29249 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-BLECOUCAL PERMITNO. 29249
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
B111I1DING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL O TE
piou, 1150 1- I IB 6
OWNER'. PHONE: .-r5CONTRANA LIC NO:
(5 C9�-v - CTOR'S M
NAC CO 'ROLIf
'HITECDEI4GINEER: LICNO: v A P_SS:
le
CONTACT, PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMtl .0
LICENSED CONTRSDECLARATION QTY ELECTRIC PERMIT FEF:
1 hereby affirm that tun licensedd under provisions of Chirpier 9(commencing QTY B DESCRIPTION
�DAX with Section 7")of Division 31f the Businessnod Prowlegionu Code,and my license is RESIDENTIAL:
0 0 PERMIT ISSUANCE
W infibaeffect. ❑SFI3WL C1 KITCHEN REMODEL
�UZj" License Class LiaN APPhIANCPS-RESIDENTIAL
,G0. Date Comment- []ADDITION ❑PLUMBING RE-PIPE.
F-7y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
X O y 7 L understand my plans shall be need as public recons MODIFICATION
UPT0200AMPS
❑ ❑
O X'^p INTERIOR CHIMNEY REPAIR
Licensed Professional 2014000
AMPS I PROVEMENT
"•I OWNER-BUILDER DECLARATION
Contractor
ON OVER I000AMPS BATH REMODELBIEPAIR ❑DEMOLITION
QaY a
a+W hereby affirm o nth 1 1. exempt from the Cumractnre License Law for the 7NF
0 6 V (allowing reason.(Section 9831.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL OTI�FR
0.0 F which requires issuance,permit na ntmauct.alma improve,demolish,or repair any swnum f 1
barhoitsensepolsowgmiws the
ovisiosofcant forthe such Cmarmrmittorite aicensa ned aw(Chrnmem SPECIAL CIRCUITIMISC.
j (co hue licensed pSectiorolumnn").the of Division 3 the Cannanorend Prof Laws Code)
GAO thaw he
age with Section7")
and of Division?of the Business
ned aimrpt Professions Code)or TEMP.METER OR POLE INST. -
0. C�' See io is exempt therefrom and the pery forte alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
not
omthers five
hundred
doll g($50 mtit subjects the npplicnnnoacivil penalry of POWIiR DEVICES ❑TENANT ❑FOOD SERVICE
FXQy not mom then five hundrtJ)altars($500).
❑ I,as ownerofthe property,or my employees with wages na their sole compensation, SWIMMING POOL ELECIRIC IMPROVEMENT
0 will clothe work.and the structure is not intended nr offered for sale(See 7044,Business OUTLIER
laid Pmfasdons Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
3 r property who heads or improves thereon,and who does such work himself or through
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL ELECLR SQ PT.
sale,If.however,The building or Improvement is sold within one year ofemepwion,the SQ.FT.FLOOR AREA E/SQ.Fr..
owner-builder will have the human of proving that he did not build or improve for put.
poseofgakJ.
El I,as owner of the property,am exclusively contracting with I'reensed cmnrumors or
conearat the project(Sao.9Q44,Business and Professions Gude:)The Convenors Li-
c"weLaw apply to an ow rid property who builds or Lmprov<s thetoon,and QTY. PLUMBING PERMIT FEE
who ----- rs M1prnjcutswithr s(mrnctor(ellicensed pmsuantmteCmarrwar'e JAN 18 1996
Licertsb la 1
❑I ea p S .B& Co M1i
id
S U ALTER-GRAIN&VENT'-WATL'R(EA) AL
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury,one of the following declarations:
I have and will tnalrmait a Carificmeof Comart to self-insure far Workers Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
scion,as providW Tot by Section 37M of the Labor Code,for the perfomwnce of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ In...and will maintain Workers Compensation Insurance,as required by Seaton
37M of the Labor Code,for the performance ofthe work for which this permit is issued. GAS-HA.SYSTEM-1 INC.4 OUTLETS ICC.GROUP APN
My Workers Compensation Insurance carrier end Policy number art:
Cartier. Policy No: I GAS-IA.SYSTEM OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION ETES
(This union awed net be completed if permit is forone hundred dollars(S 100) GREASETRAP
or less.) PLANCI IECK PER
I unify that in the perfonnanceof the work far which this permit is issuW.I shall SEWER-SANITARY-STORM P.A.200 FT.
oat employ any person in any mnn
aer so mom No..subu
jeco the Workers'Compen- ENERGY FEE
07.. satinn Lows of Califomia.Data WATER HEATER WNEMTB;LECTR
Z Applicant GRADING FEE
to NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEMJTREATING
1^ become subjauo the Workers Compensation previsions of the Latur Code,you must SOILS FEE.
forthwith comply withsuch provisions or this permit Shull M deemedrevoked. WATER SERVICE
CONSTRUCTION uni i e im,steCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V Q Iherehy uflirm thunhere isowmstmdion lending agency lira the performance of Dae Raeiptg
GL P the walk for which this junior is issued(Sec.3097.Co,C.)
O Lenders Name TOTAL:
Lenders Address TOTAL:
M I eerily tat I have road tis application end scow tat to advice of...mum is BUILDING FEE
CA corrti l agree to comply with all city and county ordinances and glow laws whaling In QTY. MECHANICAL PERMIT FEE
V building conswction,and hereby outhmim representatives of this city to enter upon the SEISMIC FEE
shove-mentioned property for inspection purptrser. PERMIT ISSUANCE
(Wed signals to gave,indemnify and kap harmless the City of Cupertino against L'LECTRIC FEE
liabilities,judgments,costs andespemus which may in any way aawe against said City ALTER OR ADD TO MECIF
in consequence of The granting of this pemit. PLUMBING FEE
r
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNIT(TO 10,000 CFM?
SOURCE REGULATIONS,
MECHANICAL TEP.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
Signature of ApplicantlContracmr Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FTE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applieam or future bulldingsmcopnm score mhundle haaamous material HEATING UNIT CFO 100,101 BTI])
as defined by the Cupertino Municipal Code,Chapter 9.12,oad The Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER 100,000 BTU)
E]yes
F7 No
VF.MfIIATION PAN(SINGLE RI:SID) PAID
Data Raeiptk
Willdueat,vacantimsersor rc datittedding by
Bay acupas use
.Ail pna or ality Maas wMfh BOILER-COMP(3HP OR 100.fX1I BTU)
Fm huznmous air cnmaminants as dcOned by to Bay Arca Air Quality Management TOT
ttnmP
❑Yes ❑Nn BOILER-COMP(OVER 000.000,BTU)
_
I have read the hovudous mumrials requirements under Chapter 6.95of the Cull- AIR CONDITIONER ISSUANCE DATE
Forms Berlin&Safely CaM,Sections 25505.Z533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my easpomibility to many the occupant
of the mmtima enc which list he all plot m Ilamere life Cermere of Oeenpanay, 1�A!
Owner nr autmiud agent Data TOTAL:PpikQEDBY.
OFFICE