29223 (2) APPLICANT TOTILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT, PLUMBING-MECHANICAL 29223
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATF.
PHONW COMi''R C" NAME.:- IAC NO:
13 ��G
o
GNIC CONTROL R
�IRCHITEC,rENGINEER: LIC NO: ADDRESS: ❑
CG CT.- PHONE: ^� BUILDING PERMIT INFO
�\ ❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ C� ❑
LICENSED CONnsed under p DECLARATION QTY ELECTRIC PERMIT FEE
1 Hereby affmti that 1 an licensed ander rrnvixntna of Chapter v(commencing JOB DESCRIPTION
Matz with Section 7000)of Division Softhe Businessted Professions Code,eodm license is
�DO i y PERMIT ISSUANCE RNID NTIA r
in force and eel.
aUI"' License Cl — Lie.a ❑SFDWL ❑IQTCHEN REMODIiL
f-Z Date Crmncmr API'LIANC[S-RESIDP.NTIAL 'LL�af�J_y{t'xd'
m64 ❑ADDITION BING RE-PIPE.
CHITF.CTS DECLARATION ❑MULTI-UNIT STRULTURAE,
CZ�a lundresidal try plans shall bet..daspubliv([cord's ' PANE?IS
MODIFICATION
UPIO 200 AMPS
AiF�1"� Licensed Professional - ❑INTERIOR CHIMNEY REPAIR
2 OWNER-BUILDER DECLARATION 2111-100 AMPS IMPROVEMENT
E
W 6 1 hereby affirm that I am exempt from the Contractor's License Low for the OVER H")AMPS ❑BATH REMODEUREPAIR El DEMOLITION
6X 3 L V following reason.(Section 7031.5.Business and Professions Cale:Any city m county SIGNS ELECTRICAL ❑OTHER
LLLL1I u. which requires a permit to constrict.after,improve,demolish,or repair any structure
0 prior to its issuance,also,requires the applicant for such permit to file u signed statement SPECIAL CIRCUCOMI SC.
pN.. thm he is licensed punuart m theprovisiosofthe Contractors License Law(Choper9
00 (commencing with Section 700)of Division 3 of the lituinessnnd Professions Code)or TAME'.METER OR POLII INS'T. '
d W o M that he Is exempt NcreOrel n and the basis for the mictie exemption.Any violation of N13W /ADDITION ❑DEMOLITION
'^y Section 7IDIS by any applicant for a permit subjects the applicant to it civil penalty of POWER DEVICES
= of more than five hundred dollars(S500). . �IsiyNEyrNtT ❑FOODSERVICE
2 C ❑1,as ownerof the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC I'�;I"'VEMENT
�.� will dr Ne work,ardmadructureisnof imordelm,iffvred forsale(See.W/N.Business ❑OTHER
6 3$ and Professions Cale:no Contmcmea License Law does not apply m an ownerof OUTLETS-SWITCHES-FIXTURES
property who builds or improves Immon,and who does such work himself or through
his own employees,provided that such improvermans are nor intended or offered far NEW RESIDENTIAL.I3LECI R SQ Fr.
sale.If,howevu,the building or Improvement is sold within one year odou"Ietion,the SQ.FT.FLOOR AREA $/SQ.FT
er-builder will have the burden of proving that he did not build or I ha par- -' sI
p II
sarfsal<J.
❑1,as owner of the property,am exclusively contracting wish licensed contractors to TOTAL:
construct the project(See.7014,Business and Professions Cade:)The Contractor's Id-
cense
- AUG
13 11]QQ
c se law does not apply In an owner of peopeny who builds or improvcuhelcon.and QTY. PLUMBING PERMIT FEE
whin contracts for such projects with a confracmrts)licensed punuant to the Commences 1`7`7{1
License Law. PERMIT ISSUANCE75—C
11 am exempt under Sec, s B&PC for This reason (z',I Y Vr
ALTER-DRAIN&VENT-WAF17R FJO VYkVAL ' )
Owner Dom VALUATION
WORKER'S COMPENSA9'ION DECLARATION BACK FLOW PROTF.Cf.DEVICE
1 hereby affirm under penalty of perjury one rf the following declarations:
40 l haveand will maintain a Cenificafe of Consem to self-Ensure for Worker's Compe.- DRAINS-FLOOR,ROLE AS G,COND.
