29091 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PRRMIT PLUMBING-MECHANICAL
BU �O9aI
BUILDING PR W EcT IIFNTIFICAT1
ION
IILDINGAUDRESS' SANT"1'ARY NO. APPLICATION SUBMITTAL UAL'
ZZ GZ o 1'�-�Fl�l'S
CRS NAME: ` PONE: CONTRACTORS NA. li� LIC NO: ��
N/C CONTR///O���Lp
occRC i1T1;Cf/f:NGINEER: Ca �I 6 AUI RESS; I ❑ { (aO O
CONTACT. PHONE: qh C.CkPIOS (, q-1110-Tv ILDING PERMIT INFO
1
&A2
_ ^ iva E:1CunsUllant Fees Paid by Applicant(Initial) nLl m.iC4 PLUMB MECH
UCCNSED TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
X410 with See ion 90ID1of Division 3oflhe Baninex and Pr..cesionx Cndc,andmn Berase ix RESIDENTIAL, _
f4�11 O p PIiRMI'I'ISSUANCE
F+ly full Class
effect. (mak-�'L`fib ❑ADITI ❑KITCHEN
�ZW
License Cross Lica W gpPL1ANCFS-RCSIDE,YI'IAL []ADDITION ❑PLUMBING RE-PIPE
sF<amule Cummclor
ARCHITECTS DECLARATION
El MULTI-UNIT ❑STRUCTURAL.
p.7 y PANELS MODIFICATION�Z p y Z I unJersmnJ my plans shall be u.eJ ae public records
OZ ITIO 200AMPS El INTERIOR -1 CHIMNEY REPAIR
P-4Fty Licensed Professional 201-IUOOAMPS IMPROVEMENT
C Q 1 hereby affirm that am BexempthfrumDECLARATION
the Contractor's License Law fm the OVER 1000 AMPS [IBATH REMODEUREPAIR 0 DEMOLITION
EowUF following mason.(Section 7031.5,Business and Pmfexsinro Code:Any city or county SIGNS ELECTRICAL El OTHER
413 LL N which requires a permit to comuuct alter,improve,denadish,or repair any structure
F'1�0-1 prior 4)its issuance,also requires the uppllcant for such pcount to file a signed statement SPECIA I,CIRCUI'1/M ISC.
ythat he is liansal pursuam mthe pmvisinnn of the Commdors license Law(Ch ¢
4�1�00a (commencing with Section 900()of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST.
a a e 4 that he is exempt therefrom and the basis for the a1k6cJ exemption.Any violation of W BLDG/ADDITION ❑DEMOLITION
' my
Section 7031.5 by any applicant for a permit xubjeds the applicant a a civil penalty of POWER DEVICES ❑TENANT 0FOOD SERVICE
Spnot nmrc than Five hundred dollars($500) IMPROVEMENT
❑has owner of the prory:ny.or mY empluYccs with wages as their sole comcensation. SWIMMING POOL ELECTRLC ❑OTHER
F. will do the work,amt the suueurt is not intended proffered forsale(Sec.9—Business
4�1 m and Professions Cade:The Comvcmr's License Ww does not apply to an owner of OUTLETS-SWITCHES-FIX' S
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not amended or offemd for NEW RESIDENTIAL Cl SQ ET.
sale R;however,the build ingo,imp rnvitamin kond sithinore yemrnfcontpeioa,(be SQ.FT.FLOOR BA $/SQ.I'll
ownsar-builficy will have the burden of proving that he did not build or improve far pun 6q,oO00,qo
pose of sale.).
