29527 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
.CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
'
PLUMBING
,MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECT IDENTIFICATION 29527 9J27
BUILDING ADDRF. SANITARY NO. APPEICATION SUBMITTAL DATE
1 OWNER'S v Lr/ PHONE: CONT ACfOH'S NA vz CLIC NO:
—61 z -NIC C091 SOL
. =CHI /LN NEER: LIC NO: ADD I:SS: ''�cIe it C..��IC9. El75C��tr/iur Si_
CONTACT: PHoN 3: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG /ELLEEECCf T PLUMB MF,CH
LICENSED CONTRACTOR'S DECLARATIONFEF.
❑ ` ❑ ❑
I hereby affirm that I um liwnad undo provisions of Chapter(uQTY. ELECPRICPERMIT nnmenclnB JOB DESCRIPTION
O
KZ with Section'/000)ofDlvision 3 ofthe Business and Professions Code PERMIT ISSUANCE RESIDENTIAL
and my license ix
O1
WE, inense force Class
effect DSFDWL El KITCHEN REMODEL
�UU License Class Cmun - APPLIANCES-IIESIDENI'IAL DADDITION ❑PLUMBING RE-PIPE
ARCHITECTS
DECLARATION
y GZ 6 Uete - L
F.Dm ECLARATION - PANELS DMDLTLDNIT - []STRUCTURAL
MODIFICATION Z O m rZ. I understood my plans shall be used as public records MODIFICATION
OZ�D UPT0210AMPS [3 INTERIOR [I CHIMNEY REPAIR
r 4�Uii Licensed Professional 201-1000AMPS IMPROVEMENT
a F J1 dam I..exempt fr m CEASATION OVER 1"AMPS D BATH REMODEUREPAIR D DEMOLITION
y= fY a 1 hereby offimr that I am exempt from the Connector's License Line for the
ly+•7j 36 U following reaum(Section 7031.5,Business and Pmfesions Care:Any city or comity SIGNS ELECTRICAL D OTHER
W which requires a permil to consumer,alter,improve,demolish,or repair any structurey0� prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAECIRCUIT/MISC.
y That be is licensed pumuanno the provisionsof the Canrnco 's license Low(Chapter 9
Immmcncing wish Secuan 7000)af Division3 ol'the Busineu and Professions Ctde)or TEMP.METER OR POLE INST. COMMERCIAL:
d y ce K that he is exempt therefrom and on,basis for the alleged exemption,Any violation of D NEW BLDG/ADDITION D DEMOLITION
iC 4. Section 7031.5 by any applicant fors permit suhjects the applicam o civil penalty of POWER DEVICES
W-s ps DTENANT ❑FOODSERVICE
FZQnot more than five hundred dollars(5500).
D I,as owner s of the property,or my empi,obs with wages atheir sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and rbe mmcmre is not inmaded or offered for sale(See.7044,Business D OTHER
W cad Prnlesskme Code The Contractor's License Law dues not apply 1.an owner of OUTLETS-SWITCHES-FU TURES
d 3 property who builds or improves thereon,and who does such work himself or donugh
his own employees,provided new such improvements arc not intended or offered for NEW RESIDENTIAL ELECTS SQ ET
sale.If,however,the buildingor lmpn,coenrin sold within no year of completion,the - SQ.FT.FLOOR AREA
ownerhuilder wi 11 have the burden of proving that he did not build or improve for par-
posofsale.). -
1,as owner of the prnpeny,am exclusively contracting with licensed coatracturs to
.nswa the Notices(Sec.7044.Business and Professions Code:)The Commences 1,i- MAR
AR D 2 /Q
terse[caw does not apply to an owner ofproperty who builds or improves theren
. and QTY. PLUMBING PERMIT FEE Ir' 1996Q
who contacts fa such projects with a antmpursu
couri)licensed ant to the Commennes as
License Law. PERMITISSUANCE GuY UI LIUe'GTI I IIVU
❑ I am exempt under Sum. ,B&P C for'hisreason
ALTER-DRAIN&VENT-WAT I'
Owner DaVALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following de[limanon,
,•D l have and will maintain a Certificate ofCtnsenrto self-insure for Worker's Cooper. DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPE CONSTRUCTION
satin,as provided for by Section 37m)of the Labor Code for the pimira n ince of she
work fur which this permit is issued. FIXTURES-PER TRAP
D I have and will maintain Worker's Compensation Insurance,as required by Section
3700 orthe Lal, Code,lin the Par...nanceof dre work for which this permit is issued, GAS-EA:SYSTEM-1 INC,4 ourrimS
OCC.GROUP DPN.
