29212 APPLICANT TO FILL IN INFOR 4TION WITHIN RED LINES-USE BALL POINT PEN ONLY
. CITY OF CUPERTINO BUILDING-ELECTRICAL, - I'IiRMITNO. ^ �S
^'BUII,DING DIVISION ' APPLICATION/PERNIIT PLUMBING-MECHANICAL 29212
2 L
' IIIIILDINQ PRU.IF,CI'IDP:NTIF'ICA'1'ION
• BUILDINGADDRHSS: t - SANITARY NO. APPLICATION UBMI AI,DATE
EN:YAME:3,,- P ON RACI'O 'SYIAME: LIC NO:
N/C CONTROL#
ARCHI iCf/ENGINIi13R: - LCNO:
• CONTACT: + PHONE: BUILDING PERMIT INFO
r,." :, .. ''1 ,❑ Consultant Fees Paid'by Applicant(Initial), •�BLDG, a ELECT .'PLUMB MECH
+ LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensd under previsions of Chapter 9(commencing QTY ELECTRIC PERMTI' FEE
O ❑ ❑
JOB DESCRIPTION
'
ith Section]000)ofDivision" 3oHhc llusi DP fesslo nIm lien cis
�DO y PIIthil l'ISSUnNCi; RESIDENTIAL "
n full fnrco'dhd
C
aVU�" Lmcda Is. - Lic.# ❑SPDWL ❑KITCHEN REMODEL
yah De¢ Commcmr t AI'PLIANCFS-NI?.STDEM1TIAL ❑ADDITION O PLUMBING R'H-PIPE'
Fprn ARCHIIT.CPSDECLA AI'ION + ❑MULTI.UNIT ❑STRUCTURAL
Z O I understand my plans shall he used as public records PANELS,
OZn .„ MODIFICATION
u0] Licensed Pmfic,omad -- 201-IN VAMPS ' ❑INTI?k TOR OCHIMNEY REPAIR
201-uxx1AMPS IMPROVEMENT -
�Y OWNER,eventI?R DECLARATION OM1µRKXAMPS El PAT RHMODP IiP R EMOLITION
Ly W 6 I naso affirm that 1 am event from the CaCode:
e:Any c'Law finite P(36U following (Section 703 1.5,Business dProfessionscale Ay ty orcountyEL
SIGNS EC ❑
TRICAL, OTIiIiR
YY17 O whichrequire, peonto t contract, h p Jm l:h P yswcmre -
�yy pram t: :. I' 4 ❑ Ipli I ll II 'y' I:taencu SPI'CIN.CIRCUI'I'IMISC. -
Wp" Nath 'I -
licensed a t th p "n ed fC ct ' L .'(Chapter)
TGp� (caro ncmgwrNSecoan]000)nfU vsm J fNe Business di f .arts Codc)nr TIiMR METER OR 1101E IN
dqi5 K Nat he is exempt Nercfmm and the iasis fol the allege]exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION -
W�m
Section by any applicant for a permit.subjems the applicant to a civil penalty of POWER DEVICES ❑TENANT El FOOD SERVICI?
SZZ not mora than five hundreal dollars S500)
CO El 1,us owner of Ne property,army employees wish wages as met...l<urmpematio i. SWIMMINGPOOLIeLECTRIC IMPROVEMENTd, m wJl do the work,end the.wmure is not imendnt orolTercJ for sale(Sea]ID4,Business - ❑OTHER
W 3! and Professions Cale:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES -
property who builds or improves thereon,and who does such work himself or through
his own employees,provided thaosnch improvements are not intended nr offered for NEW RESIDENTIAL ELELTR SQ IT. rt A s n
sale.11;however,the bulldingar imprnvanteal is sold within nneyenrot'cnoicadom no, SQ.PER:OOR'AREA $/SQ.IT.
owner-builder will have the burdenof proving Nat he dW not build or improve for poo
pose of axle,. - - APR 16 1996
❑1,m t the p of the property,,B exclusively mmmalns wird licensed cnntmdo. m TOTAL:
construct the project(Sec]04Y,Business and Professions Code:).1.11-11-1 a Li- -
cenveLowdoesnmapplymanowncrot'property whit hulldN or improves Nareon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with it conlmemr(g licensed pursuant to the amwdols I CIl1 V
Ur lilj f Ge Ti 1114U'
License law. PERMIT ISSUANCE.
I am exempt under Sec. ,B&PC far this mason _
AL ER-DRAIN&VENT-WATHR(CA)
Owner Dam VALUATION
�WOR K17R'S COMTE NSNTION DECLA RATION BACK FLOW PROTECT.DEVICE i
• I hereby affirm under Penalty at perjury one of the followi ngdeclamtions:.
