S 0239 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CFFY OF CUPERTINO
BUILDING-ELN:C'1'RI ICA PERMIT N(1.
BUILDING DIVISION APPLICATIONiTERMIT PLUMBING-MECHANK'AL S 0239
BUILDING PROJECT IIIIWTIFICATION
HULLOING ADDRESS: SANITARY NO, APPLICATION SUBMITTALDAfIi
D D �a�► of 1,a h v er f i ti v
ER' NAMEI�SJ ^ It-ViRrIACTO 'S NAME: LIC NO:
KK TS SIC CON'IROLM
�ARC[ TECT/ENGINFER: LIC No ADDRESS: ❑
CONTACT: PHONE: BIJILDING PF,RMIT INITO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
OZ
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEC nl.n 'r
1 hereby auditor that I am licensed under pmvisium of Chapror 9(cmnm
ontlng JOB DESCRIPTION
withS«don lBMB ofDivixion3onne et,mee,x aha Profession,code,and rrry ltarnsc ix
W O p PERMIT ISSUANCE. RESIDENTIAL
�IyF in full force and eRttt, bb❑SPDWI. ❑KITCHIiN REMOUIiI.
aVtt]] Lirose Class LieM APPLIANCF_S-RESIDENTIAL. �DITION El PLUMBING R&PIPE
,-I Datc Contractor
r�Dti ARCHITECTS DECLARATION PANELti MULTLUNI'I' 0S RUCfURAL
F 1 understand my plans shall be used as public accords MODIFICATION
CZ a UPT0200AMPS [IINIHIUOR ❑CHININHYREPALR
F+4 LLOl Licensed Pmfessinnul 201J1000AMPS - IMPROVEMENT E]SWIMM ING POOLS
Sg j OWNER-BUILDER DECLARATION OVER IINNIAMPS El BATH RIiMODEWREPAIR DEMOLITION Q I hereby affirm that 1 am exempt from the Contractor's License I.ew for the
66x13 LLWa._ fallowing rn,easoIS«too 703 IS.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
y which inquires a permit m con,mr,alma improve,demolish,or repair any suarame
,E]_Og priorro its issuance,rdo.reyuinestbart atom forsach pe.i0ofileaaignal statement SPECIAL CIRCUIT/MISC.
,E y that he is licensed proonal lodre pr..vision,nature Commor
ct 's License Law(Chapter 9
Of cOf pO (commencing with Section 7000)of Division 3.1 be Buninexs and PtrfirWun,Osiris, TEMP MI TER OR POLE ST. COMMERCIAL:
dyp4 c p� Ent he is enempl IheroGmn and the basis for the alleged exemption.Any violnlinn of El NEW BLDG/ADDITION El DEMOLITION
W�
lattice 7111,1 by anyapplicant for o permit sobject,lire applicant to a civil pannity of POWER DEVICES ❑TENANT ❑FOODSERVICE
�Z6m t more than five hundred dollars(8500),
❑ I.s ownerofthe progeny,or my employees with wages as their sole conrpen.sation, SWIMMING POOLELE RIC IMPROVEMENT
FC will do the work,and thcstructu,e is nor intended cro0bred for sale(Sec.?(k4,Business ❑OTHER
W and Professions Calc:The Cnnlmaoh License Law Joe,nor apply man owner of OUTLICTS-SWITCHES- TUNIS
a 3 property who builds or improves thereon,and who aces such work himself or through
his own employees,provided that such impmvemcr,x are not intended or offered far NEW RESIDENT]A),EL. 1' SQ
sale.If.however,Rebuilding orimprovemem is sold within oneyear ofcompletion,lire SQ,I.-Il ,0 VSQ.FE
wneo-builder will have the human of proving that he did not build or improve for per,-
se of sale,. JUL
1,s owner of the progeny,am exclusively Protrusions with licensed cnntette% m T AL —„1
rearre athe profot (Sec.oan Business and
rtanProcessions Code:)The Cnmraaon, n
cense Law aces not apply man owner of property who builds or improves thereon,an QTY. PLUMBING PERMIT FEF. C"-Y
who contracts for such Intricate,with a contracmgx)licensed pursuant the Contrvarls Vf' CANE
License Isco. PERMIT ISSUANCE H 17NU
lam cop under Sec. .B&VAI
this nn
ALT(?H-DRAIN&VENT-WATI3H(IIA) VALUATION
owner Dam
WORKERSOMPENSA U
PACK hLOW PR(➢'ECI'.UIiVICii
hereby up
maintain
ai under penalty ne perjury ane of the followingW rker'smw.
