S 1094 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING-MECHA IC,M, v1�nTNO.
1094
BUILDING DIVISION APPLICATION/PERMIT rING PRNG.MEVENMGM,
NI111.DING YROdF:CT'IDEN'CIPICATION
BUILDING ADDRESS: SAMIARY NO. APPLICATION SUBMITTAL DATE
Bole - 4es or. Comr4-i't-to 95o/ �2e
O 'S NAME: �� TIO 9 CON'1'RACfOR' NAME'. Air IC O SIC COMCROLg
ARCHITECDENGINEER: LIC NO: ADDR6S5: ❑
WE I
CONTACT PHONE, BUILDING PCRMIT INFO
❑ Caneultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
hICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT' FEE
1 hereby aubm rho I am licensed undo provisions of Chapter 9(commencing JOB DESCRIPTION
Z as,h 7O if Division A ofthe Business and refssion de, dory Poen¢i, RESIDENTIAL;
Iy00 q PERMIT ISSUANCE
F-ty� mfull force and eRcuC1 o [,/5� ❑SFDWL ❑KITCHENRFENODEL
V F' Liana Ci Off' l.ie Mit
6 V °CTTA�� APPLIANC1iS-RESIDENTIAL []ADDITION ❑I'LUMRING RF;-PIPE
mQycnnvocmr
FOm ARCIII'IIiCT'S DECLARATION PANELS
❑MIICTI-UNIT ❑S'rRUCTURN,
Z O In Z 1 undersand my plans shall be used es public records MODIFICATION
OZ— UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
W Licensed Procosul 201-1000AMPS IMPIROVEMF,NT E]SWIMMING POOLS
OWNER BUILDER DECLARATION OVER INNIAMPS ❑061'11 REM L/NIiPAIN ❑DIiMGI,I'lII
CL Q 1 hereby reason.(act that 1 am exempt train tbn Cssion% ,o I:Any a Law lou the .rte �1
, 3'F whichity,me, (Seetian]O3LABusin,.unerve,,sslom C.or
or county SIGNS ELECTRICAL
❑OTHER `TILt►^rA,�ll'��
a y which reyuirez a(erred to connmct,alter,impmvc,demolish,nr repair any.¢moire
F�-OQ Prior la a"issuance,also rations the applicant for such permit In,rile a signed sanment SPECIAL CIRCUIT/M ISC.
that he is lie it pe-ounah.ffic,nomen,ofih Contractor',I L IChupmr9
0COMMERCIAL(cot c g Th S 't ]I%10) D l III B : I I f 6dc)or TEMP ME'T'ER OR PUl.li INST'.
a L e C that by iseserrintharefirmatind,helvasis for the alleged excmpu n.A y viulihima.f ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of POWER DEVICES
lin not mom than five hundred dollars($5W). ❑TENANT ❑FOODSERVICE
IMPROVEMENT
p Q ❑ Lothwnendthe he uh,mmyempl,ycexwithwag,sastheirsole compen. ines, SWIMMING POOL ELECTRIC
i x 0 will Professions
and he Th Costa tots Licensor Law
hot apply toHn,owner
[10 1-1 IIiN
H
w
and erry who
GWe:The Contractor's License w law does nm apply s if owner of OUTLISI:S-SWITCHES-FI%TURES
113 lik u..who builds p impede,,such
and who does such tintk Ned or.1 through
his awn employe¢,prevlded that such tach, mcnts are not intended or,Rend for NEW RESIDENTIAL ELECTR SQ FT
wle ll;b,wever.the building orimpmvemem i,sold within enc year nfntmplctinn,the SQ. lIX)N AREA §ISQ.II'.
