29510 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29510
BUILDING PROJECT IDENTIt'ICA'f1ON
BUILDING AUDRiSS: � ' /Y s ` SANITARY NO. APPLICATION SUBMITTAL DATI
O ER'S NAM[: P ONE: - pNDtACfOR'S NAME O � LIC NO: �� �
2\ t1C�1 1]M�r RIC CONTROL#
ARCHI'fECI*fENGINEER LIC NO: ADDRESS: I ❑
PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG P�JL�E,�C/'r PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ` ❑
1 hereby affirm tha I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
won with Section 7")of Division 3 infthe Business and Professions Code.and my license is
won RESIDENTIAL
F O L ease Clcand effect. PERMIT ISSUANCE
L'�F ❑SFDWL �l17'CHEN REMODEL
QUO License Class Lie.N N/�
rFn6a Data Cmdramr APPLIANCES-RESIDENTIAL ZV ❑pDDRION ❑PLUMBING RE-PIPE
t.Gw ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O-Z ' I understand my plans dull he used as Public records MODIFICATION
OZ^0 11PID 2(NIAMYS ❑INTERIOR ❑CHIMNEY REPAIR
F�•F.W Licensed Panic ssional IDI-IINXIAMPS IMPROVEMENT
�h0 w[4j OWNER DECLARATION
efo OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
XL,t Q 1 naso affirm that 1 1. exempt from the Cession,Co License Law for the
360 following reason.(Section](IJLS,Business and Profession,Code:Any city or county SIGNS HLT:C'1'RICAL COMESlit W y which ma a rel n permit to construct,alter,improve,demolish,or repair any ort,
'7y6Eprior to its issuance,also requires the applicant for such lernniOm file a.signed.cta4menl SPECIAL CIRCU IT/MISC.
that he is licensed pursuant to the provisions of the Committers License Law(Chapter 9
(commencing with Section 7")of Division J ofthc Business and Profssions Code)or TEMP.MEIE.R OR POLE INST. COMMERCIALthat he is exempt therefrom and the basis for the allegedxe
conniption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
•„h Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
4�45sle
not mom than five hundred dollars(5500). ❑TENANT ❑FOOD SERVICE
Sp ❑I,as owner of the property.or my employees with wages xuheir sell,compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
F will do the wnrA.anJ Ne nmcmmis std intended nndfcted for sok(Sec.]044,Bmines< OTHER
lural`m and Professions Cade The Comtracmr,License taw does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
d 3^ pmpeny who builds or improves thereon,and who does such work himself or mrmgb
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEM SQ PT.
sok.If.hawaver.the balance,impmvement nofild sialmone ye—fntmplinum.the SQ FLOOR REA s,sQ.Cr.
m
er-hundcr will have the burden pmving that he did not build or improve for put-
of --.
sum er of the property,am eedusively contracting with licensed c„mmdars m T
comas I IM project lSec.]M4;Business and Pndromr,CmdeD The Conbaemr's Li-La—lana,
APR
�C
se lawds nm apply loan owne,ol p.,Kny who hmidsor imprInc.,,., nd
oves n, Q'TY. PLUMBING PERMIT FEE IirR u
n
who contracts for such projmes with s cwntracoub)licensed limsunnt la the etmtmcmr',
Lt<cn. law. PERMIT ISSUANCE
I erupt under Sec. ,B&P C for this reconsi
- >II T 'Ur UUP'cftIINV
Dae ALTER-DRAIN&VENT-WATER(EA) "r. VALUATION
WORI 'tS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 erehy affirm under penalty of perjury one of the following declarations:
❑Ihava vnd will mainmina Certificate nfConscnuo xlGinsurc for Workers Compere- DRAINS-FLOOR.RODE AREA,COND.
sail as provided for by Section 37M m the Latin,Code,for the lrerfnmmnce of the STORES TYPE CONSTRUCTION
walk far which this pumil is iaoed. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insuranceas manned by Section
3701 nfthe LaMu Cade,bathe perforomemaf the work lit which this permit i,issued. GAS-1iA.SYSTEM-I INC.4011TLE1'S OCC.CROUP APN
'My Workers Compersat ion Insurance carver and Policy number ore:
Carrico Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GRI:ASF/INDUSTRL WASTE,INTERCEPTOR
('Chis section need not Mcmmplmed ifthe pcnnit is for enc hundred dollars(S I W) BUILDING DIVISION FEES
or less.)Lay that inthe perfomwork for which this permitisissued,lshall
GR17ASE'[RAP
L ECK FEE
not employ any Pmmin any manner oas In become subject the Workers Compl,n- SEWER-SANITARY-STORM EA.200 FT.
EN? Y FEE
0Z salon laws of Calaminia.Date WAT17R HEATER W/VENTA LECTR
Z O Applicant GRADING FEE III
M NOTICETO APPLICANT,If. ftm arakirrIbm Ccnificate of Exemption you should WATIiR SYSTEMOREATING
a , become subject to the Wmkers Compensation pneviume of the labor,Cade,you must SOILS EEE
fonhwim comply with such pro,ito em this permit shall be deemed mocked. WATER SERVICE
7z CONSTRUCTION LENDING AGENCY NEW R[SIIILNTIAL PLMB.' sQ.FT. PAID
U0 1ambyaffmnm thmthercisvconstrvcdcal lendingagency for the pebarroancenf Date mcipt#
f: the work for which this permit is issued(Sm.RAA,Civ.CJ -
0 U Lender,Naim TOTAL:
W Lender's Address I I'
Ro 1 cmay that 1 have read this applsenion and slam that the above information I. BUILDING TEP
Vi coned.I ago m commply with M city and compy ordinamcs and state law,relating m QTY. MEC I IANICAL PERMIT FEE
LJ Z bulldingrnnauuoinn,and hereby em mriaaor,ar- tativcsnf this citym enterupoothe SEISMIC FF.H
Heal,-mentioned rmien,for inspection parrytscs.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMITISSUANCEELECTRIC FEE
Iinbilitiesjodgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in colosp Ince of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIH HANDLING UNIT(TO lO,OW CFM1f)
SOURCE REGULATIONS. MECHANICAL F,E Qt
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIO TAX
Signature of ApplicanUConuacmr Date EXHAUST HOOD(W/DUCD HOUSING MIT .ATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the lipplimmor future buiMing¢cupaina me or handle baoadmat material HEATING UNIT TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 25532(,)'? HEATING UNIT(OVER 100'"BTU)
❑va, 0N
A I
LE
BOILE1.-CINPAN(SIN 100.000 BT PAID
oma RecciPl#
Will bl the air contaminants
infurore building by the B use ea Air Qu or choices which BOILER (3HP OR IIXI,IXID RTU)
nim hvnNnm'air mnmaminnnts as defined by the Bay Area Air Quality Management
isain't TOTAL:
(]Yes ON. BOILER-COMP(OVER 100.0 )BTU)
I have mail the hoe adoi s materials requirements mall Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Hwlth&Safety Code,Sections 25505,25533 anal 25514.1 understand tha if the NEW RESIDENTIAL MECH. SQ.Fr.
building does nm cumendy have a tenant,Nat it is my MsPm ibility to notify be occupant
of the rtyaimmenms which must be met Pim to issuance of a Certificate of Oempancy. \�1/7 Y//
Oiermor mahamed agent Date TOTAL: ISSUED BY: ter✓"
OFFICE