29792APPLICANTTO FILL-IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING- ELECTRICAL
BUILDING DIVISION APPLICATIONTERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO. L n 2
9 L
BUILDITt ADDRE6 <� �
SANITARY NO.
APPLICATION SUBMITTAL DATE.
OWNER'SS NAME: \ PH E;
s� S
CONTRACTOR'S NAME: LIC NO
3
N/C
❑
CONTROL#
tCHETECT/ENGI EER: LIC NO :
G k (¢Aficla 1,
ADDRESS
q ,
CONK PHONE:
r�
ED Consultant Fees Paid by Applicant (Initial)
I
BUILDING PERMIT INFO
BLDG 171 ECT PLUMB ME H
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am Bcen,ed under provisions of chapter 9 (caatateaB1Og
with SmIam7000)of Division 3af1he Business and Professions Codamd my lice me is
in full fnceand effect.
l.lcans. Cbrs, Lic. ;Y
3 Date Contractor
QTY.
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL•
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RH PIPE
❑MUCD -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMPNT
❑ BATH REMODEL,REPAIR ❑DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
j ARCHITECTS DECLARATION
I I undmiti nd my plans shall M1c used as public records
Licensed Professional
OWNER-BUILDER
boomDECLARATION
CorroON
1 herebyeffirm (Sect that 1 am exempt s an the conancmry t: Any, Law medic
1 following reason. (Section 7031.5, Business end Professions Code: Any city or county
iwhich requires n e, also re cnnmthel,,Ii, improve, demolish, or repair any swaurt
I prior to its issuance, also require, me upplicam for such penniuo Oleasigned staemem
that he is licensed purwannn the pnry sot the Convenors License Law lChapor9
(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) it
mat he is exempt therefrom and the basis for the alleged cxc ninam. Any violation of
Section 9031.5 hyany applicant for a permitsubjees the"p,liean,toucivilpenulty oP
not more than five hundred dollars (E50E,
❑I, as owner of the property. or my employees with wogs as their sole compensation,
will do the work, and the structure is not intendedoroffered final, Sm. 7O, Business
i and Professions Code: The Contractor's License Low does not apply to an owner of
property who builds nr improves thereon, and who does such work himself ar tbmugh
his awn employees, pvcwhud that such improvements me not intended or offered far
sale. If, however the building or improvement is sold within one year afcmnplction ,the
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of saleJ.
❑ 1, as owner of the properly, am exclusively contracting with licensed etmracmrs to
construct the project (Sec ]Btq Business and Professions Co le:) LIc Commerce s Li..
tense Law does not apply to an owner ofpmperry who builds or improves thereon, and
who contracts for such projects with a eomranor(s) licensed pursuant to the Comremar's
License law.
❑ 1 am exempt under Sec. . B & P C for this reason
PANELS
UPTOAIOAMPS
201- IOfXtAMPS
OVER I(XIOAMI'S
SIGNS HLITTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
'COMMERCIAL'
❑ EW BLDG /ADDITION ❑ DEMOLITION
NANT Cl FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECT
OUTLBI S- SWH' CUES -FIX RES
NEW RESIDENTIAL ELECTR SQ
SQ. Pt. FLOOR AREA
�� ��
Qy p'
1PT� p'41
$ /SQ. Pr
1
QTY. PLUMBING PA T
FEE
PERAfIq'ISSUANCH
ALTER
ALTER - DRAIN & VENT - WATER (FAJ
BACK PLOW PROTECT. DEVICE
Owner
ON
COMPENSATION DECLARATION
._ I hereby affirm under penalty of perjury one of the following declarations:
❑Isaac andwillforby nettle. 370eof Ca Ube, Code.,urefur Workersr. of th-
ration, , provided for by Section 3'IIXI of me labor Cnde, for the perfarmance of the
work fns which this pemtai is issued.
❑ 1 have and will ode, fan Worker's Compensation ce of thw Insurance, h required by Section
J"IO Worker's Labor Code, for pertunnance of the work for which this permit is issued.
