29308APPLICANT TO FILL IN INFORMATION WITHIN RED LINES •USE BALL POINT, PEN ONLY' •'" -:`'-i
CITY OF CUPERTINO BUILDING - ELECOUCAL
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING -MECIIANICAI.
BUILDING PROJECIL IDENTIFICATIO
PERMIT NO. O
,
BUILDINGADDRESS:
I SANITARYNO.
APPLICATIONSUBMITI'ALDATE
21 7 —q
OWNERNAME: 1'H(1NE:
l NI'S
C(
t" LIC NO'.
N/C
COM1TROLP
❑
�)
/ G�I
rpw..N J LIC NO,
ADDRESS:
CpSEALT; PIroNe:
❑ Consultant Fccs Paid by Applicant (initial)
G BUILDING PERMIT1�/O-_/Ct%/l
BLDG ❑ PLUMB LDMB 1LC 1
2
G ❑
LICENSED CONT'RACTOR'S DECLARATION
T ndtdnv arrmn that I am licensed ander Prwiaon, of ennpnT v ¢ammenemg
QTY ELECTRIC PERMIT, FEE-
JOB DESCRIPTION
`
PERMIT ISSUANCE
wish Section 700prcd ion Sof the Braine licenuis
in full force and cff t.
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
APPLIANCES - RESIDEN PIAT.
PANELS
Licen Iss Lic.p
Dmc Centmcun
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
(D ADDITION ❑PLUMBING RE -PIPE
❑MULTLUNIT ❑STRUCTURAL
MODIFICATION
UP TO 200 AMPS
❑INTERIOR C1 CHIMNEY REPAIR
IMPROVEMENT
El BATH REMODEVREPAIR (]DEMOLITION
[]OTHER
LicensW ProficAm al
OWNER -BUILDER DECLARATION
m exempt from the Cotncmth
1 hereby affirm that I am ev License Law for e
following reason. (Section 7031.5• Business and Profesnimns Code: Any city tar caunry
201-100EAMPS
OVER ]"AMPS
SIGNS ELECTRICAL
which traders a peanut to construct, alter, improve, demolish, or repair any saucinrc
SPECIAL CIRCUIT/MISC.
prior to its assume, alma requires the applicant for such permit to file a signed statement
Inas he is licensed punuanuo the Provisions of the Contractor's License Law (Chapter 9
TEMP. METER OR POLE INST.
CQ�1:1 )�.
(commencing with Section 7") of Division 3 of me Business and Professions Code)or
that he is exempt metefmm and me basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDGION ❑ DEMOLITION
POWER DEVICES
Scetion7031.51w any applicant for a permit subjects the applicant to a civil penalty of
not mare than five hundred dollars (S30(1j.
❑Los owner of the pmpeny, or myemploys maim wages as meirsole compensation..
will do the wort aed me structure is not intended oroffercd for safe (Sac. 70.14. Business
NANT FOOD SERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
�•
UTLETS - SWITCHES - FIXTURES
oral Professor. Cade: The Cia aanors License Law does not apply to an owner of
property who builds at improves thereon, and who does such work himself or through
his awn employar, provided that such impnwem ons are not intended or offered for
We. IL howeven meboildia,murnprwarmot is sold withinone yeerofmmpletlon.the
owner.builder will have me burden of proving that he did But build or improve for par-
poseafsalc.).
❑ I. as owner of the property, am exclusively remaining with licensed comentom t
NEW RESIDENTIAL ELECTR SQ FT.
SQ. FT. FLOOR AREA
^M,
da.�
VSQ. FT.
im
wily., me Find., (Sec, 7044 Business and Professions Code) The Convectors L'
rde Taw does ata apply to an owner of Propcmy who builds or Improves thcaon, andpPLUMBING
who cohtr.tsfor such pmjenswtthaconvanonsllicence pursuannotheComanors
E3 lam�mquNar Sec. ,B&PCformnrcasan
-
C �j Q
FEB 15 ICJ s.I CV
PERMITY
b`i"a,"4us..-.-. e.e, as.+Lasix' ._s<
PERMIT ISSUANCE
Owner Dete
ALTER-DRAIN&VENT-WATER (EA)
7IIS •,JI` V �a
�`ayVrl
WORKER'S COMPENSATION DECLARATION
1 hereby aBum under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insum for Warkers Compen-
.tion, . pmvieed for by Section 37M of the father Code, for the Performance of me
wssued
BACK FLOW PROTECT. DEVIC
DRAINS- FLOOR, ROOF. AREA. C
STORIES TYPE CONSTRUCTION
FIXTURES - PER TRAPfarehichorw1
. x Compensation Insurance, as equimd M Section
navandwlsmtnsWoh
of the Labor e, Qc me performance of the work for which this permit.. issued.
