S 1721APPI IrANT-TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING, -MECHANICAL
BUILDING PROJECT IDENI'IF-ICA'TIOY
PERp1TT N0, 1721
`V
BU'I'L)DING ADDRESS:
SANITARY NO,
APPLICATION DAT]
^QSUNMITI'AL
O NIiR'S NAME: PHONE:
ON]EACTORS NAME LIC NO'.
2
NIC
CONfROLM
_
MG�ARCHITECT/ENGINEER'.
❑
LIC NO.
ADDRESS -
CONT'A(.T: PHONE:
BUILDING PERMIT INFO
BLDG t Cf PLUMB MECII
❑ Consultant Fees Paid by Applicant (Initial)
❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby alarm Ohm I am licensed under provisions of Chapter 9 (commencing
withSection 7000)ofDivision 3 bribe Business and Profee/ss��ionnss�Ca�da and my license is
arcLicenseC:�
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL: KITCHEN REMODEL
f�
PERMIT' ISSUANCE J' G_l7
tJ
APPLIANCES-RESIDENTIAI.
%�%-1 1��
Date � QTY Cnmm�'r kVl4 A Yv"r��
❑ADDITION ❑PLUMBING L PIPE
OMUL9'bUNIT STRUCTURAL
MODIFICATION
❑INTERIOR 0CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH REMO Ef/REI'AIR ❑ DEMOLITIO
❑OTHER
ARCIBI'ELTS DECLARATION
m plans eh ndu. public ria rd.
I License rnles,,cnal
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from thee Conlncmi s License Law for the
I terns 18.11 S, Buaincss and io Cool: Any city ost rotor,
PANELS
UP TO 200 AMPS
201-IIN)DAMPS
OVER ]"AMPS
SIGNS ELECTRICAI.
de structure
improve. demolish,
which requires n permit re conswct, alter, improve. demolish, ores sig any ewnurc
wh ch re Permit
I priormits issuance, also requires the applicant for pcmtino Blcasigncd statement
thus he is licensed pursuant 1. th, pmvisibns of the Cornelia, a License Law lChvp¢r 9
SPECIAL CIRCUIT/MISC.
COMMERCIAL'
(commencing with Section 7") of Division 3 ofthe Business and Professions Crde)or
that he is exempt therefore and the basis for the alleged exemption. Any violation of
• Section 1031,5 by aoynpplicanlfora permit suhlecls the applicant to a civil penalty of
TEMP. METER OR POLE INS' F.
O NEW BLDG/AUDITION O DEMOLITION
[]TENANT ❑ FOOD SERVICE
POWER DEVICES
m more Nan five hundred dollars (8501).
O1, as owner ofthe prolixity, or my employees with wages as their sale compensation,
will do the work, and Ile structne Is nal intended reoffered far sole (Sec. 7I94, Businass
i and Professions Code: The Commetors License Law does nm apply to un owner bl
❑THER
OTHER
SWIMMING POOL ELECTRIC
OUTLETS - SWI 'fCHE.S- FIX' rURES
NEW RESIUIiNT1A1. ELECTR SQ FT.
• ,.limy who builds or improves thereon, and who does such work himself m through
his own employees, provided that such improvements arc not intended or offered for
sale. IL howeveb the building or improvement iswld within oaeycafof completion. the
SQ. FT. FLOOR AREA $/SQ. FT.
will have the burden of proving that he did but build or improve for put,
TOTAL:
pocr-builder
se of.aala.).
❑ 1, as On,, of the pmpcn, um exeluxively contracting with licensed Cmlmcanx Ib
QTY. PLUMBING PERMIT FEE
onsauct the project (Sec. 7044. Business and Professions Code:) The ContmetaYs Li-
seLaw does not apply to an Owner of property who builds or improves lhercon,and
who contracts for such projects with a conuactons) licensed pursuvm m the Contractor's
License law.
O I um exempt tinder Sec. . B & P C for this reason
All !D VALUATION
PERMIT ISSUANCE
AI:TER -DRAIN & VENT- WATER (EA)
Owner Data
WORKER'S COM PF.NSATION DECLARATION
BACK FLOW PROTECT DEVICE
s
fk
` 1hereby illmaiunder Penalty (if perjury one ofthe billowing r Worker'sCo
Olhave and will meinminaCrnificae of Conserv to self -insure for Workers Cnmpen-
TY;C0N.STRUCTIOI
DRAINS - FLOOR. ROOF, ARG 9ND.
satibn, as provided for by Section 3700 of the Labor Code, for the performance of thework for which this p:mdl is issued.