1y WorkersCCq sa wlnsumncec 'tt and Polity nu
Cartier:
LON y `
DRAINS- FLOOR. ROOF, AREA, COND.
S :.4.
" -- - FI1 IIVLI
TYPICONS'rRUCTION
FUTURES -PC:R TRAP
GAS - IIA.SYS'fliM - I INC. 40lIT1.L>I'S
OCC.GRDUP
— \
APN
GAS -EA. SYSTEM OVER 4(EA1
Tl CAfH OP1; ( OPM M WORK
COMPENSATION INSURANCE
(Ibis section need not be cmnplmed if the permit is forone hundred did ma IS Had
or less.)
I certify that in the perl'ommnce nl'the work for which this,orm, is issued, l shall
nth employ
p y any person is any manner sows m beconse suhjea m the Workeri Camper-
Apple Laws of Co ifomiu. [)are
tint
GREASF/INDUS'IRL WASTE INTERCEPTOR
L 'G VISION FLIES
GREASH I RAP
PhANCHEC
SEWER - SANITARY -STDRM EA. 200 FT.
ENERGY PI .
�O
WATER I [EATER WHEN PELECTR
GRADING PEE
NOTICE
NOTICE bj APPLICANT: If. atom making this Croons of of FUnuor o Corte, you should
became subject to the Worker's Compensation provisions of the labor Coda you must
funhwith comply with such provisions nr this pemsit shall he deenod invoked.
CONSTRUCTION LENDING AGENCY
I hachyaffirm that there isaconsuuction lendingagency funhe Perfortnanceaf
the work for which this permit is issued (Sec. 3090, Cie. C.)
Lender, Name
WATER SYSTP.M ?RGTING
SOILS FEE.
WATF:II SERVICIi '
PAID
NEW RESIDENTIAL PLM E3. SQ, PR
Dam u M
If CIII/
Lenders Address
)
I certify rout I have rend this npplicapon and clam that the above information is
once, l agree tocomply with all city and county ordimmums and state laws relating to
building convection, and hereby authorize representatives ofthis city to enter upon thu
shove- meraimcd property far Inspection purpmc,'
(We) agree to save, indemnify and keep hurmlesn the City of Ctpenina against
liabilities.jidgteens,consind experoes which at., many way merueagairm said City
in nsecuence of the gmming ofthis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
BUILDING P'
„y
QTY. MECHANICAL PERMIT
FEE
PERMIT ISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO IB,DX) CFM)
EH
IHOUSINGMUIG
AIR HANDLING UNIT (OVER 10,000 CFA)
TAX
gignamrc pplica rm path
DOUS MATERIALS DISCLOSURE
Will the applicant ar future buildingocenpunt nos nr handle h:aunlous mnterlul
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code• Section 25532nd?
[-1 Ye. E] No
Will the applicant or future building occupant use cquipmem or devices which
Kit hazardous air contaminants as defined by the Bay Area Air Quality Management'
Distdeb
❑Ye, ❑Nn
I have read the Incurious materials imuarements under Chapter 6.95 of the Cull-
fames, Hmlth & Safety Cade, Sections 25505, 25533 and 25534.1 understand that if the
building does not currently have a tenant, mat it is my aespmsibility m notify me occupam
of the requirements which must be met prior to issuance of a Cer ificme of Creature,
�Owntt nr aothonzN ,gem Data 17
EXHAUST HOOD (W /DUCT)
'ION FEE
HEATING UNIT (TO 100,000 BU)
HEATING UNIT (OVER 100.000 B'I'U)
PAID
VENTI IAI']ON PAN (SINGLE RES III)
Date , van N
BOILER- )
COMP CHIP OR 100.0(1(1 BTU
TOTAL:
BOILER - COMP (OVER 100,00X1 BTU)
AIRCONOITIONER
ISSUANCE DATE
"
ISSUED BY: _ j V
NEW RESIDENTIAL MECEL SQ, FT.
T )'
OFFICE