sation,as rovided for b Section 37M of the E.abtr Cale,for me STORIES TYPE CONSTRUCTION
P Y p<rlormenc<rf the
work for
have
in this Tema issued. FIXTURES-PER TRAP
❑ 1 have antl will maintain Workers Compensation lazamnce,h required by Section
My .the Labor Ord[,for the perfomtencerf the work for which this pvnnit is issued. OAS-I?A.SYSTEM-I INC.4OUTLETS DEC.GROUP APN
C.Work p a' nl came Policy nlicy number
s
Carrier Policy Nn; � d? GAS-L'ASYSTEM-OVER 411?A) a
CEkT1FICA E OF EXEMPTION FROM WORKERS' -
COMP E completed
N INSURANCE GREASFJINDUSTRL WASTE.INTERCEPTOR
(This sectiontt
nd nm be completed iOhe permit is forone hundred dollars(EI W) BUILDING DIVISION FEES
or less.) GREASCTRAP PLANCHECK FEE
1 certify thm in the any n mance of the work for e bloc this the W is.,,'C,1 shell
nowmploy any person in any manner so,as to hectare soh ttnolhe Workers'Cnm _ SEWER-SANITARY-STORM LA.2W FT.
2i mind Laws of Califomla.Dim ) pv^ ENERGY F1313
O WATER HEATER WNCN9'/IILRLTk OITAUING PLC
O
Applicant
y NOTICETOAPPLICANT:e.If.Co making thisvisios of ofE abortiodyoushould WATER SYSTEMOREA'1'INC
become subject comp m the Workers Cions or tis previsions of the Lahr Coda,you must SOILS FILE
W
forthwith comply with such provisions or this pcmtit shall Ce deemed revnkeA. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY
7 ,Z NEW RESIDENTIAL PUMP. SQ.FT. PAID
L)O work
which
thi that themerm,I isoissued
construction0[ending agency for the perfrmmnc<nf Date Receipt
W i'-t he work for which this Mrmit ix inued(Sac.3097,Civ.C) _
O L) Ider's Name TDTAl
Lencader's Address L
GI certify that 1 have read this applic.a..and sone that the above Informoart is BUILDING PCE
In correct.l agree to comply with all city and county ordinances and smte laws relating to QTY. MECHANICAL PERMIT FEE
U 2 building construction.and hereby authorize representatives of Nis city to coercion the SEISMIC FEE
` above-mentioned property,for inspection puryoses. PERMIT ISSUANCE
(We)agree it)save,indemnify and keep harmless the City of Cupertino against ELECTRIC TLE
liabllities,judgments.cosis and expenses which may in any way acerae against said City AMER OR ADD TO MGCIi.
in conmqpermit
uctum of the granting of this per . PLUMBING FF.E
APPLICANT UNDE.RST NDS AN ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Ig00 CPM)
UI '
SOl kCE REG . al, MECHANICAL FEF.
AIR HANDLING UNIT(OVEN 10,000 CFM) CONSTRUCTIONTAX
Signa�Appli<anUComrau. Dmc EXHAUST GOOD(WR)UCT) HOUSTRUCTI NTAXNFEF.
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant score rehandle hazardous material HEATING UNIT(10 110,010 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sectio.25532m)? HHA'I'ING UNIT(OVER 1(0,(g0 BTU) -
❑Yes I ON.,
VIENNA LAI'ION PAN(SIN01.13 RES ID) PAID
Date Receipt Will the air contaminants
vinfmure building oveby the Buse equipment Urdeviceswhich BOILER-COMP(3HPOR Iq),01OBTU)
nit hazardous air ronmminants az defined by the Nay Area Air Quality Management
District? TOTAL:
❑Yex nNu BOILER-COMP(OVER 103.000 BTU)
I have read Ne harvdous materials requirements under,Chafer 6.95 of the Cali- AIR CONDITIONER
Chapter ISSUANCE DATE
buiforliHealthnoSafety Code.
ea tina 25505,is 533 in) and25534,1 to nobly
thatifthe NEW kIiSIDLNTIALMGCfI, SQ 17.
oftheng dare not an,.1in ly h nom No mem.that it is my responsibility to @e occulpparry, -
ofthe requirements which man he met prior m issuance nl1 Cenificme of Occupancy.
Owner or authonud ngem Dam TOTAL: ISSUED BY:
OFFICE