FIXTURES -PER TRAP
GAS-G.SYSTEM-1 INC.4 OU11
of the work foyrmwhhiicchthiiss Permitislissued.
O I have and will maintain Workers Compensation hrrible, us required by Section 3700 ofthe LLfa-bor Code,foprr the performan'r
N
GAS -EA. SYSTEM-OVER4(EA)
carcpe
J My �osm�YY11PSYl1Y1CTI ,N..rul Y�SI ��±s
7RUILDING
CERf1FICATIi OF EXEMPTTf�N FROM WORKERS'
INSURANCE.
GREASE/INDUST' RL WASTE INTERCEPTORCOMPENSATION
VISION_
GRGSETRAP
(This section noel not be completed ifibe permit is forces, hundred dollars ($100)
or hew.)
SEWIiR-SANITARY-STORM F.A. 21NIfT.
I7NERGY FEE
I cert by that i a the perbirmancc of the workfor which this permit is issaal.I shall
not employ any person in any manner su us to become subject to the Workeri Compen-
WATER HEATER WNENVELECIt
GRADING FEE
smion Laws Of California. Dore
Applicam
p NOTICE TO APPLICANT. If, after making Nis Certificate of Exemption, you should
become subject to the Workeis Compensation provisions of the Labor Cale, you must
WATER SYSTP.M?BEATING
SOILS HE
yfbnbwith comply with such pnrvininns nr this permit shut l be dolma! revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
]herebylffiral that there isa conswction lending agency for the perfomtmccof
+ the work Ra wneb l si Ntrad k iashed (Ser. 3091. Civ. C.)
Lendeis Name
PAID
NEW RESIDEWIAL PLMB. SQ.IT.
Date RaeiplM
OTAL :
BUILDING
TOTAL:
LendcPa Address
1 certify thin I he real this application and sere ]hal the above inlumbr m is
ov
0 raormet,lagme to comply withal] city and county ordinances and state laws relating to
hank ing connwetion, and hemby amhuri a representatives of this city m enter uprm the
abrwe-mentioned property for inspection purposes.
(We) agree to save, indemnify and kap humrless the City of Capetian against
liabilities, pldgmevls, loans and expenses which may in any way accuse against said City
QTY. MECHANICAL PERMIT FEE
SEISMIC
PERMIT ISSUANCE ��•
AIXER OR ADD TO MECH.
ELECTRIC PEC
PLUMBING HE
1
in consequence of the gmming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT (TO 10,090 CFM)
MECHANICAL HE
SOURCE REGULATIONS,
AIR HANDLING UNIT (OVER 111.000 CFM)
CONST RUCTION TA
Signal of AppliccbmC wcmr ate
EXHAUST HOOD(W/DUC)
HOUSING MITIGATION PEE
HAZARDOUS MA'TERLALS DISCLOSURE
Will the applicant of future building ascription store or handle huurrdous material
as defined by Ne Cupertino Municipal Code, Chapter 9.12, and the Heahh and Safety
Code, Section 25532(x)1
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (DYER 100.0l13'TO)
VENTILATION FAN (SINGLE RESID)
[I Yes ON.
PAID Dare Recciptg
'Will the applicant or future haddmg ruupam uac eqw owcou or devices which
ehazardous air contaminants as defined A. by the Bay AAir Quality Management
mit
BOILER -COMP QHPOR 10,00 BTU)
TOTAL:
BOILER -COMP (OVER IINk0001 BTI)
District?
C) Yes FNo
AIR CONDITION- ER
ISSUANCE DATE
I have read the hmindous materials requirements under Chapter 6.95 of the Cali-
NEW RESIDENTIAL MECH. SQ. Ff.
humid Health Is Solely Code, Sections 25505, 25533 and 25534. 1 undontvnd that if the
building Jas not curren0y have a tenant, thus it is my maponihildy locality the occupant
ofthe res iremcnts which must he mel prima) issuanceofa Certificate of Occupancy.
TOTAL:
ISSUED BY: SIPE
Owneriamomrired agent One
OFFICE