29241 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY r
CI TY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINC-MECHANICAL
- 2 9 2 A 1
BUILDING PRO)ECq'IIIENTIF'ICATION L LG+
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
*i�n 'Pito c .
OWNER'S NAME: PHONE: CONT ACTOR'S AMG: LIC NO:
1,^ -Vexk O�Ii %.orf XS 0 NIC O If
r RCHITECMNGINE : LIC NO: A)DRESS: ❑ T I
f+lx{O'1 Mbr G�(�
CONTACT: . . n_ PHONE, /510 BUILDING PER T
Lat.-SI Lr f)lS.O`R ` ❑ Consultant Fasts Paid by Applicant(Initial) LB Dc� EJf�E(jr PLUMB MECH
(oz3�90jo fXlj' ❑ ❑
LICENSED CONTRACTOR'S DECLARATION. QTY. ELECTRIC PERMIT FEE
I hereby effort that I am licenced under previsions of Chapter 9(commencing JOB DESCRIPTION
QZZ with Section]OW)of Division 3 ofthe Busitioninl Professions Code.mdmy license is
00 n fallforce and effec ..11 \' PERMIT ISSUANCE
RESMENTIAL
F�sIZS LiceP:, I.it.# r�T�Rro Wil ❑KITCHEN REMODEL
N 6 Dole Co.ours _ APPLIANCES-RESIDENTIAL DDITION ❑PLUMBING RE-PIPE
F.D'es ARCHITECTS DECLARATION PANELS - ❑ LH-UNIT ❑STRUCTURAL
Z O Zj- 1 undersanJ my plans shall M used as public records
O Z UPT0 2M AMP$ MODIFICATION
rrr4l• Licensed Pndessi m L1 INTERIOR El REPAIR,
p 201-11X10 AMPS IMPROVEMENT
�d2 OWNER-BORDER DECLARATION
1 hereby affirm that I am exemptmmmr
from the Coc 's License Law for the OVER 1000 AMPS ❑BATH REMODEVREPAIR ❑DEMOLITION '
06U following mamn.(Section)031.5,Business and Professions Code:Any city m county ❑OTHER
LL pF-' which rt vires a t to constrict,alter.inn SIGNS ELECTRICAL
q Penni prove,demolish,of repair any structure
vprior m its issuance,also requires the applicant for such pennant)rite a signed aatement SPECIAL CIRCUIT/MISC.
tvyvtyy�sy
that he is licensed pu emat to the provisions of the Contractor's License Law(Chapter 9
Cao (commencing with Section7000)of Division 3 of the Business and Professions Code)or TEMP.METIiR OR PO LE INST. '
a`y (y that he is exempt therefrom must the basis for the alleged exemption.Any violation of BLDG/ADDITION ❑DEMOLITION
h
Section LS by tiny epplicamfara permit subjects the applicmno tort Penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
ZOnot mom than fisc hundred dollars(8500). - IMPROV N}
❑1,as owner of the progeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,east the suuctum is not intended Proffered formic(Sec,7044,Business ❑OTHER
6a� and Professions Code:The Connector's License Lew does not apply P)an owner m OUTLETS-SWIT r5-FIXTURES
pr0peny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or ofPereA for NEW RESIDENT L li :CTR SQ Fr.
axle.IL however,the building or imprevemem is sold within one year of completion,the SQ.FT.FLOOR AREA &SQ.PT.
pcaner-bailaerwill have theburaenOfPOMPgthnhedidnotbuildorimproveforpPn C�nr Ut liUr'CfiI1NL)
osaof sale.). -
❑1,as owner of the popery,am exclusively contmeing with licensed contractors in TO
conormt the project(Sec.7044,Business and Prnfessinns Co.-,The C.Pow" .