❑Las owner of the pot am exclusively contracting with licensed contractors to TOT
construct the project(Sec.7044.Business and Professions Code:)The Comracmfs Li-
ceree Law docs not apply to an owner oP property who builds or intprovcs thecon,.,,it QI'Y. PLUMBING PERMIT kV TW
who remove,for such projects with a conlmcmr(s)licensed pursuant the Comracmex
License law. PERMIT ISSUANCE
❑dam caampt under Sec. ,B&P C far this maven
ALTER-DRAIN&VENT-WAl'Ell IEA) VALUATION
Owner Dole -1-7-1-7 lqq
WORKI?H'S COMI'13NSATION DECLARATION BACK FLOW PRO'fIeCT.DEVICE
I turner affirm under penalty o(perjury one of the following declarations:
I havevndwill mainmina CenificamofCousem m selGinsurefor Wmkcrs Compete DRAINS-FLOOR.RUDE AREA,COND. STORIES 4 TYPECONSTRUCTLOt
scion,as provided for by Section 390)of the Labor Code,for the performance of the
work for which this Noun is iaueJ. FIXTURES-PER TRAP
0 Ill...and will and main Worker's Cnnmcnxalion In amines.as acquired by Section
3710 of the labor CNc,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS ()CC.GROUP APN
My WorYer'a Compensation sumnceyamer end Poli, n ta1Nr '
T Cartier. J Policy Nn.. kA/iksuGAS-EA.SYSTEM OVER 4IEA)
1 CERTIFICATE OF EWPIION FROM WORKERS' GREASEIINDUS'I RL WASTE INERCE"OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('Ibissectionnecdnot Mcnnsnemo ifthc pemmin is Future hundred Jollas($100) CREASE TRAP
or less.) PLANC111iCK IEE
I certify that ionic performance^f the work for which this permit is ixmi l shall SEWER-SANITARY-STORM EA.201 FT.
not employ any person in any manner en as to become subject o the Workers'Compete ENERGY FEE
Z mime Lawsaf Culifianum.Date WATER HEATER WNENTMLECTR
z O Applinant GRADING FEE r
h 7
NOTICE'1'0 APPLICANE If.after making this Ccr ificam of Exemption,you should WATER SYSTEMaREATING
become subject to the Workers Compensation provisions of the Labor CNc.You must SOILS PER
forthwith comply with such previsions or this pxnnitshall M deemed rtvuked. WATER SERVICE
a CONSTRUCTION LENDING AGENCY NfiW RESIDENTIAL PLMB. SQ.FT. PAID
UO 1 lmmbyeffrm thorn there iso construction lendr,ageney fur the performance of Dam Rcceiptp
LL P the work for which this permit is issued(Sec.3099,Civ.CJ
TOTAL:C) U Lendels Name
TOTAL:
W Lender's Addrtxs
a man]ecrify that I have rethis application and state that the ahwe information is
BUILDING FEE
N comm,t lugme to conmply with all city; it rountyoNinaness and smle laws relatingto QTY MECHANICAL PERMIT FEF;
U Z buildingcunswction,and hereby amborim represenmlivesofthis city memer upon the SEISMIC ItiE
aMvumentioned property for inspection purpi PERMIT ISSUANCE
(We)ague to save,indemnify end keep hurnakw the City of Cupertino against ELECI'ItIC FEE
liabilities,judgments.costs and expenses which may in any way acerae against said City ALTERORADDTOMECH. PLUMBING FEE
in nmmcqucnce of the grinning of @Is
fiction.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,(XXICPM) MECHANICAL IEE
SOUR SGUL TIONS.
10--1 _9 I0 AIR EXHAUST LING HOOD UNIT(OVERIO.gp CFM) NSTRUCfION TAX
Signumm ppimm ntmcmr Uvte EXHAUST HOOD(WIDULT) GUSING MITIGATION FEE
HAZARDOUS MAI'11RIALS DISCLOSURE
Will the applicon or future bulldinicupanl smrc or handle hvardous material HEATING UNIT CII)100.010 BIU)
as refined by the Cupertino Municipal CNB Chapter 9.12,and the Health and Safety
CNc,Sccnion 25532(a)'I HEATING UNIT(OVER B0A00 BTU) //yy
❑Yes 0 N PAfld
VENTILATION PAN(SINGLE RIiSID) Dam Reccipta
Will the upplieum or future building occupant use equipment or devices which BOILER CHP OR IBB,000 BTU)
iw hasardous art conuminantx as JefinN by the Buy Arta Air Quality Management To IAL:
m°nct9 BOILER-COMP(OVER 100.0(X1 BTU)
❑Yes ❑Nn
I have read the hmmkmv mmcrms myuir,sten nndcr Chopmr n 95of the Cni. AIR CONDITIONER ISSUANCE DATE
fomda Ilwlth&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FI'.
Wilding Jens ed currently have a truant,that it is my resrymaibilitym mnify are occupant of the requirements which must Mand prior m ierawm of a Certificate of Occupancy.
Owner nr umhorimJ agent Data TO'I'AI,; ISSlllill By:
OFFICE