S 0129 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY DP CUPERTINO IIUILDING-ELECTRICAL. PHRMITNO.
CHANICAL
BUILDING DIVISION APPLICATION/PERMIT PING PROJECTIDENTOFIC S 0129
BUILDING PROJECT IDENITFIL'ATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
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OWNER'S NAME: HONE: CONTRACfOR:'NAME: LIC NO:
)N NIC CONTRULX
R'VTECT/I:NGINF.F. : LIC NO. ADDREtiS: ❑
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CONTACT: PHONE' - . .y / BUILDING PERMIT INFO
D �e ff (N t7 �T/ ❑ (,L09nlfant an aitll_byy Applicant(Initial) .PLIIAN ELECT PLUMB MIECH
Ir
LI ENSED CONTRACTOR'S DECLARATION QTY EI.F.CTRICPERMIT FEE �
pW 1 herchy affirm tbnl I am licensed under fnrvisionn of Chap¢r 9(commencing JOB DESCRIPTION
F I�Z with Section]IXIB)of❑ivision7of the Nosiness and Professions Crate,anJ my license is RESIDENTIAL,
�- in full fommnd effect. PERM I .UANCf?
❑ WI. [I KITCHEN REMODEL
NlU" Li¢nse Chis Lic.X AI' IANCES—REMDEWAL DITION C1 PLUMBING RE-PIPIT
Z W Dme Contractor
�n 66 MUL -UNIT ❑STRUCTURAL
5,7rn
ARCHITECTS DECLAMATION PA IS
Z 1 underamnd my plans shall W used ar public records MODIFICATION
ZOZ-O p 1PT02 [I INTERIOR C3 CHIMNEY REPAIR
[.. ¢I Licensed Professional BBB IMPROVEMENT ❑SWIMMING POOLS
tJq' S�aj OWNER-BUILDER DECLARATION .lA S ❑ ATH REMODEIJREPAIR [3 DEMOLITION
I hereby air,.that I am exempt from the Contractor's License Law for the
O y U following reason.(Section 7001.5,Business and Professions Cash:Any city Or county Sl r 'CTR OTHER
O which requires a permit to c mm on,alter,improve,demolish or repair any stmcwm
prior to its iseuunw,vlsa mature,thoap1I amt for such mat 1.flea signed syatemam SPECIAL ' IT/ .C.
INy} that he is licensed pursuant o the pmvisinns of the Commutes License Law(Chaper9
10 COMAHfQA'
�µ'QD (commencing with Section 7")of Division 3 ofthe Businessund Professions Code)Of TEMP.MFTF.R L'
dy e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of - NEW TO. DITI ❑DEMOLITION
Dlmy
Section 101111,any uppfcum font perminsulicetsthc appllcam ,,a civil penaltyal' POWER DEVICES A [3 FOOD SERVICE
4477 tame than rive hundred dollars($500).
❑L as Owner ofthe property,or my employees with wages is their stale compensation, SWIMMING POOL CLE C 'E FysdEFl
will dothe work,and the swcmre is not intended muRered for sale(See 7044.Business us,. ' R�
18 lis
and Professions Carlo:The Cmrtmcon,License Law dues not upply to ua owner Of OUTLETS—SWITCHES—FI TURES .x
property who builds or improves thereon,and who docs such work himself in through
his own employees,provided that ouch improvements arc not intend eJ or oRered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If.however,the building or improvement is sold within, year of completion,the SQ.FT Fl.(K)R AREA SISQ.Ff.
