29953 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL 29953
BUILDING PROJECT IDEN'I H`ICA('ION
BUILDINGADDRESS' SANITARY NO. APPLICATION SUBMITTAL OATI
17973 Pia / c If t
OWNER'SNAMIi HONE CONT :TOE'S NAME: LIC NO:
/lm/•f p2r1`( NIC CONTROL#
ARCHITECT/ENG EER: LIC NO: ADDRESS. �&fLL al""Y ST 5C 1707
CONTACT: PHONE: �•7 r ✓ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DcgZ with Section 70(I01of Division 3 of the Business and Professions Cale,, dmy license is RESIDENTIAL'
FOO in full force and eftec / L 21 PERMIT ISSUANCE
yWF b ✓ ❑SFOWL ❑KITCHEN REMODEL
F6F+UU 4cunsa Class �?�b L'aM Ciammical APPLIANCES-RESIDEMHAL [-]ADDITION ❑PLUMBINGRI>PIPF,
+aQa Dmc TSDHC
ARCHITECTS DF.CLARAI'IUNOMULTI-0NIT []STRUCTURAL
~m Z I understand my plans shall he used as public records PANELS MODIFICATIONZOy;Q UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-HoMAMPS IMPROVEMENT
,_I OWNER BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMGLITIO
C C Q 1 hereby affirm that I um exempt fmm he Contracmrs Licensc Law,for the
�q(�a U following remora,(Section 7031.5.Business Laid Professions Core:Any city orcovnty SIGNS ELECTRICAL ❑OTHER A wn 1 \.
W 3 y
0 construct.which requires a permit construct.alter,Improve,Jemnlieh,mom,any sometsometimec
pnuriousiscuanec,alsofe,mmxdm.pplicum for.ucb lemma.filemsignedslatemem SPECIAL CIRCUIT'/MISC.
Ythan he is licensed pros an to the provisionsufthe Contractor's License Law(Chapter9
1+10N (commencing with Section 700(Bof Division 3 of the Business and Professions Cartel in TEMP.MEIERORPOLEINST COMMERCIAL:
d y M C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Yal1 4N• Section 9031.5 by any applicant for a permit sahCc"the npplicanuo a civil penalty of MOWER DEVICES []TENANT ❑FOOD SERVICE
SDnot more than five hundred dollars($50(j), IMPROVEMENT
❑I.as owner of the property.or my employces with wages as their sole compensation. SWIMMING POOL ELECTRIC
(.., will do the work,and the structure is not intended of offered for sale(Sec.0144.Business OTH
W"'m and Professions Calc:The Conurr o's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6 3^ ptnpeny who builds or improves thereon.:md who does such work himself or through
his own employees,provided that such improvements me nut intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale If,howevm,the building or improvement is sold within one year efcompinion.the SQ.F.FLOOR AREA $/SQ.FI�
Pumer-builder will have the burden of Moving that he did not build or improve for put- �r
ne al Clc). TOTAL
1,as owner of the property,am exclusively contracting with licenced contmLie,m
cmmamra he project(Sec.7041.Business and Professions Core:)The Cmumucmrz s Li- 7AY 2,9
Li-
Cease Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE1996
who contmets for such projects with o Contractions)licensed pursuant it)the Contractor's Js-I
License Law. ` PERM]IISSUANCEa (Ilj 1p-
0 I am escmpm under Sce. .B&P C for this lesson k" 11 0,1 y
ALTER-DRAIN&VENT-WATER HIM VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-moure for Worker's Comfort- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
satiom,as provided for by Section 37M of the Labor Core,for the pe foram c of he
ork for which this permit is issued. FIXTURES-PER TRAP
0 1 have and will maintain W..lac,Contpcnsatinn lalmoncw m inquired by Sccnitm 'r
3700 of the LeMn Code.for the performance of the work for which this Permit is issued GAS-IiA.SYSTF,M-1INC.4 OU'1'I,HIS OCGGROUP APN
My Workers Compensation Imumrmce carter and Policy number am:
Came, Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICNI It OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR
(This section need not be completed if then is for one hundred dollars(8100) I{UILDING DIVISION FENS
Penni GREASE'IRAP
or less) PLANCHECK FCIi
I certify than in the performance ofnhc work for which this Permit is issued.lxhall SEWER-SANITARY-STORM G.200 FT.
I employ any proamn any manner vo as bs become suhjeato CWorker:Compen- ENERGY FTSE
O Z station Law 'fmm (yam WATER HEATER WNPNT/ELECI'R GRADING THE
Applicant
NOTICE TOA ,,PLICANTIf.fmWorkee,C. umotinp nicate of e—mpLafor n.youu mull WATERSYSfEM/TItLATING SOILS FEE
F' " become
object mm the Workers Co motion provisions of the Calm Code,you must
Omhwinh comply wish such provisions nr nM1ie Permit shall the deenuJ revoked. WATER SERVICE
7Z CONSTRUCTION LENDING AGENCY NEW RESIIyENT1ALYLMB. SQ.FT. PATO Date Receiptp
U 0 (hereby affirm conservationrm
that there is a conservation lending agency for the perfoance of
W F the work for which his permit is irsuod(Sea 3097,Civ.C)
O V lender's Name TO'Ah:
} U.1 Lcmdera Address At a
I certify that 1 have read this application and state than the aMve information is BUILDING FEEAN
p�.r Toa correct.1 agree to comply with all city and county ordinances and stale laws relating no QTY. MECHANICAL PERMIT FEE
UZ building Construction,and hereby authorize erresentutivesofthls City tenter upon'he SEISMIC FEE
air m-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree nm save,indemnify and keep hrmlcss the City of Captain.against ELI:CfRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH.
PLUMBING FI
in consequence of the granting ofthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH LI,NONPOINTAIR HANDLING UNI'1'(TO III IXX)CPM) MIiCHANICAI.('IIF.
SOU EGU ATIONS.
AIR HANDLING UNIT(OVER 10.001 CFM) COISSTRUMONT X
rgm m AI rcanUCnmm Iyatc EXHAUST (WIDUCI} HOUSINGMITIO ON PER
HAZARI S MATERIALS DISCLOSURE
Willnheapplicam nrfumrebuildingmcopammare mhandle hvnrdouaamamnal HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Cale.Chapter 9.12.and the Health and Safety
Gde,Section 255320)? HEATING UNIT(OVER 1(10.000 BTU)
❑Yes ON. VENTILATION PAN(SINGLE RIiSID) Uu( If
PAID
pt
WII oro applicant a building occupant use equipment or devices which
emit hazardous air contaminants
nm as Defined by time Bay Area Air Quality Management BOILER-COMP CHIP OR 100.000 BTU) 'OTAL:
Mistrial BOILER-COMP OVER 100,000 PTU)
❑Yes 0 N
I have mail rhe havar&ms materials mquiremenm under Chapter 6,95 of the Cub- AIR CONDITIONER ISSUANCE DATE,
forma Health&Safety Core.Sections 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL.MECH. SQ.FT.
building does nm emrently have a tenant.taut i.is....v, tnsibility to notify theoccupant
of the mamr-cmens w hich must be met prior to issuance ofCnifictc of Occupancy.
Owner or mahonzed agent Date TOTAL: ISSUED BY:
OFFICE