29108 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO, 0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
•o_5-�s � itli Y"p Iflile 66155-r- l'�- S
O NER'S NA E: - I' ONN: CONTRACI'O 'S NAVI: LIC NO:
6 26 0 0 0 NIC Imo/ CDNTTRD p
W ARCHI ECfIENGINE : .IC NQ ADDRESS: r' r A ❑ ( V
CONTACT: PHONE: (lG BUILDING PERMIT INFO
n ���' /] Q/�� / ❑ Consallanl Fees Paid by Applicant(Initial) HLDG/ ELECy PLUMI MECH
Er
LICENSED CONTRACTOR'S DECLARATION (� QTY. ELECTRIC PERMIT FEE
I hemby affiant that 1 oto licensed under provisions of Chapter 9 frommencing JOB DESCRIPTION
oz tit Sealian'm )mf Divnm3sggm Bustoes,amIProfessions Colonnd my license is
Iy0 in full fomeandefact. PERMIT ISSUANCE
�4.UZ�j License Ossa Lic.x - FDWL ❑KITCHEN REMODEL.
NQS Dace _ Commcmr APPLIANCES-RESIDENTIAL.. EIATJDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURAL
~y z l understand m leas shall be used as Public records PANELS
z0 YP pu MODIFICATION
Oz�O UPTO2W AMPS C3 Licensed [I CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT
F, OWNER-BUILDER DECLARATION Ira
I hereby affirm that 1 am exempt(nim rite Convumor's License Law for the OVER IIXXI AMPS [I BATH REMODEVRF.PAIR �DEMOLITION
3aeU. following mason,(Senion 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
.R.LLO iq which requires a permit to common,she,,impari demolish,or repair any stmnue r
Ho.Q.1 priorto its issuance,alsorequins the applicant for such permit too u signed statement SPECIAL CIRCUIT/MISC.
} that he is licensed pursuant tote pmvisionsofthe Contractor's License Law(Chapter9
(emenracingwith Section7000)of Dwisim13afthe Businexsand Profusions Code).,
M . TEMP.METER OR POLE INST. COMMERCIAL:
a
❑NEW BLDG/ADDITION ❑DEMOLITION
if W
Section?031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES OTENANT ❑FOOD SERVICE
2 Y not mora thea five hundred delta.($500). IMPROVEMENT
Q ❑I,a.s ownerol the property,or my employees with wager as their.sale compensation, SWIMMING POOL ELCCT IC '
pp�� will do the work,and the uncture is not intended mattered for sale(Sec.7034,Business ❑OT'HIiR
STand Professions Code:The Contractors License Low does not apply to an owner of OUTI.I TS-SWITCI iris-FIXTUR:S
613^ property who builds or improves thereon,and who does such work himself nt through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sele.If.however the building or improvement is sold within one year ofcompmtiomthe SQ.FT.FLOOR AREA $/SQ.FT.
of Balder will have the harden of pnwing thw he did nm huilA ar improve for par- �T^^
ownc i/s G7
pose of sale.). -
❑saosowner ofthe(See.70am 44,
nosiness
contracting veldt:licensed eCrontracros m �2
nmswm does not (Sea.oar weer of and Employ
who
Code:)The es thereon,
Li-
exam l.uwdce or such ply roan owneeofpmpery whosedparimproves thereon,end QTY. PLUMBING PERMIT FEC
who contacts for such projects with n conwnogq licensed pursuem m the Cnmactnr s
License Law. PERMIT ISSUANCE.
1 am exempt under Sec. t ,B&P C fonhis reason
Owner Date ALTER-DRAIN&VENT-WATER IIIA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO=DEVICEsill".• I hereby am en
ffirunder pahy of perjury oneof the following declarromm: `
I have and will maintain a Certificate of Consent o self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONS'fRUCI'ION
cation,as provided for by Section 37W of the Labor Cade,for the performance of the
work far which this permit is issued FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insumna,as required by Section
37M of the Labor Cri far the permina ttce of the wells far which this permit is issued GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Worker x Compensationsura
insurance canner and Policy number are:
Coricr. Policy No.: GAS-HA.SYSTEM-OVER 4(IA)
CERTIFICATE OF EXP.MPTION FROM WOR KERS'
COMPENSATION INSURANCE GRFASFIINDUSTRL WASTE INTERCEPTOR I Nr IVISION FEES
section need tot lm eontplemd l I the permit is Intone humod dollars 1$1Nq GREASETRAP
or IessJ PLANCHE n�
Loy any that
per in the perfmannce rseasiwork for whichthisthe Workuoedlshall SEWER-SANITARY-STORM PA.200 PT, a�
51
not employ any Croon in any manner seas to become subject to the Workers'Cnmpen- ENERGY S
c7Qz Limo,of California Dam
Applicant
- WATER HEATER WNL•NT/ELISCIR GRADING
G r~N-s NOTICE TO APPLICANT:If.aper making this Certifimm of Exemption,you should WATER SYSTIiMfI'REATING
h become subjat to the Workers Compensation proaway of the LaMr Code.you man SOILS ITE
forthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE IFr
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PE PAID
V 0 I hereby affirm that them is a construction lending agency for the performance at Daa Recci p
the work for which this permit is issued(Scc.3097.Cl,C.)
O Lenders Name Q T TA L:
WLenders Address It
LL 1 cenlfy tlms 1 have read this upplicmion and anemia the above information is BUILDING FEE
(A correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
7
U a building commuction.and hereby authorim represcetatives ofthiscoy memerupon the a SEISMIC IEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE sa�
(We)agree to save.indemnify and keep hamtless the City of Cupertino against L ELECTRIC FEE i
liabilities,judgments,costs and expenses which may in any way name against said City ALTER OR ADD TO MC:CH.
in consequence of the granting of this petition. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,000 CIM) MECHANICAL FEE
SOURCE
sREGULATIONS.'
-2/41- AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCIONTAX
Sign pp CatSign Cot Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hmutdous material HEATING UNIT(TO 100,000 BTU)
es defined by the Cupertino Municipal Code.Chapter 9.12,and the Heah and Safety
Cede,Section 25532m)P I HEATING UNIT(OVER INi BTU)
❑Yes FIN. PAID h) •'1
VENTILATION PAN(SINGLE RESID)
Will the applicant or future building occupant use equipment or devices which Date "R!c p p�—
pp gt p .Air n BOILER-COMP OHP OR 100,000 BTU
Dis hazudous air mnmminems ox defined by the Bey Ates Air Quality hlonagemem ) TOTAL:
❑ietrin7
NA
❑Yes ❑Nn BOILER-COMI'(OVBR 100.000 BTU)
AIR CONDITIONER L 1 f A
I have read the hazardous Sections
5 5,2553 encs under Chapter rsta of the Cali. "I�ISSUANCE DATE
fnmia Health&Safety lly have
Sections 25505.25537 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. lr"
buildingJas notcurrency have a oactn,thato ismer responsibilitytonotifytheoccupant
of the requirements which must be ma prior to issuance of Ccnificum nf(kcupnncy.
Owner or authorized agent Date ISSUED Y.
OFFICE F