29838 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - BUILDING-ELECTRICAL PERMITNO. /"1
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. L a
BUILDING PROJECT IDENTIFICATION
BUILDINGADDR S: - SANITARY NO. APPLICATION SUBMITTAL DATI
rrr��ti l s z9
OWNER'S NAME: !-� P NE: CONTRA 'S AM^ LIC NO:
I / �� ✓O.N/C CONTROL)
'RCHITECT/ENGINEER: c.• LIC NO: ADDRESS: ���"'777
CONTACT: ^ A PHONE: BUILDING PERMIT INFO
D?"/ SIO Consultant Fees Paid by Applicant(Initial) BLD EIaF-¢ -PLUMB MECH
LICENSEDCONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT5FEP JL-
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Q 09z with Section 7000)of Division 3 of the Businessand Professions Code,andmy licenae is RPSIDFNTIAL
rr O'0 in full hateraid effect. PERMIT ISSUANCE
�UU Lkenae Clens _Lic.M ❑SFDWL' 11 KITCHEN REMODEL
G6 DareCnmacmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
nth ARCHITECTSDECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z I understand my plans shall be used us public records MODIFICATION
OZ-0 UPT02WAMPS C1 INTERIOR El CHIMNEY REPAIR
F4� Licensed Professional 2014000AMPS IMPROVEMENT
swzE OWNER-BUILDER DECLARATION OVER LBW AMP$ ❑BATH REMO I/REPAIR DEMOL
O a W 6 I hereby affirm that 1 me exempt from the Contractor's License Law for rhe
3 O6U following rcmnn.(Section Bntiness and Professions Cale:Any city or county SIGNS ELECI'NICAL ❑OTHER
Wra which requires a permit to consumer,alter,improve,demolish,or repair any structure
Anon.its iamance.also requires Ne.,pliant for such Permit file a rquedoercmeat SPECIAL Cl RCUIT/MISC
2, } that heir licensed pursuant tonic provisions ufrhe Contmemr's License Law(Chaprer9
ua GC (commencing with Section 700)of Division 3 ofrhe Business and Professions Code)or TEMP.METER OR POLI?INST. COMMERCIAL:
06 that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 70315 byanyapplicam fora permit auhjectsrhenpplieam to a civil pcnalty.f POWER DEVICES
❑TENANT ❑FOOD SERVICE
not more Nan five hundred dollars(SSU). IMPROVEMENT
Q ❑ Lmawnerafrhe properly,or my employms with wages us rbeir.vole rompenxminn, SWIMMING POOL ELECTRIC
will Probes
wank,and Ne awcturc is nos intended orofferul s mr,a(Sec.7o14.owner
DOTTER
oW Profcssiom Code:The Convhe......
. I..it a dodratnorapplytolf owner.f OUTLPTS-SWITCHES-FIXTURPS
hpoismyis own who builds or improves thereon,and who don such wort himself of through
his awn employees,e provided that such mens is old w are not intended m offered for NEW RESIDENTIAL ELECTR SQ IT.
tela lL however.the building or improvement is sold within one yearsfcamplerinn.be SQ.FT.FLOOR AREA LSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for our.
❑1,as owner of the property,sin exclusively commuting with licensed contractors to T /
scandal the Project(Sec.7044,Business sad Professions Code:)The Camrdaar'x Li-
cense Low does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE 21996
who contracts Nr such projects with o comments)licensed Formation o the Conaucmr's
License Law. PERMIT ISSUANCE
E] in I sexempt under Sec. ,B&P C for his rcamn A I 1-u 111' lJh UUI'L"f91INC)
Owner Dae ALTER-DRAIN&VENT'-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby alfinm under penalty of perjury ane mine following drelaaiinnx:
El I have and will mainNin a Certificate of Conant m self-insure for Workers Connect- DRAINS-FLOOR,ROOF AR .GOND STORIES TYPE CONSTRUCTION
sarion,as provided for by Section 370 of the Labor Cale,for the performance of the
work for which this permit is issued. s I FIXTURES-PER TRAP -
❑1 have and will maintain Worker's Compensation Insurance,in required by Section
370 ofdre Labm Code.ffporrdw perhormyance ofthe work for which this Permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETSC.DROOP APN
Cnmeoeke g�AnsT1- ywt,A/fl�c Pol YNo.Yn mlxrare: GAS-EA.SYSTEM-OVER 4(EA)
1 TEDPIDA 1' FROM .RS' ep
COMPENSATIONN INSURANCE GHEASFIINDUSTRI-WASTE INTERCEPTER !r
BUILDING DIVISION FEU
('This section need not be completed if the permit is Torose hundred dallaralgla0l GNEASETRAP
or IcseJ PLANCHECK FEE
Loy anylhatPerso the Performaanymannce ro theas
wad for whichthis o permit isissued.'Comen. SEWER-SANITARY-STORM EA. FT.
nor employ any person in any manner w es m became aubjnno the Workers'Campen- ENERGY FEE
0 nation Laws of California.Date WATER HEATER WNE.NTMLECTR
Z. Applicant GRADING FEF:
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMTREA'TING SOUS IIEE
aibecome subject to the Worker's Compensation provisions of NU Labor Code,you must
fSa forthwith comply with such provisions or this permit shall he deemed ratified. WATERSERVICE
aQ
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Date ecel t
L)Q I hereby amrm that them is a construction lending agency for the performance of P
the work for which this permit is issued(Sec.3097,Civ.C.) I -in Alto-
0 F' Lender's Name TAL
Lender's der's Address- 7O'
a - , BUILDINGFFF.
1 emify slut louse rcatl this application unA arae that Nc above information is
N cmrect.l agree in comply with all city and county ordinances and state laws reaming to TY MECHANICAL PERMIT FEE
L) building construction,and hereby amhmiu repreWmorlvea ofthi.s city m enacrupan the SEISMIC FEE
above-mentioned pmPnry for inspection purposes. PERMIT ISSUANCE
KK
(We)agree io nave,indemnify and keep harmless the City of Cupenino against ELECTRIC FEE
liabilitics,judgmems,costs and expenses which may in any way acume against said City ALTER OR ADD TO MECH.
in consequence of thegaming of this perms. PLUMBING FEE
APPLLCA U SRSTANDS AND V ILL COMPO VITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL F
SOURC/�,t'N/�S}f�y�`J�AOTIONS.
L,/ /• AIR HANDLING UNIT(OVER 109(KKICFM) CONSTRUCTIONTAX
Signal of Applicam/Comae Data b EXHAUST HOOD(W/DUCT) HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE;
Will rheapplicamorfumre builiingoecupam mum orhandle hamdims maenal t HEATING UNIT(TO I0,Oo0 BTU) s
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? HEATING UNIT(OVER 10,00 BTU) -
❑YeaIa VENTILATION FAN(SINGLE RESID) PAID
Will the s lsema of future mildin mcu t use equipment or devices which Date Receipt N
PP g Pan ea Air BOILER-COMP(3HPOR a0000BTU)
-�errdt haratdous air conuminenu u defined by the Bay Arca Air Quality Management _ TOTAL:
Distinct? BOILER-COMP(OVER 10,00 BTUI
Yea
I have mad the humorous marensls requireenmtder Chapter 6.95 of the Cali- AIR CONDITIONER
mts IZA ISSUANCE DATE
Forms Heulft&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building doe. um tiny have a rcmod.t tit is my"Insensibility ra nmify the resonant ,
of or
which mush Ip rto issoan nfa Cert reoflXcupaw.
00
Ownero a g t Utaat ISSUED BY:
OFFICE