29378 ,APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO - BUILDING-ELECTRICAL. PERMITNO. 2 9 3 7
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. L VJ 3 1/ IYJe
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY IN APPLICATION SUBMITTAL DATE
b 2S 3'S q A,
OWN R'S NAMP.:� I L PHONE.: ^L g O ACfT'S NA LIC NO:
G VI i NIC CONTROL#
MR*CHITHCT/ENGI1vl CNG: 9 ADDRESS: ❑
•f 7//wWp./1 _
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ a< ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby gffnm that I am licensed under previsions of Chapter 9(commencing JOB,DESCRIPTION
WaZ with Sectinn]INJn)nf DivisionJof the eueinexs and Pmfessions Cale,and my licnvse is 1 RESIDENTIAL:
O in full force and effect. PERMIT ISSUANCE [I SFDWL ❑KITCHEN REMODEL
�Uy License Class
LicC....# - APPLIANCES-RESIDE.NTIAI. '
�I...yWUp�
Data- tar []ADDITION ❑PLUMBING RE-PIPE
no ARCHITECTS DECLARATION ppNEL$ ❑MULTI-UNIT' []STRUCTURALX O��J, 1 understand my plans shall be mud ae Public records MODIFICATION
0z�a UPT0 2M AMPS
A F�( '(]IR CHIMNEY REPAIR
Licensed Pmfessional 20Id000AMP5 - IMPROVEMENT
OWNER-BUILDER mDECLARATION OVER I"AMPS . ❑BATH REMODEUREPAIR 0 DEMOLITION
m U I hereby.(firm that 11. exempt from the Contractor's License city
o for the
O1- following rcamr.(Section]onstru Business and vee demil C,corrx arm or county SIGNS ELECTRICAL []OTHER
rel LL which require a .atim to construct.slur,improve demolish, file
repair any structure
��O pdonaits issuarme,also rtyuircs the applicant such pcmrit to fileesigned etatelMnt SPECIAL CIRCUIDMISC.
} thmheislicensedpurtuammtheprevisions of the Conuuctur's Licanu Low Chapter 9
<� (commencing with Sectinn]OIN))nf Divisi,n3of the Business sod Rvfessiom Code),r
00
TEMP.METER OR POLE INST.. 2��" COMMERCIAL:
and he is exempt themfrem and the anis for the alleged exemption.Any l Taman of NEW BLDG/ADDITION ❑DEMOLITION
4 not Section7031,5by any
undrediwllarsSnt for a pennit subjects Ne xpplicenun.civil penalty of POWER DEVICES []TENANT ❑FOODSERVICE
not more owner
five hundred dollen y employees
p 6 do the work,and
property,or toded with their compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
a�+�GGGG O ❑ P pe Y• Y entP Y 6w as
Ii dome work,and the he Contractor's
is not intended oro w ba!,reale(Sec.o an Business ❑OTHER
and Profession Code:The Contractor's Licenu Law saes not work
hi s if owner of OUTLETS-SWITCHES-FIXTURES
his ownroperty who huiWs or vided t a thsuch i and who nts each work himself ll through -
sat own however
the
building
that such mens is
seold w are not intender nr ndibre,for NEW RESIDENTIAL ELCCfR SQ EC' It
sale.ILhower will hava thingorimprovemcnt issalhadidnone ildori provetiomthe @Q.hT.FLOORAHP.AY SISQ.FT.
ownerbuilder will have the huNen of proving that he did oat build or improve fm par- AR
pose of selene
❑I,as owner of the propcny,am exclusively contracting with beamed contractors to T
construct the pmject(Sec.]814,Business and Pmfessions Cade:)The Contractor's Li- 1,99
cense Law does not apply to an owner ofpmpeny who builds or improve thereon,and QTY. PLUMBING PERMIT FEF. CryUh [r•VY g
who contracts for such projects with a conmctons)licensed pursuant to the Contractors llryU
License law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this sic! recon
Owner Date ALTER-0RAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECLDV.611
.I hereby affimde
unr penalty of perjury one of the following declaration: BACK
I have and will maintain a Certificate of Continuo self-insure for-Worker's Compero DRAINS- .00 •STORIES TYPECONSTRUC ION
more.as provided for by Section 37W of the Labor Code,for Ne performance of the
rk
❑I have and will maintain Worker's Compensation Insurance,n required by Section
for which thisprow,is issued, FU(TURESF-R
37Wofthe Lobar Code,fnnheperformanceof Ne work for which this permit is issued. GAS-EA.. - INC.
