29361 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELHLT'RICA1, _ - PERMITNO,f..
BUILDING DIVISION APPLICATIONIPERMIT ' PLUMBING•MRCHANICAI.
BUILDING PROJECT(BEST IF'ICATION ^
SANITARY APPLICATION�SUBMITTAL DATEBU7ijg
ES:
OWKK SL $ NfiCSW ME
V�te—_ .1 .—� N/C CONTNULM� 4IT
( ARCHITECT/ENGINHF.R: - LIC NO: AD ROSS s
CONTACT: g PHONE. BUILDING PERMIT INFO
. .• . ❑
Consultant Fees Paid by Applicant(Initial), BLDG ELECT PLUMB MECfI
" LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm shat I am licenxd under provisions of Chapter 9(commencing LOB DESCRIPTION
�aZ with Sation 70011)ofDivisionl of the Business anJ Professions Cnde.and mylicenx is
IyOp is I'ERMI'I'ISSUANCE RESIDENTIAL:
~W[= full force tuW eff - ❑SFDWI. ' ITCHEN REMODEL
L�F..UU License Class Lid.p a A APPLIANCPS=RF_SIDENI'IAI. t
ra<i Dme Commnor '` .�•e ❑ADDITION ❑PLUMBING RE-PIPE
11••.. > ARCHTri=s DaCLA ION PANELS ❑MULTI UNIT ❑STRUCTURAL
Z pm❑ ,,1,mderatand myphms,fact M:useJ uv public rcenNs : "'" 's' ' ��• MODIFICATION
OZYJC - - UP T02W AMPS 0INTERIOR ❑CHIhINF.Y REPAIR
F��W Licensed P¢teuimtal '201.10(10AMPS IMPROVEMENT
9y _1 OWNER-BUILDER DECLARATION OVER100DAMPg � ' - ❑BATH RIEMODBVRF.PAIR El DEMOLITION
W I heathy affirm that I am exempt frain the Contractor's License Law for the
l+l LLa V following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
0 F- which requires a perm,to construct,alter,improve,delnrlish,or repair any suburban,
m
prior to its issuance,also requires the applicant lot such permit m file a signed statement SPECIAL CIIICUIT/MISC. ial—
III•^�^�^�,,, ps
,but he is licensed puh%uam to the pnwisiam of the Contractors License Law(Chapter 9
(commencing with Section 7")of Didision 3 o the Business and Professions Codd)or 'I EMP.METER OR POLE INST. - - '
a M C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW B G TION ❑DEMOLITION
Y• Seltinn 7031.5h an Ii'ma forupennn adijemx,hu upplicmn,tn a civil penalty of POWER DEVICES
�y y hundred t ` ❑TEN "C FOOD SERVICE
FZY
not more than liv<hundrcd tallest,l$SW). IMP OVEMENT
a0 ❑1,in owner of the propcry,or my employees with wages ax their sole compensation. SWIMMING POOL.ELECTRIC
wi 11 do the work,and theatrocmre is not intended moffertd for sole(See7D34,Business - ❑OT�I
da and Profession,Code: The Cn.hactor's License law does ma apply man owner of OLD LEIS-SWITCH ES-FIXTURE$
a' .. property who builds or improves thereon,and who does such work himself or through - h
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECIR SQ PI'. P
sale.If,however the building or improvement is sold within oneycm ofeampktimh,she - SQ.IT PILLAR/gR�JF'1� $/SQ.T'L
er-builder will have the handed of looOd,that he did nm bai".r improve for par.
pnm.f sale.). IWAR, 4 199
01,as owner of the pmpt am exclusively contracting with licensed contractors to .TOTAL:
mwm the project(See 7044,Ila>ineas and Podc,,in 11 Code:)The Contr.mors I., /sT��
cense Law does not apply to an owner of property who builds or improves,hereon.and QTY. PLUMBING PERMIT FEE? ITY.Ur UUt`'EHIINO
who contracts for such projects with a canwemct licensed pursuant to the Cannot
License Law. - pERMITI55UANCE '
I nm exenpt under Sec. ,B&P C far this reason �.
AI TER-DRAIN&VENT-WATER(EA)
Owner DaVALUATION
Dole
WORKER'SC(IMPENSAI'IONDECIARATION BACK FLOW PROTECT.DEVICE /''q/,.)
