29265 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. � � �� �
BUILDING DIVISION APPLICATION/PERMIT PLUMPING-MECHANICAL '
RUILDING PROJFLCT'IDI?NTIFICKFION
BUILDINN��DRESS: L SANTIARY NO. APPLICATION SUBMI'fl'AL DATE
3
;JlIONE
OWNETTM � IIC NO:
NIC CO/)N3'ROI.�
RGHITICllNGINE? p
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LIC NO: ADj/)R•i 7m��,�////Ly /(�/ /1 V'^✓� ❑ (, • .��
CONTACC PHONE: BUILDING PERMIT INFO
Q Consultant Fees Paid by Applicant(Initial) BLDq ELECS PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE rCrX�' y�LTT• X
1 hereby affirm that 1 am Iicemedunder provisions of Chapter 9(cm
omencing JOB DESCRIPTION
WQWZZ wish Section](1f10)ofDivision 3 ofthe Business and Professions Code.and my license is PERMITISSUANCE R -ID NTIA
{s� full Tose and etrect. 6 w1w;Z3 ❑SFDWL CITCHF,N REMODEL.
O Datc Clvss Contra JlleY
to G Date Cmmramur AI'I'LIANCES-RCSIDF.NTIAL .r ❑ADDITION 0PLUM131NC RE-PIPE
11--��prn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURALyptx�Z I understand my plans shall be used as public records MODIFICATION
O Z— UP TO 2310 AMPS
— i" Licensed Profcsinnal El INTERIOR ❑CHIMNIiY REPAIR
.i 2(ll-1"AMPS IMPROVEMENT
QaY OWNIran ,scR-BULO[R DECLARATION OVER 1000AMPS
vyy+a 6 1 hereby ufYnn thm 1 nln exempt from the Gmtrucmr'x License Law lie In, ❑HATH RI?MODEUREPAIR El DEMOLITION
bd ali U following remon.(Section 7011.5,Businea.and Pfofessions Code:Any city m county SIGNS ELECTRICAL. El OTHER
YY1l LLO t; priwhich requires a pcmut m rnnuwn,alter,improve,demolish,or repair vny swcmre
F i-v� or wits issuance,also requires the vppiicam for such p<rmino fileasignedsm¢meot SPECIAL CIRCUI'UM1SC.
y
that he is licensed pursuant the provisions ofthe Contractors license law(Clupter9
00 (commencing with Section](MkB of Ddvislan3 ofthe Business and Professlnns Code)or TI!MP.METGR(JK POLR INET. COMMERCIAL:
d ea that he x exempt thmefrom and rhe basis for Lha alleged exmnplinm.Any violanion of
+ -,N Seetion7031.5h any applicant for El NEW RLDG/ADDITION ❑DEMOLITION
y permit subjects the applicant penally of IN)WI?N DEVICES ❑TENANT ❑FOOD SERVICE:
= y not more than five hundred dollars($500, '
[I SWIMMING of she pmpcny,nr my empinyecswith wages as their s�lemmpensation, SWIMMING POOL ELECTRIC IMPROVEMENT
ae0 will do the work.and Ne structure isno.intemdedmoRered for side(Sec.J(R4,Business _ ❑OTHER
� m and Professions Code:The Contractors License Law does not vpply to an owner of )UTLETS-SWITCIIES-FIXTURES
property who builds or Improves thereon,and who does such work himself or through -
- his own employees,provided Not such Impns,cuu is arc not intended or offered for NI!W RESIDE'N'TIAL HLECTR SQ FE
sole.IL however the building or improvement is sold within one year ofmmpletion,Ne SQ.f?.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for no-
pose of sal,.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to AL. pee n A
nmwn the p Ject(Sec,]1144,Rminess and Promeni.ns GOc:)The Contractor',,LF I- P T
cense Law does not apply to anrwn,'of prnpeny win.baildsor imp...eslimmon,und QTY. PLUMBING PERMIT FEE r
who contracts for such projects with a conammou(s)licensed pursuant o the Contractor's ��� ek G ����
License Law. PERMIT ISSUANCE
C]I em exempt under Star. ,B&P C fonhis reason
ALTER-DRAIN&VENT-WA'r13R(PLA)
Owner Dme CitI Vf VVi`ALU(?TI�N
mmae,WORKER'S COMPENSATION DECLARATION RACK FLOW PNOfECT.DEVICI? 1y �g)�/kik
Ihandwillreby maintain a penalty of e of Coneneoflhefollawior declaration. _`0 `vV
.Dihave and will maintain etion 37M of he LabrCrudensure for Comper- DRNNS-FLOOR.RWF.ARfA.COND.
