S0370 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION . APPLICATIONTERMIT PLUMBING-MECHANICAL S 0370
BUILDING PROJECT IDENTIFICATION V
BUILDINGADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
10 464
q
OWN R'S AME: P NL: CONTRACTOR'S NAME: LIC NO: ^ � ��
� NIC CONTROL p-
• ARCHITE UENGI iR: - LIC NO: A L fat ❑
/ C
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RI,DG ELECT PL�U—�M/y MECH
LICEN ❑ ❑ LJ ❑
IC
I hereby affirm
am
WOO 1)amnleCa M=Z with Section n�Rcy hSIDtraffic TCJ ie#eO,�ofeA'ionlChapter
Code,anJ mYlice mivanJ mYlice sc iki ORATION TY PE
APPLIANCI ISSUANCE
PERMIT FEE lioKFID❑ADDI'I'IONIAJOB DESCR��UNBING RF.PI`L
Acc
IAL
F<w CTS DECLARATIONN PANELS OMUI:H-UNIT El STRUCTURAL
m Z dcisland my plans shall be used as public records MODIFICATION
-NFQ � F UP TO 200 AMPS F1 INTERIOR OCIUMNEY REPAIR
Win. mfcssionrd 201-1000AMPS IMPROVEMENT OSWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS O HATH REMODELIREPAIR 0DEMOLITION
C Q 1 hereby affirm that 1 am exempt from the Contracmex License law for the
3 P F following reason.(Senior 9031.5,Bminesz and Professions CNe:Any city or county SIGNS ELECTRICAL ❑OTHER
m w1hieh requires a permit to consimn,alter,improve,demolish,or repair any structure
Emotions ie wituce..k.maninstheappfcarl fnr.uch permitmEle vsignN smtm^enl SPECIAL CIRCUIT/MISC. ( f
E }� that he islicpswd pursuant totheproWsinnsofine Convacmrx License law(Chapter 9
C 6� (commencing with Sieion90W)of Division3 ofthe Business and Profiaoions C(sde)or TEMP MLTBR OR POLE INST COMMERCIAL:
non he is pion t therefrom and the basis for the alleged ex^mptmin.Any viola( 11 of 0 NEW BLDG/ADDITION 0 DEMOLITION
.Mn, Section 7031.5 by any applicant for a Permit subjects IM1e applicant to a civil panaltyof POWER DEVICES [I TENANT OFOOD SERVICE
nm marc than five hundred dollars(55(ID).
Z} IMPROVEMENT
E=Qn ❑Lashe owner
k,IM1e property, moyces withwages reale((Seolee.
044,Bunion, SWIMMING POOL IiLECfRIC
p., will N tew err,and me he Corcia io irnerded ceno,La does
of apply Win.Business T
and Rofcxsinns Cade:The Conuacu,Ls License Law does nal apply to an owner of WTLB'I;S—SWITCHES—FIX'I'Gaps
pmperty who builds m improves Ibe....and who does such work himself or through
his own employees,provided Nat such improvements are not intended nr offered for NEW RESIDENTIAL ELECTR SQ I°I'.
scl,.If,however,IM1e building or improvement is sold within on ,,wva"nmplctiovthe SQ.FI'JlOOk AREA 9SQJrl'.
isner-buildcr will have the burden of proving that he did hold orimprovefor pur-
poseid sale].