I hereby affirm under penalty of perjury one of the following declarations: ,O vv
•� I have and will maintain a Certificate of Crnwnt mself-insure for Worke%s Comped- DRAINS
-FhWR,ROOF.ARCA.COND,
station,as powhIM for by Section 3700 of Ne Labor Cade,for the performance of the sToRAS TYPE CONSTRUCTION
work for which his permit is issued. FIXTURES-PER TRAP'. s (h
❑I have and will maintain Worker's Compendom Insurance,as required by Section -
3700.17the Lades Cade,for the pedonmmhce fthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
OCC.GROUP APN
My Workers Compensation Immanence canicr ad nPolicy number are: -
Currier: PNicy No,: GAS-EA.9VSIEM-OVBR4(EA1- •, ..
CERTIPICATE OIr EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRPASFIINDUSTRL WASTE INTERCEPTOR
(This xetion need..'be,c.mlletetl ifthe permit is nature hundred dollars($100) - BUILDING DIVISION FLEES
GRIEASETRAP -
ur less) " - - '' PLANCHECK FEE '
I certify that in the perfmmonceofthewohfmwhicb this permit is issued,lshall SRWPR-SANITARY-STORM FA.200 F`K t
nm employ any rson in any manner,so as it heeanre sobjeeu.the Walken'Comped- ENERGY FCR
M
,� smiin Law,. ali(omi: to _� - - ' WATIER HEATER WNHNI/LLF.CI'R
Applicant GRADING FEF.NOTICE TO P L a0er m •this Cenificat .f En npti. ,you sthould WATER SYS'fEMITRFATINGbecome subjectI.the Worker's Comp ' ton provisions of the Labor Code,you must SOILS fnnhwi,h comply with xsh piavisi.n,. hinpermit shall ba deemed revoked. WATER SERVICE'
P. Q .
CONSTRUCTION LENDING AGENCY NEW RESIDIENTIALPLMB. •SQ,FT. PND
U 0 Iherchy affirm th.nhere isaamstroctiun lending agency for the Perfonnunce of D e cceip,X
the work for which this Permit is Issued l b.3097.Civ.C.) -
"�ULender's Name TOTAL: '
(2I Lenders Address
G I ccnify that I have read this application and state that the above information is BU11.DI f1k. �•
N correct.I ogre. ,,comply withal)ciny ad.,act,mckmmces and ewtu laws relating to QTY. MECHANICAL PERMIT 1 FEC - O
U Z Famidingcunstria,ion,and hereby awhorize rupmsenmtivcs of this city neenterulmn the SEISMIC FEE t
annvoment.ned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamdess,he City of Cuperino nlimi st ELECTRIC PER
liahilities,judsmems,emu mdezpenses which may in any wayaccrue against said City ALI'ERORADDTOMECH.
in consequence of the granting of this permit. PLUMBING PE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO IO,oct)CPM)
MECIJANICAI FEE #1'
SOLI Rp t 10 9.
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTI)NTAX
.hg.amFeof Applic.iLCot dor lam EXHAUSTHOOD(W/DUCT) t�
HA% )OUS MAI BILL ALS DISCLOSURE SING MH'IGA PCE'
Will the applicant or future building occupant store or handle hazardous materials HEAPING UNIT TO 10IDd010 BT U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilcmlth and Safety
Cade Section 255320.)7 i HEATI NO UNIT(OVER.I 00,01 BTU) +,
❑Yes "714a VENTILATION FAN(SINGLE RESID) PAID
1,11 the applicam or future Willing aacupant use equipment or devices which '' Date Ree
mit hazard h rs air cam comma,io defined by the Bay Area At,Quality M re,emeIP -
m BOILER (3HPOR 100.000 OTU)
,.. �Dlatr cin 1v BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑Nn L:
I have read the huanNnus mmeriale m uirtmenrt antler Chapter 6.95 of Thu Cali- AIR CONDITIONER '
4 p ISSUANCE DATE
fomin Health&Safety currently
have
Sections 25505,25577 Zmale,p 25574.I understand that if Ne NEW RESIDENTIAL MUCH. SQ.Fr. _ �\
of
buildingr "m a m an,which am"aromas, o,I.is my mspI.CediO to notify exmsccopant
of the requirements whicham"tc inn prion.i.aunnee nl a Cenifca¢of Occurynhcy.
' Owner or authorized agent Date ISSUED BY:
OFFICE 1 .