29290 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.ELECTRICAL PERMITNO. ^^^^0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL '' L 9 L VJ,I
BUILDING PROJECT IDENTIFICATION '
ILDING ADDRESS: of J SANITARY NO. APPLICATION SUBMITTAL DATE
of33vo KIS ,SG G'wE"Rb Pot mbl# V�3
NEI'S NAME!: PHONE Ltjp NTRACTO l'NAME: LIC NO:
XW /✓/� NIC CONTROL#
•ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑ 1. iq
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLUGELE PLUMB F.0
LICENSED CONTRACTOR'S DECLARATION TY ELECTRIC PERMIT F EDG Z I hereby affirm mat I am licensed under provisions of Chapter 9(commencing JO DESCRIPTION
pJ talo Sauon]Om)of Division 3 of the Bosincss vnd Professions Cole,and my license is RESIDENTIAL:
Fl O O % PERMIT ISSUANCE
in full force and effect.,
❑ ❑
UU SFDWL KITCHEN REMODEL
9
GG V V License Class Lic.p
i �•7d-4 DateConwcmr APPLIANCES-RCSIDP.N"f1AL DDTTION ❑PLUMBING RE-PIPE
I„ptrl ARCHITECTS DECLARATION PANELS ❑M TI-UNIT ❑STRUCTURAL
120! 4 I understand my plans shall bcmxdaspablic records - MODIFICATION
OZ�-f UI'T021q AMPS ��,,// MODIFICATION
❑CHIMNEY REPAIR
Licensed l'rofessianal 201-IIXg AMPS �� IMMPPRHOVPvNENT
X •,.I OWNER-BUILDER DECLARATION
yy OOCC 'Q I hereby affirm that I am exempt Boothe Conlracmrs License Law,fur the OVER IOIIf1AMPSF ❑BATH REMODEUREPAIR 0 DEMOLITION
5d a 0.V Il
following reason ISec(ion 7031.5,Business and Professions Code:Any city or county SIGNS ELRC'DUCAL OTHER
4471 u� which requires o permit to constmct,alter,improve,demolish,or repair any swcwre
yprior m its issuance,also requires the applicant for such Permit rile a signed suametn SPECIAL CIRCUIT/MISC.
Mit} matheislicens punuantto Nepmvisionsofthe ContactorsUcenul.uw(Chapter9
OM (commencing with Section 7")ofDivision 3 ofthe Business and Professions Code)or TEMP.MITI'ER OR POLO 1111.
ZT OM
0. 0 that ha is exempt Ibereffnm and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section'!031.5 by anyappllcanlfor 11 permit subjects the applicant to a civil penalty of POWER DEVICES
H ❑TENANT ❑FOODSERVICE,
z} not more than RvchunJrWdallamyempl IMPROVEMENT
Q ❑Lo the owner ,the property,nnnyet intended w(mwages ered fos their soa compensation. SWIMMING POOL ELECTRIC
O andwilJrfhewons and the he Coeisnot's License aw does
e(Slytoan Business ❑OTHER
end Professions Cale:The eves thereca License law moa nes apply m if owner of OUTLETS-SWITCHES-FIXTURES
a' .. properly who builds or import h thereon,ad who ms such work himself or through
his own employees,proviMA hot such impmvemema arc nm intended or offered for NEW RESIDENTIAL GLC•CI'R SQ FT. �Q�
sale.If.however the building or improvement is sold within one year ofcompletion,the SO IT.Iq. I REA &SQ.IC.
owner-hailder will have the burden ofpaving(hat he did not build or improve for pur
Pose of aale.).