cense Law does not apply m an owner of property who builds or improves thereon,and QTY, PLUMQi P FEE
who contracts for mch projects with a contrectogs)licensed pursuant m me Contmnoex
t License Law. PERMITISSUANCE
❑lam exempt under Sec.�B&P C for this reason '
ALTER-DRAIN&VENT-WA .R VALUATION
Owner Dor
WOR KEEPS COM PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I honbyuffirm nnderpomdry Pfpcojitynneofthe followingdeclarations:
❑I have and will maintain v Certificate of Consent msel&insure for Worker's Compan. DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPECONSTRUCTION
.scion,us Provided for by Section 3]W of the Labor Code,for the performance of the -
itforwIt h this pennft is iswaed. FIXTURES-PER TRAP
have and will maintain Workers Compensation Insurance,as required by Section
3 Wofthel.abnr Code.far the pcdonnunco of the work foo wbichnis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
M Wor Coqq�� ti Insurtnce,ionnerand Polic -
Camer.=rr Policy No.. u GAS-ISA.SYSTEM-OVER 4(EA) t
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMEIDUSTRI.WASTE INTERCEPTOR
(This section need not be completed if the Permit is for l,�ol1ms($1 W) BUILDING DIV 'ION FEES
yyyy0000���� GRP.ASETRAP
Putemp PLANCHECK FEE `
(certify that in the pednrmmcc of th far which this permit is issoed,lshall SEWER-SANITARY-STORM GA,2IXI FT.
Put employ my person in any manner s m heeome sublecuo the Wnrke.i Com,.- - ENERGY FEE
Z scion Laws of California Uate
O - WATER HEATER WNPM/ELECTR -
Z � Applicant GRADING FE
Vrl
y NOTICE TD APPLICANT:11',afror making this Cenidmo of Laboroio d you should Wq'rER SYS'TEMITRF.ATING
a C become su comply
m the Worker's Compensvtion pmv ns of the Labor CNe,you must SOUS FEE
{>a ry forthwith comply with such Prnvimons Pit is permitshall reed mvnked. WATER SERVICE -
Q
5 Z CONSTRUCf10ty',L ING AGENCY NEWRFSIDEN'1'IAL PLMB. $Q.FT. PAID
L) 0 I hereby aRirmthatmem iy<nommction lending agency tot the Performance id a RweiPtM
Gia the work for which this PemtiN4 issued(Scc.309],Cis.C.) -
O Lender's Num, / _ "TOTAL:
Lender's Address TOTAL: -
y 1 certify that I have read this application and sono that the above information is BUILDING FEE �a
V2 cnnect.I agree to comply with.11 city and county oninancoandsmm laws relating to QTY. MECHANICAL PERMIT FEF.
L) building cmumnamim,and berebyauthodm represematimsofthls city to ether upon the SEISMIC FEE
above-memumed pmpcny for inspection Empri • PERMITISSUANCE
(We)agree to rove,indemnify and keep harmless me City of Cupcniw against ELECTRIC FEE
liabilities,judgments.costs and cxpansns whichin,in any way accmc againstmid City ALT ER OWADD TO MECH.
in consequence of the granting of this pennon. PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO 10,000 CFM)
SOURCE REGULATIONS MECHANICAL FE
AIR HANDLING UNIT(OVER 10,00 CFM[) CONSTRUCDONTA
Sngnature of IicantsComractor Doo' EXHAUSTHOOD(W/DUCf) HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURE:
Will the applicant or future building occupant store or handle huandous tnaorial HEATING UNIT(TO 100,000 BTU),
as defined by the CLpenino Municipal Code,Chapter 9.12.and the Health POPE Safety
Code,Section 25532(x)'! I HEATING UNIT(OVER I(Indian BTU)
❑Yes
VT:NTILAPAID
PAN REBID) Uao Receipt
Will the applicant of future building oecup ma use equipment m devices which BOILER-COMP(JHP OR 100.0!X1 BTU)
mit hazardous air cnnmminann as defined by the Bay Area Air Quality Management TOTAL:
istrict^
Yes }U� N_o, BOILER-COME)(OVER 100,000100,000 BTU)
❑
I have mad the hvamous tsaoda6 rtquirtmema under Chapter fi 95 of the Cnli- AIR CONDITIONER ISSUANCE DATE
fame Health&Safety Code.Sections 25505.M533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently hry ..mens,dat it is my responsibility to notify the occupant
eras which mus Mom prim to iss nee PfvCmificate of Oce paw. t
Ib
Owner or ret zed agen - D e TOTAL: ISSUED BY:
OFFICE