My Wnrker'e pens Insurers artier and Policy mbeoarc'
n Policy No ` GAS-EA.SYSTEM OVER 4 BDO
CERTIFICATE 7EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASI%INDUS'FRL WASTE INTERCEPTOR
(I is section need not be completed if the p mout is for one hundred dollars IS 100) BU I LDING DIVI. TIN FEES
m less.) GREASETRAP - PLANCHECKFEB
Icandy thin in the performance ofthe work f.rwhich this permit is issued,I&hull SEWER-SANITARY-STORM LA.NO FT.
not employ any pennon in any tonne.so esus become subjecno the Woken'Compem ENERGY THE
Z satum Laws of Cnlifomia.Date WATER HEATER W/VEMUELECI'R
ZO Applicanl GRADING FEE
!'n NOTICE TO APPLICANT.If, it,,making this Certificate of L'xatnptlon,you should
WATER SYSTIiM/TREATING.
a ^ hecame sobjecuo the Wtrkcr'e Compensationprat mono;of the Latin,Cale,you must SOILS FEE
G forthwith comply with such provisions.,,his permit shall hedeentedo,,mad. WATER SERVICE -
a
CONSemisacONLENDING AGENCY NEW RISIDENTIAL PLMB. SQ,En PAID
I herebyumrmthat
permit i isacol(Site 30lending agency for the Ncrfnrnnccof 0 keceiptp
w� the work l'nr is this permit is issued(Sec.9097,Civ,CJ
O U Lendces Name - TOTAL:
Lender's Address TOTAL:
yI certify tint 1 have read this application and note that the above inrnrmutinn is BUILDING 5
h correct l agree to comply with all city and county nNinancesmal Imre lawsrclmingm QTY. MCCHANICAL PERMIT FEE
U Z building construction,and hereby authorize repreeematives tfthis city to enter upon the SEISMIC F17.
above-mentioned Ptolemy for inspection purposes' PERMIT ISSUANCE(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
IiabilitieS,judgmems.costs and expenses which may in anyway acame against said City ALTER OR ADD TOMECIL
in consequence of the Seaming of this Permit. PLUMBING FEE
'APPLICANT NDERSTA ID AND WIL OMPI \' 'H ALL NON-POINT AIR HANDLING UNIT TTO 10.000 CPM)
$ Ce =1 TO
MECHANICAL E
AIR HANDLING UNIT(OVER W."CFM) CONSTRUCTIO 'AX
Sj are of Applicanil m mcmr Date EXHAUST GOOD(WIDUCT) HOUSING MITIGA' ON FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the up'remn nr future building occupant more nr hanJlehmardoun materiel HEATING UNIT(TO IW,IgO BTU)
as defined by the Cupertino Municipal Cale,Chapter J.12,and rhe Health and Sul'ety
Code,Section 255321a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes Fl N. PAID
VENTILATION PAN(SINGLE RESID) Date RmdptI
Will the applicant or future building occupant use equipment or devices which
cordo haeardous air contaminants as defined by she Bay Area Air Quality Management BOILER-COMP(JHPOR I00,000BTU)
Orono? TIAL'
❑Yes 7N
BOILER-COMP(OVER 1110,0011 Ii'1U) -
I have mad the hazardous materials tuniremems under Chatter 6.95 of the Cali AIR CONDITIONER
I p ISSUA EDATE
fomiaHealth,dews&Safety dylCame,Sections25505,is 533 myand25534.1ilit, cunt,th thatifthe NEW RESIDENT IAL MECH.' SQ,IF.
huildi redoesnae.,whit yhave a,met that it ismyeofir luifiNenfythestin,
of Ne rtquiremenu which must be and Flri.r m issuanm of n CeniR<ase of Occupanry.
Owner maathodzW agent Date TOTAL: ISSUED BY: — a�
OFFICE