sation,mshichmJ(peby Section 37M of the labor Code,for the pertomrance of the - STORIES TYPECONSTRUCTION
w rk forwhich thispermitis issued.- PI%TURES-PCR'fHAP `
❑1 have and will maintain Worker's Coat
ante of
w Insurance, h require)by Section '
My Workef the r's
Censatin Insurhe ance
cancerddPolicyforwhich this permit is issued GAS-EA.SYS'TF:M-I INC.40U'TLE'I'S OCCGROUP MIN
Co Worker's Compensation Insurance wmeroli Policy number am:
Carrier. Policy No.: OAS-f:A.SVS'IPM-OVER 4(FLA) -
CERTIFICATI!OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEUNDUSTRL WASTE INTERCEPTOR
TThis section need not he completed if the permit is for one hundred dodo n(SI(I0) BU11. ISION FOES
or less.) GREASETRAP� PIANCHECK IT
.r
toy any thatPerson
the performaany
nce rIn the work for which this the it Wrkes'Confirm- SEWER-SANITARY-STORM EA.2W Ff.
' not employ any person in any manner sat 1s m become subject the Workers'Cnmpen- ENERGY D?E 1 - 7
0 sation Laws of Califomia.Date WATER HEATER WIVENT ELF.CR
Z . Applicant GRADING F
w+� NOTICE'1'O APPLICANT:If.aper making this Ceninepe of 17,sounion,you should WATER SYSTIiMffREATING
aFr become subject to the Workers Compensation pbo
mvisions of the Lar Code,you most SOILS F 3.
Ya forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE
5
CONSTRUCTION LENDING AGENCY Z NEW NTSIDENTIALPLMB. SQ.FT. PAID
V p work
which
that mouth i iswed(See.3Wending agency for performance of Dme Receiptk
-� F the work for which thio permir I.iasaeJ(Sea 3(19],Cie CJ -
Lenders Nunn, pq to
Lender's Address L • TOTAL:
S1 certify that 1 have read this application and nam that the above information i. BUILDING F 7. YL ra
Iqcorrect.I Per m comply with all city and..myordinances and state laws adia ng m QTY. MECHANICAL PERMIT FEE
U 71y building construction,and hereby authorize representatives ofthis city it)enter upon the SEISMICF !
above-mentioned fampeny 1'o,inspection purposes 1117RMIT ISSUANC17
(We)agree to save,indemnify end keep haonl,ss the City ol'Cuperlino almost EL RI
liabilows,judgments,costsundexpenses which may manywayeccmc against said City ALTER OR ADD'TO MECH. -
consequencein of the Roaming of this permit, PLUMBING FEE
APPLICANT UN TAN ' D WILE/COMPLY WITH ALL NON-POINT AIR HANDLING UNITUO MAXICFNH
SOURCE REO T MECHANICAL PEE
�a7 AIR HANDLING UNIT(OVER 10,M)OCFM) CONSTRUCTION TA
Signa re Ii aY/ Ls r le EXHAUST HOOD(W/DUCT) HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicantar future building acepant same.,handle hazardous nournil HEM[NO UNIT(TO 1041%0 BTI))
m defined by the palmation Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(1)", /3 HI?A'fING UNIT(OVER Ioq(Nl()WE Of
El Yes VVINo
//VV VI3M1'ILATION PAN(SINGLE RCSID) PAID
Will the applicant or furore building occupant use equipment or devices which Date R im N
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(JHP OR 100,000 BTU)
Disuict] _ n� BOILER COME' IM - 'TOTAL:
❑Yes
. . \ter l�'.O - MID BTU) .
I have mad the haza(rJdouss"-ntarmt,requirentems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE '
forma Health&Sam,,Code,Section.25505,25577 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does rot currently have u tenant,that it ms oy re,fansibiliry to nmify the acupant
of the requirements which must be met prior m issuance of.Certificate of Occupency.
r ,
Owner or authorized agent Date TO L: a
ISSUED BY:
OFFICE