros not wrently bacon mn:nn,Omt it is my responsibility unmdfy thmxcnprnt J T9
of the oa,mormenb which time M met pito.to issuance of a Cenllicnte of Occupancy.
Ownc.or.,arborized egcut Date TOTAL: ISSUED BY:
OFFICE