29869APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING PERMIT'
BUILDING - ELECTRICAL
❑ Consultant Fees Paid by Applicant (Initial)
PERMITNO..
BUILDING DIVISION
APPLICATIONJPERMIT
PLUMBING MECHANICAL
29869
)TY. ELECTRIC PERMIT
FEE
BUILDING PROJECTIDI?NTIFICA'1'ION
PERMIT ISSUANCE.
BUILDING ADDRESS:.
,
-
CADDI'I'ION
MULTI -UNIT
SANITARY NO.
APPLICATION SUBMITTAL DATE
PANELS'
rAle,
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.D
- MODIFICATION
UPT03IX1AMP5
ME.
O ER'S '+p(ME:
I'I10NE:
CON'1'RACIXAasJAME:
OVER IWOAMPS
SIGNS ELECTRICAL
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COMROLp
ARCIETECUENGINGER:
LIC NO:
I ADDRESS:
-
❑
POWER DEVICES❑
TZ�S
1 herelVaffirm that I am licensed under provisions of Chapter 9 (commencing
will Smtion ]BINB of Division 3 of the Hiu'in... and Professions Code, and my license is
n fun tutee a Q 7 I R 12
License Lis Jd Conno—`7`—
Ume -Com DECLARATION CaaPT
,'- ARCiill be use IaECLARATION '
lundersmnd my plana shell he used as public records
Licensed Professional -
I
OWNER-BUILDER DECLARATION
Ihereby ul'firm met aat corm from te hCotoacuu's L; cense Laos for the
following reason. (Section 703L.5. Business and Profexeiem Code: Any city or county
which'regolres a Permit In u no ... t..1R , impmve, demolish, or repair any xoutdone
prior to its issuance, also requires the applicant for such permit to file a signed statement
that be is licensed pumuam to, the pmvlsinns of the Cormacka s License Low (Circler 9
(commencing with Section ]00) of Divisian 3 of the Business and Profnsi... Code).,
that he is exempt Ihemfrom wtd One basis dome alleged exemption. Any violation of
Section 703 L5 by any applicant for a permit subjects the applicant to a civilpenally of
not more then live hundred dull... (19IX8.
❑ Las owner ofthe property, or my employees with wages as meir sole compensalion.
will do the work, and the sunrrmis not intended oroffered for sale(See 71Na, Business
and Professions Code: The Contmele, License Law does am apply 1. an owner of
progeny who builds or imprmes thereon, and who does such work himself or mrougM1
his own employees, provided that such itnprmxmenu are not imetand or offered for
sale. IL however, the budding or improvement is sold within one year of completion, the
nwner-builder will have the burden m proving that he did are build or improve for,,.,
Fs owner of the property, am exclusively contracting with licensed contractors to
ponnmci the project (See ]WJ, Husiness end Pmfessintts Code:) The Contractor, Li-
cense Law does Tint apply to an owner of property who hulas or improve,, themnn, and
whocnnuunsforsuch proj<mswitha m.Rr,tm(,) licensed ruminant to the Comraanr's
License Law.'
El/�
I am exempAtnder Sm. y
, 4, +--- , R as P C for this reason
- -
BUILDING PERMIT'
INFO
❑ Consultant Fees Paid by Applicant (Initial)
BrtL-DDG�G FiI EEM'
PLUMB MECH
)TY. ELECTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SF'DWL D KITCHEN REMODEL
PERMIT ISSUANCE.
APPLIANCES - RESIDENTIAL
-
CADDI'I'ION
MULTI -UNIT
El PLUMBING RE -PIPE
STRUCTURAL.
PANELS'
'
_J
.D
- MODIFICATION
UPT03IX1AMP5
.
• D INTERIOR
- IMPROVEMEN,
C BATH REMODEUREPAIR
DOTHER
D CHIMNEY REPAIR
❑DEMOLITION
201-1000AMPS
OVER IWOAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
-
TEMR METER OR POLE INST S
COMMERCIAL-:
WBLDG/ADDITION
❑DEMOLITION
POWER DEVICES❑
NANT
IMPROVEMENT
D OTHER
El POLL, SERVICE
SWIMMING POOL IUXC TRIC
OUTLETS - SWI'I'CHIis- FIXTURES O -
NEW RESIDENTIAL ELECI'R SQ PT
SQ, F1'. FLOOR AREA
S/SQ. FT
1 cmby'affmn under penally of perjury one of me lollosvlrg declarations:
❑ 1 ha a aral will maintain a Certine:ne of Consenuo self -insure far Werkds Compen-
vourk , as pmvideJ fur by Section 3]00 of the hbor Cade, for IM1e perfomanee of IM1e
work lave and
this permit ix issued. '
❑ 1 have end will maintain Worker's Compensationofthw rkfor whi as required t i Section
37NMy of Labor Code,
nsationheperfne cancer and Folic forwhichmis permit is issued.