(have and will main tains tion 37W of the emar Code,for the robsou Comf the DRAINS-FLOOR.R(mp,ARBA,COND.
satins,as provided 6r by Section 3]00 of the LIM,r Code,for the performmncc(if the STORMS E
work for which this pemrit is issued FIXTURES-PER TRAP
rl I have and will maintain Workers Compensation Insurance,as revinal by Sarins37M of,he LaborCode.for rhe performance of,he work for which this permit is ismed. GAS-IiA.SYSTEM-(INC.4 OUTLETS OCC.GROUP
My Workers Comperselion Insurance eerier and Policy number are:
Curfcr. Policy No; GAS-EA.SYSTEM-OVER 4(RA)
CERTIFICATE OF EXEMPT[ON FROM WORKERS'
COMPENSATION INSURANCE GREASIJINDUSIRL WAS'Fit IN'I'HRCFP'TOR
BUILDING DIVISION PHI35 _
('Those,«tion necA nal be complaed lithe pemrb is lmrme hnndrcJ Jollury(SlW) GREASE TRAP
nr IessJ PLANCfIIiCK PEE
Icenify,hat in thcperfounanceofthe work fnrwhich thinperniris issued l shall SEWER-SANITARY-STORM HA.20(1 FT.
not employ any person in any manner ma s m become subject to the Workers'Connpen- ENERGY IBE
oz sot ion Laws of Cithfnmiu.Date WATER HEATER WNEN'1'/IiLI3C1'R
Applicant GRADING FEE
yy O
Pfit, NOTICE TO APPLICANT:If.after conking this Ceaifcom of EVar tion,you should WAI 17R SYSTEM/TREATING
,LI ,tet become subject ,,the Worker's Compensation pmvlslmrs of the Labor Code,you must SOILS ITT
IaIJ Q forthwith comply with such provisions or this permit sbull No deemed naval WNF17R SERVICE
ns CONS'I'RUCTION LENDING AGENCY NEW RESIDENTIALPLMIi. SQ.ET PAID
lido I hereby affirtperformancehere is a construction lending agency far the performance of Dat R ciplN
m
( the work for which,his permit is issued(Sea.3097,Civ.CJ
0 larders Name TOI'AI.:
V Lander,Address TOTAL:
G1 cur ify that I have read this application anJ xlme,ha,the above information is BUILDINGUI
:0 correct.l agree to comply with all city and county onlinana,and share laws War ing to QTY. MECHANICAL.PERMIT FEE
U � buildiogconstmdion,and hereby mnhmize represcrundyss of this city to enter upon the SEISMIC FEE,
aMwe-mentlnnea progeny I'ar inspection puTt PERMIT ISSUANCE
(We)agree to save,indemnify and keep hxtmlcss the City of Cupertino against ELECTRIC FEE
linbilitics,judgmemx.ensu end expenses which may inenywayaccrueagainr said City ALTER OR ADD TO MECH.
in cnosequencc al granting of Nis pcmri,. PLUMBING FIiE
APPLICANT UNDER TANDS vD W .L f PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,(NN)CPM)
SOUL EGULATI MECHANICAL FEE
3J AIR HANDLING UNIT(OVER 10.0N)CFM) CONS'1'RUCTIONTAX
Signamtsof A,pli.miummuct L t Finite P.XHAUS'THOOD(W/DUCT) HOUSINGMI'GGATION E
HAZARDOUS MA ERIALS DISCLOSURE
Will thcapplicanlor future buildingaccapanl store nrhandle hazardous natedal HEATING UNIT(TO I00,01M B'1'U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Saber
Code,Section 25532(u)? HEATING UNIT(OVER 100,011 BTU)
LI yes 0N PAID --
VF.NTILATIONFAN(SINGLEFOR B)) Uma Receil N
Will the applicant of furore oblates l use equipment or devices which BOILER-COMP(3HP OR 1001X10 RTU)
emit hazardous air mm
ntninanls as defined by by the the Buy Arco Air Quality Management T(.
District? BOILER-COMP(OVER IIN)INNI B'TU)
❑Yes E]No
I have mailthe hmamos ma,erialxquirtm
reens AB CONDITIONER under Chapter 6.95 of the Cali- ISSUANCE DAFIi
fomla Health&Safety Cade,Sections 25505.25533 and 2553l.1 understand that if,he NEW RESIDENTIAL MECH. SQ.ET.
building does not currently have a Leman that it is my responsibility to notify In,occupant
of the regnircmea,s which mast he met prior to issuance of a Cenificme of Occupancy.
Owner or aumnri td agoal Data TOTAL: ISSUED By:
OFFICE