E] 1.as owner of the property,am exclusively contracting with licensed contractors In TOTAL
instruct the project(Sec.90n4.Basin,,,and Prolcssiens Co.,:,The Cn....v,
Law does min apply toanowmar ofpmpenywho udd:or imro
pves thereon.and QTY. PLUMBING PERMIT FEE
verve b
ho contracts far inch pnjects with a rnnaaarogs)licensed putsaanun me Contractors
License Law. PERMIT ISSUANCE a 01 am exempt under Sec. .B&P C for this reason
ALTER—DRAIN&VICNT—WA'1'Hk(PLA) VALUATION
Owner Data
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under Penalty of perjury,one of the following declarations:
F1 I have and will maintain a Cenitieatc of Consent to self-msure for Woiv Cmnpcn- DRAINS—FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRl1CTION
cdion,as provided for by Section 3]01 of he Labor Cade,far he perturramcc of ah, /
. work far which this permit is issued. FIXTURES—PER TRAP
ve trod will maintain Worker's Compensation Insurance,as required by Smtinn
`J oflM1nLarLar Coda For the perfnrntaace^Ime work for which mix permit is ir_sia,l GAS—EA.SYSTEM-1 INC.40UTLETS (ICC GROUP APN
My Worker s pc do Inxur nit cancer and Policy
Camcc�/-c rl/aL policy Na.:mm�hcrl-- GAS—PA.SYSTEM-OVERi(EA)
CERTIFICATE OF.EXEMPT ION FROM WORKERS' GREASFJINUUSTRI.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
This section recd not be compkoduf he pc.it is for one hundrcddollms(SIM) GREASETRAP
or lesc7 PLANCHECK FLC
Icenitylhatirrunperfonnantt^f the work Rnwhichahis pcmait is issued,lshall SEWER—SANITARY—STORM o m mm EA.200 FT
ndl,mo
play any pentn in any manner sas Acaoc sable,, IM1e Worker,Cnngmr- ENERGY FEE
OZ saionlancsof CaGfomia.Data WATER HIW ER WIVENTIELECI'R GRADING FEE
Z 2 Applicant
NOTICE TO APPLICANT:If,after ranking this Certificate of Exemption,you should WATER SYSTEAOIRCATING
F become subject .,he Worker's Cnmgroodmin provisions of the Labor Code,you nmol SOILS IPE _
Q1'onhwkh comply with such perm,cions iii permit shall he deemed revoked. RATER SERVICE
(M10 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U0 I hereby affirm that mere is a con,amcdon lending agency for the perfomaance of ltd rte Rec,i x
the work far which this perms ,lssuul(Sec.3a)9.Civ.C.) 4• y
01" lender's Name VCLIjIHr I.:
U Landds Address T( AL:
r� a I ccnif,mat 1 hnv,read this application rad same that he nMrve information is BUILDING FEE
.F.t la correct.l agree to comply with all city and coany ordirances and state laws remin,to QTY. MECHANICAL PERMIT FEE
U Z building cmmroction.and hereby uniform representatives of this city to enter upon the - SEISMIC FEE
above-mentioned progeny far inspection pmfww,. PERMIT ISSUANCE
ONO agree to save,indemnify and keep harmless the City of Capenino against ELECTRIC FEE
liuhilau,,judgmems.coxmand expenses whielnnuy many way as*uc against said City ALT ER OR ADD TII MECH.
PLUMBING FEE
asequence ene
in he grous of this permit.
APPLICANT U' ERSTANDS NU WILL COMPLY WI HALLON-POINT pIR HANDLING UNI'I'(TO 10.000 CFM)
MECHANICAL,;E
SOUR Z, ATIONS.
U AIR HANDLING UNIT(OVER 10,NX)CFM) CONSTRUCTION TAX
SightnuF ofApplicantaCcarmicoor Dam EXHAUST HOOD(W11i HOUSING MITIGATION FEE
IIA]ARDOUS MATERIALS DISCLOSURE
Will the applicant nr furore building occ,Nant store or handle hneardous inumnal HEATING UNI'L CHS 101 It'TO)
as defined by IM1e Cupcnino Municipal Code.Chapter 9.12.and me Health and Set.,
Code.Section 25532(a)^ HEATING UNIT(OVER IDD.(XX)HU)
❑Ycs ONo PAID
w VENTILATION PAN(SINGLE HF,SID) —Dam R,ceiPlM
Will the applicant or future building ocsmpanl use equipment or devices which it
emit houndous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(3IIP OR 100.00 BTU)
Dismal lTOT
❑Yrs ❑No
BOILER—COMP(OVER IgI.(Mp BTU)
I have read me hnm
madous uermixsequirtemc under Chapter 6.95 of me Cali- AIR CONUITI(INER ,/ ISSUANCE TATE
mmir Health&Sap ty Code.Sections 25505.8533 and 2551.I undcouaml that Buse NEW RISIDENTIAL MECH. SQ.FT // _qC C7 7
broda,dm.amta only have a tenant,that it is myrespon%fility notify me occupant /
nl'them metra hich mu lb Ipnnrtoissuuncenl'n Zia
mnIOc,�uP.sn, ��
�Zia" n TOTAL: 7�
Owner or au red agent em ISSUED BY:
OFFICE