My Workers Compensation Insurance carrier and Policy number are
Carzicr. Policy Nn:
CF;RTIPICAOMPE COMPENSATION
FRAM WORKERS'
COMPmpleted if INSURANCE
(This section Dina not M1e completed IIme nem+h is I'oronenunrtrul dollars fBBxR
or )'
Ic n'fY dam (lie riturrounce ofm work ]or h eth I mit d 1II
ne ply n
may i n y : I m hec :ub/mu theAmours' C rope,
,Zot
sation Low, of Califtimans. Dam -
0 01Applicant
NOTIC-
f0 P rThi AI,. the ANT If (ler making this vision se the
1 rpt n i, you should
^' became subjm m it Worker's Compensation provisions of the labor Cede, you muni
G (nnbwiih mmp1Y with such prnvisinne nr This Permit xhall he decmW invoked
z r CONSTRUCHONLENDING Ag agency
Iheathy affirm Ihmthem issed(Se3( lending agency for me performance of
the work fur which this permit is issued (Sec. 3119], Ci, CJ
ULenders Name
{>J Lender's Address
a 1 minify that 1 have read this application and state that We above information is
V1 convert. 1 agree to comply with all city and county ordinances and state laws relating to QTY,
building construction. and hereby aumeriee representatives ofihis city to enter upon the
above-mentioned property for inspection purposes,
(We) agree to nave, indemnify and keep harmless the City of Cupertino against
liabilities.judgments, costs and expenses which may in any way acme against said City
in consequence of the granting of this pem+it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCBREGULATIONS.
Signatum cf ApplicanUCommcmr Dote
HAZARDOUS MATERIALS DISCLOSURE -
Will the applicant or (marc building e, Chapter
erre or handle Heallous material
a defined by the 32pertinn Municipal Code, Chapter 9.12, and the Health and Sufery
Code. Section 25532(.)'! ,
❑Yes No
Will the applicant or future ted ding «cupant use equipment or devices which
'emit hazallous air contaminants as defined by the Bay Arca Air Quality Management
Disnin1
-1]1'es ❑No.
I have tad the hazardous materials asmiremenn under Chapter 11.95 of the Can-
Potain Health & Safely Cafe, Sections 25505, 25533 and 25534 1 unded rnd that if the
building dies not cumendy have a lc...I that it is my responsibility to notify the «ca,nt
of the requirements which most bit met prior to issuance of a Ceti cote of Occupancy.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN as VENT- WATIA (EA)
BACK FLOW PROTECT. D17VIC17
DRAINS- FLO61L RODE AREA, CONE).
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. d OUTLETS
GAS - EA. SYSTEM -OVER q (EA)
GREASFANDUSTRI. WASTE INTERCEPTOR
GREASE
SEWER SANITARY STORM EA NX1 F'1'.'I
WAI CR til ATI R WNLN I /LLECTR'
WATER SYSTIeMaRIiATING
WATER S17RVICF
NEW RESIDENT IAL PLMB. SQ. ET
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTI!R OR ADD TO MECH.
AIR HANDLING UNIT CTO 10.000 CFM)
AIR HANDLING UNIT OVER 10,000 CPM)
EXHAUST H(HOD (W/DUCO r
HEATING UNIT (TO 100,000 BTU)
DEALING UNI T(OVER 110,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER- COMP (HIP OR IIpJNMI B'I'U)
BOILER-COMPIOVER 100,0001ITUl'-
AIR CONDITIONER
NEW RESIDENTIAL MECH.SQ.FT.
OFFICE
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PEE
.JUN J x,1996,
PO/.
VALUA'l IONLe(5 cow r-
Ijllu
STORIES r 11 TYPECONS'IRUCIION
SEISMIC E 1 r (ri7
ELECTRIC F\.
PLUMBING FE
MECHANICAL FE i
CONSTRUCTIONTA
HOUSING MITIGANON EE
I -AID'
hate
ISSUANCE DATE