er farilder will have the harden of proving That he did not build or improve for par-
posc of olcJ. /O
❑1,as owner of The Profen&arr exclusively contracting with licensed contractors to T V ii
crmwet the project(Sec.7014.Business and Professions Code:)The Commutes Li-
cense Law does not apply to an owner of property who build or improves thereon,and QTY. PLUMBING PERMIT FEE 1 C7*�
who contracts for such projects with a contractors)licensed pursuant to the Common's `'.7
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. .B&P C for this mason
ALTER—DRAIN&VFW—WATER(EA) VALUATION
Owner Date IO
WORKER'S COMPENSATION D[CLARATION BACK FLOW PROTECT.DEVICE pr'�r/�C„
l will
mai under Certify Certificate ofComene of the foli re for
eclaer's Co V
r]Ibeve and will main by an.. 7M of Con senna Code sunfor Workersce Comfort. DRAINS—FLOOR,ROt]F,AREA,COND. 5'I'OMIB TYPE CONSTRUCTION
work(as provided for mi Section 37(X1 of the Labor Code,for the perfnnnunce of the
work far which this permit is issued. FIXTURES—PER TRAP
❑ I have and will maintain Woreces Compensation Insurance,as required by Section
3700.17the Litho Cods.for the performance ofthe work for which this permit is issued. GAS—EA.SYS'TEM-1 INC.4 OUGAITS OCC.GROUP APN
My Worker' nm ns ti n Insurenc Policy number
icy No.: GAS—EA.SYSTEM OVER 4(EA)
CERTIFICATE OF : NFROM WO ENS' GRFASFJINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE DIN DIVISION FEI3S
(This section need nm he completed litho permit is for one hundred dollars($100) GREASETRAP
or less.) PLANCH
I verify that in the performance ofthe work for which this permit is issied.I shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Compere- I?NERGY
9;1 iisis
,Z onion Lows of California.Data WR'I'ER HEATER WNENTIELECTR
0 Applicant GRADING FEE
ti NOTICE TO APPLICANT:IL after making this Ccnificate of lixcmption,you should WATER SYSTEMTREKfING
become subject to the Waimea Compensation provisions of the Lelmr Crde,you most SOILS FEE
Oj forthwith comply with such Provisions or this permit shall W devoted revoked. WATER SERVICE
WW Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMD. SQ.FT. PAID
V p (hereby oRnn that herc isaconstruction lending agency for the performance of Dole a nX
rr the work for which this permit is issued(See3097,Civ.C.)
0 U Lender's Name 'OTAL:
Lenders Address
�a 0. RUILDINC IL Isi,
FLr I certify that 1 have read thisapplicationun and stone that the above information is
% correct.lagrcm
agree with all citytyand
nJ ccounty ordinances rod state laws reading to QTY. MECHANICAL PERMIT ��slzi-sfvdcUU
077, building concoction.and hereby authorize repremtmivcsofthis city tocnler upon the E
ahssve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEF.
Iiabilities,judgmentx,costs and expenses which may in any way mcme against said City ALTER OR ADD TO MUCH,
PLUMBING FEU
inconsequence of theming of thio permit.
N
APPLICANT UNDERSTANDS AND WIT COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1'O IO.BIIfI CFM)
MECHANICAL .F.
SOI/R :GUI S.
AIR HANDLING UNIT(OVER WANT CFM) CONSTRUCTR
Slinature of fplicant/Contrac Date EXHAUST GOOD(W/DUC) HOUSING MITIGATION
HAZA U ATERIALS DISCLOSURE
Willthenpplicanto future building occupant store or handle hazardous material HEATING UNIT(TO I10,000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cade.Section 25533007 HEATING UNIT(OVER 100.000B'fU)
El yo, 0N VENTILATION PAN(SINGLE RFSID) PAID
Date Receipt p
rdou
Will the applicant ar future building mcupanl use equipment or devices which
.it hazas air contamnts
ianm defined by the Bay Ana Air Quality Management B(]ILER—COMP(3HP ON 100,0N)BTU) TOTAL'.
atnnl
BOILER—COMP(OVER 1(10,(100 BTU)
❑Yea C]No
I have mud the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade.Sections 25585,25533 sand 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does nm currently have a reran,that it is my responsibility to notify the Occulted
of the requirements which must be met prim to issuance of it Cenificme of Occupancy.
Owner or authorized agent Data ^I ISSUED BY:
OFFICE