reh ander will have the roof of proving that he did not build or improve tort pur-
poxe of sale.). 7 IF
h as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.TNA,nosiness and Professions Cdc:)The Contractors Li- p G
cense Law does not apply to an owner of property who builds or improves mcrcen.and QTY, PLUMBING PERMIT FEE W
who contracts for such p sects with a contractors)licensed pumuum mthe Contra,mr's
License Law. PERMIT ISSUANCE u
1 am exempt under Sec. .If&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER H;A) A UATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECC.DEVICE �s ff �Ur h N0
Ihereby offimt under penalty of perjury one of the follwing declarations: CI1Y V�
❑I haveand will mainminiCerifcare of Conscntmself-insure for Worker's CmH,m- DRAINS-FLOOR,BULL AREA,CONED. STORIES TYPE CONSTRUCTION
sai,n,a.pmvidcd for by Section 37M of the labor Cede,home performance of rhe
k lin which this fail i.issue.). FIXTUR12S-PER TRAP
I hive and will inainum Worker's Cion, in i Inmmnce,as recanxil by Section
] )of the Labor Cute.for the performance of the work for which this permit is issued. GAS-M.SYSTEM-IINC40UTI.17'I'S UCC GROUP AIN
My Worker tnytyu and Policy qtr GAS-F:A.SYSTEM-OVERs(EA)
Cartier.. ,. z.�ytsecarnePolicyNn.:7 O d
CHRTIPICATOOOFF'EXEMPfIOP IRO OR E
COMPENSATION INSURANCE GREASE%INDUSTRL WASTE INTERCEPTOR
('this section need nm becomplated if thc,inrut is forms,hundnddollam(8100) BUILDING DIVISION FEES
or Icss.) GREASE"rRAP PLANCHECK EEE
Icenifyrhat intheperfomtanceofNewnrk brwhich thi,N.i.......cal,I,mII SEWER-SANITARY-STORM F.A.200 FI'.
not employ any parson in any manner sit as to become subject to the Workers'Camper- ENERGY FEF.
Q Z onam Lee,of Odin....its.Dam WATER HEATER W/VENT/ELECI'R
Z Applicant GRADING FEE
fq NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEM/7REATING
a ; become subject to the Workers Compensation previsions of the labor Code,you must SOILS FEC:
fnnhwith comply withsuch provisions or this permit shall Pro deemed revoked. WATER S17RVICH
0
UZ CONSTRUCTION LENDINGAGENCY NEW RILSIDENTIAf.I'LMB. SQ.FT. PAID
V I herebyhifhmnhenex,i isa (ser.construction30 lending agency for perfommnceof Da copra
U. P the work for which this pcnnit is issued lSec.309].Cie CJ
O U Lenders Name TUTAL
U Lcndcrs Addms, TOTAL,
Fy I certify that I have read this application and state that the above inlbrtnndon e, BUILDING B
In comet.I agree to comply with all city and county ordinances and nae laws relating m QTY. MECHANICAI.PERMIT FEE
(,JZ building consuuction,and hereby suthnree mpresentativex of this city m enter urym the SEISMIC FEE
ablrvomcntloned property for insp,n inn purposes, PERMIT'ISSUANCE(We)agree m save,indenm ify and keep harndcas the City of Cupertino agoimt ELECTRIC FEE.
Iiabilities.judgmetns,ensu and expenses which may in any way uecme against s,fid City ALTER OR ADD TO MIiCH,
o
in on mits ace of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB.000CFm
SOURCE REGULATIONS. MECHANICAL ItiE
AIR HANDLING ON['P(OVER 10,fNN)CFM) CONST RUCTION fAX
Signawn of ApplicantAmbactor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURIi
Will the applicant or future building occupant store or handle hzazNous materialHEATING UNIT LTO 100.000 BTU)
inN
as de by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code.Section 25532(a)'1 HEATING UNIT(OVEN 100.000 BTI])
❑Yes El No
VENTILAI']ON FAN(SINGLE RES ID) PAID
Will the applicant or fuer,Fvilding occupant use equipment or de we,which Date Receipt X
emit hararduus air contaminant,a,defined by the Bay Arcn Air Quality Management BOILER-COMP(:3HI'OR 100,000131 U)
Dismla" TOTAL
❑Ycs 0 N BOILER-COMP(OVER 100,00)BTU)
1 have real the havardous materials AIR CONDITIONER
re,25533 an under ,1 torer,or of @c Cali- ISSUANCE DATE
fnmia]Icahn does&Snlcty y .Scabms 2.1505,25533 and.',M 1 undcr,tand that if be NEW RESIDENTIAL MECH. SQ.1'I'.
building does not curtvntly hive mcnant,t ail ix my¢s nsibilitymtifYt eupam
ft RIM s t of Ilcat mf
11
Oonbj'o authoneaJ agent Doc I TOTAL: ISSUED Hy: lJ�
OFFICE