GAS - EA. SYSTEM -I INC 4 OUTLETS
OCC. GROUP APN
M u IcInsurance cam's end Polly
Cama `��/ Poliq'Nd��
GAS - EA. SYSTEM -OVER 4(EA)
CERTIFICATE OF EKESIPHON FROM WORKERS'
COMPENSATION INSURANCE
TDtissection need not be asmplaWif the permit is fm one hundred dollars (SI(gI
or lessl
GREASFIINDUSTRL WASTE INTERCEPTOR
-.. F .
('h`i`2A_ y.:'r BUR.D_ EIISIONFEESI4%' , ;.,,i -n
GREASE TRAP
PLANCHECKFEE
Icenify that in me pdrfonwnoeofthe workfor which thisPmnitis issued. l shall
ata employ any person in any manner so as ns become wbjen tome Workers' Cmpm-
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEE 2 �
WATER HEATER WNENT/ELECTR
cation Laws of California. Date
Applicant
GRADING FEC
NOTICE TO APPLICANT: If, afar making this Ccmifcam of Eumpdon, you should
became subject to the Workers Compensation provisions of the Labor Code, you must
WATER SYSTEM?REATING
SOILS Fla
foMwim comply maim such Provisions or this permit shall be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby aRrm that mere is a construction [ending agency for the Performance of
PAID
ate Recnpta
NEW RESIDENTIAL PLMB. SQ. PT.
Ne mark for which this permit is issued (Sec. 3W7. Civ. C.)
landet's Name
TOTAL:
Iaada`,neem„
TOTAL]
,
BUILDING FE �s
I carify that l have read this applicainn and nam that the above information is
QTY.- MECHANICAL PERMIT FEE ^
SEISMIC FEE 2
men. l agree to comply maim all city and county ordinances and state laws relating to
Wildine mmmortimm. and hereby smhomd repre,emutLa, of thisci, to road, uqm dm
1'T:R\IIT ISSUANCE
ELECTRIC FE
abase -mentioned proPcny for m%traction pumoses.
(Wet agree to voe, indemnify and keep harmless the City of Capdrmo apamst
ALTER OR ADD TO MECIL
PLUMBING F - i
habilides.iudgmems, costs and expenses which may in any way accrue against said City
in nsequence of Or granting of this permit.
AIR HANDLING LLNIT('IO IO0flX)CFM1
M1fEC11ANICAL liE
APPLICANT UNDERSTANDS AND %\ ILL. COMPI.Y WITH ALL NOS -POINT'
SOURCE REGGL:\TI(l\S
AIRHANDLING UNIT(OVER I0,Xa1CFSf1nBY.
Signature of Applica/Consmctir Uwe
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD M•/DUCT,
EE
HEATING UNIT TO 1!X1.000 BTU)
Will the applicant or fmure building occupant start or handle hazardous material
as defined by the Cupeni Mu :pal Coda Chapter 9.12, and the Health and Safety
,
Code. Section 25512(gT _
HEATINGUNTTfOVER IW.0000TU)
mit ch
t or lity Management
nt on Bay A.
hazardous air contaminants as defined ny the Bey Ama Air Quality Management
Wedousll the applicant infuturebuilding occupby
inrinT \ ,
I]Yu
N.eipta tin
VENTILATION PAN (SINGLE RESID)x
BOILER- COMP THP OR 100.000 BTU)
BOILER- COMP LOVER 100'. BT U)
AIR CONDITONER' '
.
L�"_`_-Y/ F
Ihave&Safet s serials rtquirtmen4`underChapta 6.95 of the Cali-
ATE
NEW RESIDENTIAL MECN. SQ. FT..
fertile Hralm &Safety Cotle. Sonans 25505.25533 and 25534. I understand that if the
'Rn seta t hav lthmit ism ItsiMaybe, 'fy the pant
f h r of s Cmifi
Owner ar antnorirN agent Data
OFFICE