29209 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECT RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 29209��O n
BUILDING PROJECT IDFINTIFIC "'ION J
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMI'ITALDAI'E
a, R VV
.OWNER' M[ 'HONE: C R'SNAME: LIC NO: NIC CONTRULg
`cam/ 3aa 6
RCu1TECT/ENGINEER: LIC NO: A> r/C L� �/y �-- ❑
CONT CT: PHONE: G BUILDING PERMIT INFO
��h'\ /'7L�1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG f: PLUM- MECH
LICENSED CONTRACTOR'S DECLARATION✓ / QTY ELECTRIC PERMIT FEE
I hereby nffimt that 1 a..licensed nude'pmvismnn.f chapter 9 feommenang JOB DESCRIPTION
WDO wahsamon0000)nf Doision3oflhe Rn,ineasand ProfessionsCde,seed my licenseis PERNI1T ISSUANCE RESIDENTIAL;F�IyF in full once and effect. CSFDWL CKITCHENREMODEL
<—U License Claes Lic.M APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
P z w Dom Contractor
costa, [I MULTI-UNIT 0STRUC`URAI.
ARCHITECTS D17CLARATION
z FO Z 1 understand my plans shill be used as public records PANELS MOUIIHCAI'ION
�_ UPT0200AMPS
O�Catj Licensed point,hmul 201-100OAMPS CIIMPROVEMENT ❑CHIMNEY REPAIR
4s, OwNEk-BUILDER UECLARAI'ION OVER 1000AMPS C BATH REMODFi FPAIR DEMOLITION
0 C Q 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
X a U following resew..(Section 7031.5.Business and Prnfir,mons Coe:Any city or county SIGNS IiLIiCI'RICAL COTTER
which requires a permit to co moon,alter,improve,demolish,or repair say
structure prior to its issuance,also requires the applicant lot such Permit o file a sigtmdslulcment SPECIAL CIkCUI'I'IMISC.
�y 'hatheislicensedpursumuatheproviman,oflheContractorsLicenseLow(Chapubg
w2:00 (commencing with Section 7000)or Division 3 ofine Business and l'mfesmom Code)or 'I'EMP METER OR POLE INST. COMMERCIAL:
a a,M K Thar he in exempt Ihcmfmm and the brail far he alleged exemption.Any violation of BLDG/ADDI'I'ION ❑DEMOLI'I]ON
W..y Section 70315 by any applicant Icor a ankli,objecu the applicant to a civil penalty al POWER DEVICESXI
NANT ❑FOOD SERVICE
not more than rive hundred dollars(551Q). I OVEMIiNT
=p F1LmmvmroftRc,mpcny,ormy withwagc•ustheira.lccnmpensmion, SWIMMING POOL ELECTRIC
p. wdldolheworka Lift wcwrc ism Jed or offer far mile(Sec.700 LBusiness COTHER
3. and I'rofexsions Code:The Cmnrac' J: l apply to on
owner f UTl.li Ts-SWITCHEg-FIXTURES
property who builds ar improves'hemin,an ork himself or t1nmi
w
ou no
his own employees,pmv'll,1hm such impmvem is arc now' tended ser offered for NEW RESIDENTIAL ELECfR SQ FT.
sale.If,however the building.,improvement is(((mlJ yesoof aumpinion.lhc SQ.IT.FLOOR AREA S/SQ.IT.
ownerbailder will hava IM1e burdenof moving; I'-,Ji tb Jed or imp rove lbr aur
pnseaame.). \
C 1,as owner of the property,am e¢w.sively cmt with tensed commcmrs la ) ,
Conswct the project(Sec.7041.Bmim•c and Pr.fesion.Cede: he Contour....Li-
Orme Law does not apply to an owner of property who builds or Improver'hereon.and QTY PLUMBING PERMIT FEE
whocartmelsforsuch pmjoas with aconmwlm(s)licnm pumuat,.'he Cuntrecl.e,
Llcnar Law. PERMIT ISSUANCE
C 1 am exempt under Sec. .B&1'C for this reason
ALTER-DRAIN&VENT'-WATER(RA) VALUxrhTN
Owner Dam
I- WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE CZ� Oct)
Si1 1
An
I hereby affirm under prnal'y of perjury one of due following Jedatatiom: IYCJJ
I hrvrmd will ammo.a Cenificarof Cnnxenuoself-inme,for workers Cnmpem DRAINS-FLUOR,ROOF,AREA.COND, STORIES TY'E CONSTRUCTION
cation,as provided for by Section 39110 of the Labor Code,far the performance of IM1e
work far which his proam,is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Inxumnce,a.required by Section GAS-EA.SYSTEMI INCA EES
371mart aLabor Code,for the performance oflha work for which this peraid is issued. OCC.GROUP APN
artier
err clic. o 'ioutAv.uy c,.arplcr and Ynlie n u rare: GAS-EA.SYSTEM-LIVER .)
