29374 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL 4
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
Q033 S, vi Arfo.�In 3 -4 /9 /'-"i
OW R'S NAM PHONE: CONNI�RACTORR NAME. LIC NO: //��
4 ion Orq PS $ 4 FTs L(a coo O w n pia S' 3 8, C/ass Y8 N/C CONTROL#
ARCHITECVENGINEER: 1AC NU: ADDRESS. ❑
CONTACT: PHONE: 1W BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG E� PLUMB IyECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby afrm,Nat 1 am Bemoan under provisions of chapter 9(commencing JOB DESCRIPTION
W�Z with Section)fl(MI)ofDivision3nfNe Business and Rolbssionz Code.end my licenu is
O in full force and effect. ` PERMIT ISSUANCE
License Class Lic.N ❑KITCHEN REMODEL
YI Dates__Counselor APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RF.-PIPE
4i ARCHITECT'S MCLARATION PANELS ULTLUNIT ❑STRUCTURAL
Z p E2 2 1 understand my plans shall he used as public records MODIFICATION
OZ'- ' UP'T02W AMPS [I INTERIOR [I CHIMNEY REPAIR
Ir Licensed Promosmaal 201.11100 AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
6 1 hereby affirm mm I and exempt from the Contacis License Law for the OVER I"AMPS EDBATH REMODEUREPAIR [I DEMOLITION
a U following reason.(Section 7031.5,Business and Professions Cale:Any city or countySIGNS ELECTRICAL ❑OTHER
Owhich ternaries a permit to construct,alter,improve,demolish,or repair any structure
h priors its issuance,Aso requires me applicant for such famous to file a signed statement SPACIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of Ne Contractor's License Law(Chaptcr9
117 LYa0� (carrommang with Section 70A)of Division 3 ofthe Businessand Professions Code)ar TEMP.METER OR POLE INST,
6 6 D
that he is exempt therefrom and the basis for he alleged exnnnion.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
10 Section 70315 by any applicant for a pemcitsuhjeas the applicant to a civil Penalty of POWER DEVICES TENANT El FOOD SERVICE
k. m more than five hundred dollars(5500).
qC6 �1,as owner of the property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
2 Chi will do the work,and the stmcnueis not inrerncdoro02rdl far.[a(Sec. Business ❑OTHER
4al and Professions Code:The Conuunors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a'3
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impmvemems are not intended or offered for NEW RESIDENTIAL-ELECTR SQ FT.
sale.If.however.the building or impoevencetn is sold within one year ofcompletion.the SQ.FT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
0 1,a
❑sasowneroftheproperty,am.Business
contracting Codi continuum t. TOTAL:
cans0uct,dproject
,plytoan Businessand
rty,who
hs ns Code:)Thee,themdr's Li- /
censeonwdoesr such plymaa with
aa,.f whosedporimpao the Contra.and QTY, PLUMBING PERMIT FEE
who arta for such projects with acomsnor(s)liccnsed pudoammthe Convenor's 3 ?%s-
0
SA
License Law. PERMIT ISSUANCE OO
❑tem exempt under Sec. ,B&PCfar this reason
Owner Data DRAIN&VENT-WATER(EA) VALUATION
-- �f/
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT DEVICE - -7e
Ihcrcby affirm under penalty of perjury one cfthe following declinations: of J
❑I have and will maintain a Certificate of Consent to self-insum for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND.
nation,M provided for by Section 3700 of the Lntror Code,for the performance of the STORIES TYPE.CONSTRUCTION
wirk for which Nis permit is issued. FIXTURES-PER TRAP
Vin 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of Ne Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCOR P APN
My Worker' Cgptpe Jap t�r�fie curyer and Policy n b
Carrier: e � nC ngVx0PnIicy No.: ���UI9�Dy 'GAS-EA.SYSTEM-OVER 4(EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This nasion need nm hecumpletcd ifdtepermit ie faronehundrW dollars(5100) GREASETRAP '1117
nr less) P NCHEC FEET Ip 7 ^? aoa C)'O
I certifythat in Ne performmce niche]rkforwI'N' perytit in issued,lshall
no,employany Pers on ymi�isto gySadt e k Workers'Camped- SEWER-SANITARY-STORM EA.2IXI FT. R
Z aadon laws of Cal19,
i Date
Z O Jgmn - _ WATER HEATER WNENT/ELECTR G DI
Applicant ii
pJ NOTICE TOA PLICANT.If.after sub g this Cenificam of Exemption,you should WATER gySTEM?RLATING
become subject to the Worker's Compereation provisions of the Label Code,you must 5
{IJ [ fonhwiN comply with such provisions or this pernat shall he deemed revoked. WATER SERVICE
� �s v rChI11VV
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM. SQ.FT. AI Data
Receipt#
U O Ihereby affirm that there is a construction lending agency for the performance of
Br — the weak for which this pandit is issued(Sec.3097,Civ.CJ
O U Leaders Name TOTAL:
Leader's Address a TOTAL:1 certify that 1 have read this application and sate Nat the above information is UILUI G TBE oa d Y�
rA correct.I agree to comply with all city and county ordinances and state laws construction,
to QTY, MECHANICAL PERMIT FEE ,(,s�
U Z building consction,and hereby amhorim represemmives ofthis cit to enter upon th¢ E ok EISMI.
u y,a-mentioned property for inspection purposes. PERMIT ISSUANCE 1$.ke DG
(We)agree m save,indemnify and keep harmless the City of Cupertino against EL IC FEE / .[ J
iabilities,judgmrnts,costs and"Notes which may in any way accrue againstsaid CityALTER OR ADD TO MECH. Rlculitki PIT ME /$' a3C
in consequence of he granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I gOdo CFM)
SOURCE RF.GULAI'IONS. M13CIIA ICAL FIiE /7-2,30AIR HANDLING UNIT(OVER 10,000 CFM) CONSTR ION TAX 6 #
Signature of ApplicanUComramnr Data EXHAUST HOOD(WTUCT) HOUSINGh TIGATTON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Intensities material HEATING UNIT(TO IW,WO BT U)
as defiaed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Data
Receipt X
Will applicantor infms a building bythe By Aequipmentnrdeviceswhich BOILER-COMP(3HP OR 100.000 BTI)
emit hmardnus air conmminnms as dufinW by the Bay Area Air Quality Management TOTAL: aI Q�/
District? O
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
I have road the hazardous materials requiremrnts uWer Chapter 6.95 of the Cnli- AIR CONDITIONER ISSUANCE DATE
forms Health&Safety Code,Sections 25505,M533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does^ vrremyhave. ams.that it is my responsibility on notify the occupant
of Ne nu which met proton issuanceofa Cedi am Oce do
OwnEi or auNdrittd ngcm / Uate TOTAL: ISSUED BY:
OFFICE