❑I have and will maintain a Certificate of Consenuo self-insure for W kcr'a Co ,.. DRAINS-FLOOR,ROOV,,AREA,COND. 1 STORIES TYPE CONSTRUCTION
union,as provided for by Section 3700 of the Labor Cole,for the performance of the
work for which this permit is issued. - FIXTURES-PER TRAP r
❑ 1 have and will mninmin Worker's Cnmpancntion Imnrlmee,as re,id al by Sen t
370[ ith d for Ne Perfmmunmof ktin wh htt per t':'sued GAS EA SYSTHM I INC 4 OUT IHI'S OCC.GROUP APN
A1yW kis locum cec olcyn t - , -
Carver dey No. GAS EA SYSTEM-OVER 4(EA)
CERT AA OFF�ROM WORKERS
' GRI ASF? NDUSJ RL WASTE INTERCEPTOR "-
_
COMPENSATION INSURANCE '
Ghis section need not ham npletal ifilar,sermit is for one hunJrul dollars IS IIBUILDING DIVISION THESNI) aREASETRAP
or leas) PLANCHECK FEE
employ
any Patin the anyinmanceof the wink for subject 1.p eW..kc,'d. ,n- SEWHR-SANITARY-STORML'A.200FT. r
nor<mploy any person in any manner se,osmbecome mhjenm he K'nrkers'Compen- 0� ENERGY THE
Z cation Laws n Culitrygr.Dune
y�0 Applictou;z f�I iN 7,1 o •h WATER HEATER WN1iN'T/ELEC'IR �✓ GRADING HER "
F7 r~Ns NOTICE. IACAN F�,aficr coding this Caddied,of xcmpnon,you should WAItiH SYSTF.M/1'kl?ATING
a , become subject to the Workers Compemmioo provisions of the Labor Corte,you mmt SOILS ITH
fJ.l foMwith comply with such provisions or this permit shall Lie discount revoked WATER SERVICE .
0
U'z, CONSTRUCTION LENDING AGENCY NEW RESIUIiN'TIAI.PLMR. SQ.PI', PAID
1JO for
whaffirm Natmit is ssued(Sec.30P,nCis, agency fortheperformanceof Date Rweipt#
LL F Newark for which this permit is issued(Sec.3091,Civ.C.)
O U Lcndcts theme _ I TOTAL:
WLender's Address j
1 certify that 1 have ad Nis application end uam that the above information is BUILDING FEE
tolllm
coned.l agree,to comply with all city and'erticy nrdinwices and state laws returngm QPY. MECHANICAL PL'RMIT PEE
V building construction.and hereby authoriee representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for impaction proposes.
(We)agree msove,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC EEE
Iiabilities,jndgments,costs and expenses which may to any way acerae against said City ALTHRORADDTOMGCH. -
Inconseyucnca of the grinning of this permit. - PLUMBING FEE t
APPLICA TONDE STANDS D WILL COMPLY WITH ALT. N-P INT AIR IiANULING UNIT TO IO,WfI CFM)"
SOURCE .EGULA S MECHANICAL FEE
AIR HANDLING UNI'P(O'ER 10,(N1(ICFT) CONSTRUCTION TAX
gnamra of pplicun of tactor Dm EXHAUST HOOD(W/DUCT)+ " HOUSING MI'T'IGATION FTSE '
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building oceupam slomnr handle humrdouc material HEATING UNIT(TO IW,(M,O BTU)
az defined by Ne CuNnino Municipal Cede,Chapter 9.12,and Ne health and Safety
Cade,Section 25532nd? HEA'L'ING UNIT(OVER 100,000 BTU) '
❑Yes ❑No r. PAID
- VBN'I'ILA'f10N I'AN(SINGLE RRSIO) Data Nmelpt#
Will Ne applicant in future as building occupancno,y A ea Air Qu tar devices which
t hvurdous air contaminants m defined by the Bay Area Air Quality Management BOILER-COMP(JHP OR IIl0,1M1B RTU)
�DirWct? - TOTAL:
No BOILER-COME GVER 100,000 BTU)
❑.Yes ❑
I huva read the,,bumnlous mmeriulx raptiremmis under ChupterfilJS nl'the Cell- AIR CONDITIONER, ,
ISSUANCE DATE'
Ymnin a., &Safety Rule,Smtiom 25505,25533 end 8534.I undemend Nat if the NEW RESIDENTIAL MECH. ,SQFT '
buildiagdrcx currently have a)�na
that his mY mpmsibilitymnntifY Nc cupam . .
-
ofthe qu wo m ( to isaoance of CcniOc
Ow c nntl o og dI tisTOTAL: ISSUED BY:
OFFICE,