/STV Qom( Policy Nn. _
CERTIFICATE OF EXEMPT ION FROM WORKERS' GRIiAS[IINDUSTRLW EI ERCE
COMPENSATION INSURANCE BU )INGU ISION PEES
(This section need not b,compled Hun,panni'is fixture hundred dollar%(5100) GREASETRAI'
ser less.) PLANCHECKF : O YA
I cmifythat in the pemmonanc tflhe work for which this permit ix iuued.lshull SEWER-SANITARY-STORMS .2
not employ any person in any manner w as to become subject to the Worker+ te
Comps ENERGY PEE �.
,Z anion La—ul California,Dam WATER IWATER W/ Nil EL'CTR
z Q Applicant GRADING PP.
NO TICE TO APPLICANT.ILafter making thi>Cenilicate.f Exemption,you sbaWd Wq'I'IiR SYSTEM/'
h SOILS FEF
becomesubject ,,the Worker's Compcnssoion provisions of I1
forthwith comply walamich provisions.1 this pabou hall be dac cdotvoked. WATER SERVICE
Q PAID
7z CONST RUCHON LENDING AGENCY NEW RESIDENTIAL PLMB. .FT' to Recci,t#
U O I hereby affirm that then is a conslradon lending agency for performance of
I'+
the work par whichmi,pconal is issued(See.3099.Civ.C,)
Q U Lenders Name TOTAL:W Lender's Address A l
0. I certify Mal I have read Ito.,application and stain mat Me above Information i. BUILDING PLL'
tq
camera.I agree to comply with all city and county arduances and slam laws mLming to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby oulhoom mpresmnativesofinis city mentor upon the SIiISMIC FIiL
.hove-manhood property for inspection purps ex. ` PERMIT ISSUANCl: t
(We)agree to save,indemnify and keep harmless the City of C.pemn.against ELECTRIC F E
Iiabilllics,juJgmcma,coos and expenses which n:ay In any wary acmcngain.nl sail Chy ALTERORADDTOMF,CIL - PLUMBING E.F. Q
in cansequcnue of the gmming of suis a
APLICERS'1'ANUS ANI I ,COMPLY WIT'{ 1 ONPOINT AIR fIANDLINGUNIT('IO IO,IMA CPM) MECIIANR aI.I:LE
TIONS. AIR HANDLING UNIT(OVER 1B0RCFM) CONSTRU. IONTAX
anVConvu r Uate EXHAUST HOOD I W/DUC) HOUSING IITIGATION PER,
HAZARDOUS MATERIALS DISCLOSURE
Will the
...
]it it(or future building orcuparm store or handle h irmous material HEATING UNIT(TO H10.00) U)
p BT
as defined by me Culmina Municipal Code.Chapter 9.12,and the Health and Safety
Cdc,Senion 25532m)t HEATING UNIT(OVER 100.0110 BVU)
C Yes 0 N VENTILATION FAN(SINGLE RESID) PAID Dmc Receipt
Will the air conga m forum building occupant use equipment Qu or devices which BOILER-COMP(3HP OR IIXLIX10 BTU)
mil hazardous air mntaminunlx x.n dcrincJ by the Hay Amu Air Quality Management TOl'
I Elastic'' BOILER-COMP(OVER 100.000 BTU)
C3Yes No
I huvercuJme hazardous materials requirements tinder Chapter 6.95 of the Cali- AIR CONDITIONER ISSU NCE DATE
fomia Health&Safety Cade.Section,2,5505,25533 soon 25534.1 understand Thal if the NEW RFSI DENTAL MECH. - SQ.1.1.
building does not currently have atenant,that it is my respmsibility I no Iify the occupant
of the rryuiremenls which mux'he ten prior m issuance of a CeniOcam.f'r.pars,
V
Owner or authorized agent Date TOIAL: ISS DY:
OFFICE