My Workers Compen>ation Insurance carter and Policy number am: OCC.GROUP APN
- Carder. Policy No.: GAS-EA.SYSTEM-OVER 4(EA) _
CERTIFICATE.OF EXEMPTION FROM WORKERS' CREASP/IN➢USTRL WASTE INTERCEPNR
COMPENSATION INSURANCE BUILDING DI VISION FEES
(Thieuction need not be completed ifthe permit is forone hundred dollars($10y) GREASETRAP
or leas.) PLANCHECK FEE
I modify that in Ne performance f1h,work for whichtbis permit is issued,le hall SEWER-SANITARY-
not employ n an rammer so as m become smHect to the Workers'Cum m STORM EA.200 FT.
p y any parson i y 1 Pe ENERGY FEE
O ,Z, ApP
Applicant Law of California.Data WATER HEATER WNENT/ELECfR GRADING FEE
A li '
r,y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATERSYSTEMOO EATING
abecome subject to the Worker's Compensation previsions of the Labor Cade,you must SOILS FEE
forthwith comply with such pmvisiom or this permit shall he demand invoked. WATER SERVICE
Q
CONS0NLENDINGAGENCY NEW RESIDENTIAL PLMID
B. SQ.FT. PA
V � Ihoeby affirm that
ere isis araconswnion lending sgrncy for the performance of nllmw Receipt
W. the work for which this permit is issued(Sec.3097.Ci,C.)
C Lender's N.me .t TOTAL: .
WLender's Address - TOTAL:
0. 1 certify that I have read this application and stain that the above information I. - 4FEE BUILD F
correct.I agree m comply with all city and county ordinnccs and arm laws relating toQTg MECHANICAL PERMIT building construction,and hereby ohorise representatives of this city m enter upon the SEISMIVME mMwe-metioned unpany(Dr inspection purposes. - '(We)agm.I. i indemnify and keep harmless theCity of Cupertimd against PERMIT ISSUANCE. ELECTliabilities,judgments,costs and expenses which may in any way accrue against mid CityALTER OR ADD TO MEGH.in consequence of the grouting of this permit. ` PLUMBAPPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM)SOURCE REGULATIONS. MECHAIR'HANDLING UNIT(OVER 10,000 CFM) CONSTSignature o(Applicant/Conmctor Dow EXHAUST HOOD DVMUCO' HOUSI
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harnrdaus material HEATING UNIT(T0100,000 BTU)
u defined by the Cupertino Municipal Code,CTapmr 9.12,and the Health and Safety
Code.Section 25532(.)? HEATING UNIT(OVER IW,000 BTU)
❑Yee FIN. VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment of deVices which Dau Rea p
mit humorous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP UHP OR 100,000 BTU)
District] TOTAL-
0 Yet
OTAL:❑Yes No BOILER-COME(OVER 100,000 BTU)
I have read the neurnmus materials«quircmrnls under Chapter 6,95 of the Cal i- AIR CONDITIONER: ISSUANCE.DAT
f sere Health&Safety Cale,Seen...25505,25533 and 25574,I understand that it the NEW RESIDENTIAL MECII. $Q.FI'.
building does oat currently have a unam7that it is my responsibility to notify the uccupunt
of the requirements which next he at pnm m issuance of a Certidicum od'Occupancy.
Owner or milam ued agent Dine TOTAL: ISSUED Y.
OFFICE