1,os owner of the properly,can eachnively contracting with licensed mramormrs to
consauct the pmjat(Sec.7014.Business and Professions Code:)The Contractors Lt.
ease Low does nal apply to nn owner of properly who builds or improves(hereon,onJ QTY PLUMBING PERMIT FEE?
who contracts(.,.such projects with a comraaons)licensed pursuant to the Contractor's
Licetue law. PERMIT ISSUANCE
❑l am exempt under Sec. ,B&PC for this reason _
A lugALTER-DRAIN&VENT-WATER(EA) VALUATION
Ownate
WORKER'S COMPENSATION DECLARATION HACK FLOW I'ROTECf.DEVICE
I hereby efRmt under penalty of perjury one of the following declarations: ——
40 (]Ihave vnd will meimain oCcnifcne o(Conum rout(-insure for Workers Compere DRAINS-FLOOR.ROOP,AREA,COND.
section,as provide)for by Sadiron 3]W of the Lubar Code,fame perfinmance of the STORIES TYPCCONSTRUCTION
work for which this permit is tomed. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labor Cale,forthe performa.moshe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance turner and Policy number are
Carlen Policy No.: - GAS-EA.SYSTF.M-OVIiR 41EA7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASUMDUSTRL WASTE INTERCEPTOR I DIVISION RIES
(Thiasutionnad not he mmpleled ifthe permit is(arena hundred dollars(Elm) GREASETRAP
or less) PLANCHECKF
I certify that is the performance oflhe work for which this permit is issued,I shall SEWER-SANITARY-STORM E.A.2m FT.
not employ any person in any counter so as to become subject to the Workers Compen- ENERGY FlfS
O ,Z scomm Lewsof California.Date
O Applicant WATER HEATER WNENT/HLECTR GRADIN •EE
G NOTICE TO APPLICANT:IL olio making this Cenifcme of F.semplion,you should WATER SYSTEMaREATING
abecome subject to the Workers Compensation provisions of the labor Code,you must SOIL
ID
forthwith comply with such provisions or this permit shall W deemed revoked. WATER SERVICE
n2. Q
p CUN e.isa,IONLENDINGgGGNCY NEW RESIDENTIAL PLMII. SQ,FT. PAID
UQ I far which
thatme.issued(S .30lendingagency for the perfontance of ate ReceiptN
LL `+ the work for which this pcmdt is issued(Sec.JTN7.Civ.C.)
0 U Lenders Name TOTAL.:
WLenders Address TOTAL.:
certify that I have rend This application and sate Ihm the above information ix BUILDIN FEE
&n correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT F E
C1 Z building canxtmnion,and hereby authorizerepaunutivee of this city to enter upon the SEISMIC E
above menton
ied progeny for inspection proposes, e PERMIT ISSUANCE
(We)agree ,,scon.indemnify and keep harmless the City of Cuperi no again ELECTR 'PEC ��'
((abilities,judgments,costs and expenses which may in any way same against said City gLTER OR ADD TO MECH, PLUMBING FEE conseque a ofthe guntingofthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POENT AIR HANDLING UNIT(TO Ify"CFM)
SOURCE REGULATIONS. MECHANICALFHE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signamrcof Applica usContractor Date EXHAUST HOOD(W/DUC1) HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hicallous material HEATING UNIT UT)Im,M)BTU)
fist14`•' p
as defined by the Cupertino Municipal Code,Chapter 9.14.4nd the Health and Safety
Code,Section 255321sT HEATING UNIT(OVER 100,000 BTU)
❑Ycs ON. VENTILATION PAN(SINGLE RESID) P
Will thea lienal or future huildin cetptN
pp g by the
Area
Air user devices BOILER-COMP f3HP OR 100,000 BTU) /s
emit haallous air contaminants as Jellned by the Bay Area Air Quality Management C,
DisWctY (Y UI4 E,I s. TOTAL:
❑Yes El No - BOILER-GDMPIDVERItA1J100 BTU) lwolltivij
I have read the haatdous not cors roquirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 15534.I undersand Ihm if me NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a anent,mat it is my responsibility to ready the occupant
of me requirements which must he met prior m isaaace of a Cmificmc of fkcupancy.
Owner or authodaed agent Date T ISSUEDB .
OFFICE