29713 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 29713
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITI'AI.DATE
6 W0 d t Z
'S NAME? PHONE: CONTRAC R'S NAME: '� LIC NO'.
r. NIC CONTROL#
•SRCHITECr/KNGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECIl
❑
LICENSED CONTRSDECLARATION QTY. ELECTRIC PERMIT FF.L El
1 hereby tfOrm that I am licensedd underanderm
pvisions of Chapter H(commencing JOB DESCRIPTION
awith Sidon itefeeDlvision3 of the Buxinwsend Profcysions COJe,and my licemeis
�O PERMIT ISSUANCB ESFDWRESIDENTIAL,
F m PoII Summit effect.
FaVZV License Class Lica ❑SFDWI. ❑KITCHEN REMODEL
NQS Date Cnnancmr APPLIANCES-RLSIDIENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
p.
L ARCHITECTS DECLARATION El MULTI ❑STRUCTURAL.
ria
PANGLS
Z Z 1 undersand my plans shall hrecords MODIFICATION
e used as public
O Z Z— llisq'O 200 AMPSO El INTERIOR 1NEY REPAIR
Licensed Pmfessinnal 201-IINI0AMP5 ;IATj�
OVIiM�
raj
OWNER-BUILDER DECLARM ON pyHR I1XN1AMP5
y 1 herchy uffrzm that I am exempt from the Contractor's License Low for the ❑ : 7 .I�F ❑DF1 I N
x 3 d V following teamn.(Section 7031.5,Business and Professions Cole:Any city or county SIGNS ELECIT AI. ❑ R
a1 4. which requires a Permit to mnstmm,eller,improve•demolish.or repair any structure,
Sodor to its issuance.also requite the npplicem for such penniuo fileesigneJ$rammer, SPECIACUIT/MISC.
,Y that he is Bermdi pursuant to the provisions of the Communis License Law(Chair,9
O� (commencing with Section]000)x1 Dlvisino3 r[thc Business and lhoresslnns Cody or TFMFAFyVOiEtPOI.EINST
d y o y that he is exempt therefrom and the Innis rnr)he ollcgeA exempuon.Any violmin-o[ O NEW BLDG/ADDITION ❑DEMOLITION
iaEl Wy Section 70315 by any applicant for a Permitsubjeus the applicant to a civil penalty art Ml BVICE. ❑TENANT ❑FOOD SERVICE:
Z y not more than rive hundred dollars(SRX)).
=� C]1.as owner of the property,or my employees with wages as their sole comoegerion, SWIMMING E 1 IMPROOTHER IEMENT
F will do the work,and the structure is not intended muttered form],(Sm TH4,Bosoms, El OTHER
Wand Professions Gale:The Contractors License Law does not apply to an owner of UILETS-S CLIP -rU(TURES �—
jy
�'3 porosity who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impmvemenu are not intended or ofrcrcd for NEW RCSIUENTIAI. ECT SQ Fr,
sada If.bowsver,the buildingor improvement is sssld within oneynro[comp——...the I CQQYIn..FLOOR AREA S/SQ,Fr.
weer-builder will have the harden of proving that he dad not build m improve for our- I- y 26 �99
poseofmleA pry ..
C]1,as owner of the property am exclusively contracting with licensed contractors in ���L
construct the project(Sm.]tDJ,Business and Professions Code:)Th,Contractor's Li.
cense Law does nm apply to an owner of property who builds or improves thereon,and QT'Y. PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed oursuamt m the Contractor's V
License Law
❑ a noon unJai B&P on PERMIT ISSUANCIE
ALTER-DRAIN&VIENT-WATER(EA)
Owns D' / VALUATION
RK R'SC IiNSAT10N UECLARAq N BACK FLOW PROTECT.DEVICE jig
I hertby athrm under Penalty of perjury one of the following dmvtion
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Cooper. DRAINS-FLOOR,ROOF,AREA,COND,
minor,as provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPECONSTRUcTiON
work for which this permit is issued, FIXTURES-PER TRAP ,
❑1 have and will maintain Worker's Compensutinn Insurance,as required by Seenion
37W of the Lebnf Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC GROUP
APN
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy Nn.: GAS-G.SYSTEMOVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE? GREASNINDUSTRL WASTE INTERCEPIOR
(This smdou need not la,completed ifthe peormt is future hundred dollars(51do) Rl11LDIN0 DIV 1510th[•EI?$
or less.) GNIEASE TRAP PLANCHECK PER
I verify that in the performann of the work for which this permit is issued,I$hull SEWIER-SANITARY-STORM EA.200 IT.
not employ any person in any manner so as m become subject to Be Workeri Contact- ENERGY FEE
s O,� alive Laws of California.Dere WATIiN HEATER W/VENT/ELECIR
Z 0 Applicant GRADING ME
r ,G NOTICE TO APPLICANT:If,ofmr making this Cenilinte or F.xempnion,you should WAT17R SYSTEMaREA'I'ING
a became suhjeet to the Worker's Compensation proviein is of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall lrt demand revoked WATER SERVICE.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT. PAID
V 0 I for
this
that them isaconswuinn lending agency for the performance of Date Rm x
V. t--� the work for which Nis Permit is issued(Sm.3097.Civ,C.)
Q U Lender's Name TOTAL:
L) Lender's Addrcav
ti1 verify dim 1 have read Nil application and state that the above information is BUILDING FI
(n comet. ? —r
I agree set comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V z building conswuinn,and hereby amhoriu moresentmfvesofthecay menteruprm he SEISMIC FEE r
" .Eves-memimwil pmorty for inspection purposes. PERMIT ISSUANCE
(We)agree moor. harmless
ave,indemnify and keep the City of Culmino against ELECTRIC FEE
Iiabiliries,juJ,rucen,enstm and expenses which may in any wryuceoue against said City ALTER OR ADD TO MECH.in cm ew,move or the 6..ti.g of this Peond. PLUMBING FIEF
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. q1µHIT('
HANDLING UNr010,(1110 CPM) MECHANICAL
AIR HANDLING UNIT iOV1ER 10,000CFM) CONSTRUCTIONT
Signature of Applinm/Contmcmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGAI'IO FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applieammi mm building occupant store nr hundlchazurdnus mu¢riui HEATING UNIT(TO 1(0.000 BTU)
as Jeflmed by the Cupertino Municipal Code,Chapter 0.12,and the Health and Satety
Code,Section 25532(m? 1 HHA'TING UNIT(OVER 100,000 BTU)
E]Yea ❑No PAID
VENTILATION PAN(SINGLE BESIDE Date Rcce tX
Will the applinntmrfuture a building racby the oa tow Bay
Air Qualitment or y
Management
BOILER-COMP DHP OR IW,WO RTU)
emit ict'i us air cnnmminants as d<Bned by the Bay Arta Air Quality Management 'f AL:
Dishier?
E]Yes No BOILER-COMP(OVER 100,000 BTU)
❑ - '
I have mail the hmeadms materielsAIR CONDITIONER ISSUANCE DATE
requirements under Chapter 6,95 of one CHIi-
fomia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MIECH. SQ.Fr
build,,does oat mormaly have a meant•that it is my respunsibiliry roundly the arupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authnfinel agent Date TOTAL: ISSUED BY,
OFFICE