29904 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI'1'NO.' ^ O4
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. L
BUILDING PROJECT IDENTIFICATION
BO zsD5: : SANITARY APPLICCAOTlNIuOTNRSUBMITTAL
ji_
L DATE
NLRS NAMEPHONE: C< TRACTOR'SNAMIi CaO
r,,,lettl 3.Ixypo
ARCfI1TECf/ENGINEER: LIC NO: ADDRESS: Q a l// E3
5_;Z
CONTACT, PHONE: IBUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG [L[ PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affmn that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�2, with Sadim70OfgnfDivision 3.f the Bmmon saad Toamasina,Code,and my license is RESIDENTIAL"
ly O in fall PERMIT ISSUANCE
tY n ffsc d .3 .Z At� cC O ❑SFDWL ❑KITCHEN REMODEL.
a U Li e G Lic,p f
�< ute� /r'r{, q� Connector APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F PANELS
5�0 Z IundcmanJ my plans shall beumdu public recoNs MODIFICATION
OZ OUPT02WAMPS [I INTERIOR ❑CHIMNEY REPAIR
Licensed Professional FBI-H100AMPS IMPROVEMENT
�Yd OWNER.BUILDER DECLARATION
K I hereby affirm that 1 am exempt from the Ceramics's License Law for the OVER IDBOAMPS D BATH REMODEUREPAIR D DEMOLITION
(�y5O0.U following reason,(Section 1031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
W LL 0.0 y which requires a Permit to construct,alter,improve,demolish,or motor any someone
prior to its issuance,also requires the applicant for such Permit o rile a signed statement S PECIAL Cl RCUI1'/M ISC.
that he is licensed pursuant to the Provisions of the Conracmrs License Law(Chapter 9
x'00 (commencing with Section 7000)of Division 3 of the B wares and Professions Code)a, 'I RMA MITI 17R OR POLE INST. COMMERCIAL:
c. e Y that he is exempt therefrom and the basis for Ne alleges]exemption.Any violation of D NEW BLDOADDITION D DEMOLITION
^w Section]031.5 by any applicant for a permit suhjeats the applicant ma civil penally of POWER DEVICES E1TENANT [IFOOD SERVICE
f..Z p., nes more than five hundred do)[.(3500L IMPROVEMENT
c O EILasownerofthe Empert,mon,employees with wages as theirsnlc contIommion, SWIMMING POOL ELECTRIC
62' will do the work and the suucmm is not intended oroffered for sale(Set,]IW4,Business ❑OTHER
and Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES rya
property who builds or improves themun,foul who does such work himself or though g
his own employees,provided that such improvements are nal intended or offered for NEW RESIDENTIAL ELECT R SQ FT. GJ 0
wle.ILhowever,to building orimpmvestmm is sold whin one yeast completion,the //fTes� FLOOR AREA E/SQ.FT.
pone,builder will have she burden of proving that he did not build m improve for pun �1 Nel ky
se of sale.), C
❑ I,as owner of the property,mo exclusively ruminating with license,]cnmrecmrs m / 9
construct the project(Se,.]014,Business and Professions Cade:)The Contractors Li. L/r, {d
Q
cense Law does not apply to on owner of property who builds or improves thereon and QTY. PLUMBING MIT FEE
who contracts far such pmjata witha contracted.)licertud pursuant to the Comrucmrs a 1/jFv
License Law, PERMIT ISSUANCE
D lam exempt under Sec. ,B&PCfonhismason _
ALTER—DRAIN&VENT—WAT VALUATION
Owner Date
WOR K ERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hemby affimt under Penallyof perjury oh,of the following deralarinima:
I]1ho,cand will aroultireCenificme.1 Consent mself-insurelirt W'nrker'v Compen- DRAINS—FLOORROOE.AREA,GOND.
touch,as provided far by Section 3700 of me Labor Cade,fear the performance of to STORIES TYPE CONSTRUCTION
weak Fitt which this permit is issued,. FIXTURES—PER TRAP
I have and will maintain Workers Compensation Insurance,as mgmired by Section
3000 of the Labor Coale,for performance of The work for which this permit is issued. GAS—BA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number ore:
Carrier: Policy No.: GAS—EA.SYSTEM-OVER 4 EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPJINDUSTRL WASTE INTERCEPTOR
(This sermon need had be completed if the pemm is furore hundred J.H.IS 100) BUILDING DIVISION FEES
arlen.) GRIASDTRAP
PLANCIiF.CK FEL
Ioyer,that..the PeHmmanceofthc wmk far which this pee W isissued.Counter.
SEWER—SANITARY—S'fORM EA. IT.
nm employ any person in any manne�vJubccnn uhiSm to the Wnrk<rs'Compcn- ENERGY FEE
� Z nation LawsilitCafomia.lyse 9GWATER If EATER WNENT/ELECIR
Anpbcan L/ GRADING ME
NOTIC APPLICANT:If,after makingthis CeniRcam of Exemption.you should
'--t r mmust WATERSYSTENUTREATING SOILS FEE
a ,✓ beesmo svomp m tic Worker's Coons or this provisions.]'the Labor Cade,.
W forthwith comply with such provisions or this pemdt shall be decided revoked. WATER SERV ICE
0., Q
CONSTRUCTION 1.ENDING AGENCY NEW RESIDENTIAL PCMB. SQ,F. PAID
U O hereby which his
that them issuemsnemion lending agency for the perfnmonce of Da Receiptp
� H the work for which this pemdt is issued(Se,.3097,Civ.CJ '
O U Lender's Name TOTAL:
Lendee.Address- TOTAL:
yI eerily that 1 have read this application and state that the above information is BUIL
In correct.i name to comply with all city and county ordinances and nate laws relating to QTY. MECHANICAL PERMIT FEE
U ,Z building construction,and hereby amhorim represenmtives of this city w enter upon the SEISh I( F '
.hove-mentioned properly for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hmmles.the City of Cuponino against ELECTRIC FEE
Iiabilitics,judgmenq cons and esoenses which may many way acemeagainn said City ALTIiR ON ADD TO MECH.
in nsequence of the granting of this permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT O O I0.f00 CFM)
SOUP .L R.OULATIONS. MECHANIC FEL
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRU NTAX
anlage of Appl]caalContmeor Dam EXHAUST HOOD(W/DUCT) HOUSING MRI TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thetpplicah or future building occupant store or handle mums is material HEATING UNIT(TO I ORD(s)BTU)
as defined by the Cupemino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sal to.25532(x)7 IIEA'rING UNIT(OVER 100,Wn DI'U)
❑Yes GNI VENTILATION DAN(SINGLE 1111 ID) PAID
Will the applicant or future building occupant use equipment or devices which Data Reeeipt M
I,
it haaallous air contaminants m defined by the Bay Area Air Quality Managenom BOILER—COMP(31IP OR 100,000 BTU)
wict?
E]Yes GNo BOILER—COMP(OVER 100,000ITIT)
I have read the hazardous maleditIS recoccuums under Cha ter b95 odds,Cull. AIR CONDITIONER
F ISSUANCE DATE
fmnia,Healthduct,a Safety Cede,Sadness 25505,25133 add
sp 25534,I understand shat if the NEW RESIDENTIAL MECH. SQ.E.
buildingdoesnotswhichameard,Love ametpthato ismyceofa Cerifimm of Theoucupem
of me mquirtsmnb which most he met poor to nfeCmifcate ofQcuparry.
Owner or umhonzed agent Date TOTAL: ISSUED BY:
OFFICE