29967 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY.
CITY,OF CUPERTINO BUILDING,-F.LRcHRICAL PERMIT NO.
+ I'- BUILDING DIVISION' / APPLICATIONIPERMIT `PLUMBING-MECHANIC'AI. II4 - 29967
I BUILDING PROJECI'IDENTII-IGA'1TON
BU1LDINGADDRESS: I SANITARY NO. APPLICATION SUBMITTAL DATE
AP
OWNF:k'S NAKHi. � , d 1 QNE ��� C i'IIACTOR'S NAh11i:_ j �`
.� GLCS/R tV1//1f'aaaM-.V�- J7 'vS-,: NIC t CON I'ROL p
�ARCHITECHR,IGISl LIC NO ADDRESS ❑
l
CONTACT' `PHONE BUILDING PERMIT INFO
l ❑ Consultant Fees Paid by Applicant(Initiop i• BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DFCLARAf10N ' QTY ELECTRIC PERMIT FEE
1 Hereby afeml matt I am hcensal unaer prmnsmns of Chapter 9 uommnneans - JOB DESCRIPTION
with Satins](KMIl of ninsmn3onheBmmess and pyCydee my hccnsen r (,��1 / ) III RESIDENTIAL:
FOO Fall fo can t S/4 I PERMI'TISSUANCF. �,
FF�U U License Cass Licht ❑ADITI ❑KITCHEN RE-PIPE
VsZW Dale this
I APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCIIITECI':S OECLAHATION ❑MULTI.UNIT ❑STRUCTURAL.
F'O h PANELS
Z O�2 Z 1 undctsmnd my plans shall be used u+publm fecund+ - MODIFICATION
oz--o UPTO 200 AMPS �.,/'�
Licensed Prnte,unial '�ILv tERIOR ❑CHIMNEY REPAIR
�pd2•,•1 OWNER-HUILDHR DECLARATION 1201-1(100 AMPS m IFFIPROVIiMENT
K 6 1 hereby affirm that 1 am exempt from the Contractor's License Law for th• OVER HXMAMPS ❑BATH REMOD UJRFaPIy{R Cl DIZ',MOL17PISO
f� Ow,U following reason.(Section]011,5,Husmcns and Prafesnnns Code Any city or county SIGNS C:LECPRICAL ❑OTHER
Yl l;W F which acquires.permit io cunslm i,alter,improve,demnUsn:or repair any st acture (/ �
fppppQ'LL0 pnorto its issuance.also requires the applaum for such permit to file a Signed statement (SPECIAL.CIRCIII I''/MISC / 11�t�
Wad
that he is licensed pursuant to the provisions of the Contractor's License Lax(Chapter 9 COMMERCIAL-: D
a O (commment,with Section7000)of Diaumn3of the Business and P..R,,a 1Code)Sir TEMP.METER OR POI-(?INST.
aiA(°m m that he n exempt therefrom and the base for the alleged exemption.Any aula mn of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^y
Section 71131.5 by any applicant for a pemntwblene the e,pl¢ammucrvJ penalty oft (POWER DEVICE$ [:1 TENANT ❑1700D SERVICE '
FZY natmore than five hundred claims 1$5001 -
O0 its owner ofthe prnpeny,or my employee+with wages m then wle compensation, SWIMAfING POOL ELIiCTRIC � IMPROVEMF.N'f,
will du the work.and the structure n not emended ur.ffered for sale]Sec.gW4,11usmea ❑OTHER
and Protensml,Code:'fic Contractor's License law does not apply to an owner of 5 OUTLETS-SWITCIflHS-FIXTURES' -
property whu builds or Improves thereon,and who does Such work himself or through A
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENT IAL ELECI'R SQ FL a -
laleJl,hnwevcr,the hualJing or inipnrvenmm as+oldxnhin one year of compleuoa,the'( ,� T ,, i _ .SQ IT FLOORARFi, ` 1 9'4 S/SQ,F..
p rnn-budder wdl have the burden of pmving(het he did not bmld or unprme for par- ���
pose of sa[e)
eaav l the p t the proper),nm cul ...ny contracting with hemmed clmmmiors to (W/•I^^ 19,
onswct the pmyem(Sec.]UW,Business and Profession+CoJe)The Commcmr's Li- ' / I '
ecnse Law does not apply m a a ownerof property tuna builds or Improves human.add (QTY PLUMBING PERMIT FEE I v!" Vr
. Lan set"Wis inn Such pnOCds wnn acimtinemrvsl licensed punudmmthe Cnntinnorn I t/ VurLf.frD V.
C] I am exempt under Sec. B&1'C far(his reason PERMIT ISSUANCE -
Own^- 1>m- I ALTER-BRAIN&VFNI'-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION I BACK FLOW PROTECT.DEVICE Jt
Iherehy affirm under pen,Jry of pmrvry one of Nelollowing Jcdaruun. �, V�
�ea Ihuve and wdl mamlain aCenificae of Cnnsenl In self.ansure for WmAer's Camper- DRAINS-FLOlJR,ROOH ARP.A,'COND, / / STORIES TYPE CONSTRUCTION
tion,as provided for by San,..3](10 of the LaMm Code,for the perfcanami,of th_ !/
work far which this perms is issued, ,I (FIXTURES-PI7R TRAP 9
I hoe and will maintain Worxp`s Colnpeasntina Insurance,as required by Serum
'
,- 37M.I'de LaMar Code,Blrthe rformance of the xnd forJ�wh�lcfh-111,43 Ihrc petmiuslssueJ, (GAS-PA.SYSI'EM-I INC 4OUTLEfS IxC.GROUP • 'APN Policy Cary Work .t h umnce rrierohii,y N., / ✓ r _��I (GAS-IAA SYS'I pi OV1iR J(?A)
Cartier,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANC17 • I GREASFANDUSTRI.WASTE INTERCEPTOR I
'. BUILDING DIVISION FP.F.S
('(hats xwon need not be nmlplemJ if lM1e pnmtnlunme hundred Jnlbirs GREASETRAP
or less) s - GREASE TRAP FEE
Loy anythaunthe any..on, oas,.lacame,bahtmspermiti+issucd,(shall SEWER-SANI'T'ARY-S'I ORM PA.200 F..
nol employ any perton in any manner so w m become mnJ<d m the WnrAen'Compcn- LENIiRCY FEE
Z~ after f WATER SYSTEMaRF-ATING GRADING P[E'
cation Laws of C.hfomin Dar
� WATER HEATER WNLNT/ELECTR
� ADPlicunt
.N.I NOTICE TOAI'P he Wink IL m.kmg this Cerofieam,h E Labor Ce,you should t
I"! becomes comp to he Worker's Compensation pmnsmm of the Labor Code,you man L SOILS FF.1?
(Wry fonhwuh comply with wchpmvsmnsnr this permn shall he deemed re keit (WATER SERVICE . I
UU z CONSTRUCTION LENDING AGENCY NEW RPSIDGNTIAI.PLMB SO FI' (PAID - Date
p ,par, .,h affinto
his at thmeicecoroSee 30 lending agency for the Performance of
H the wmklm whaeh lM1n permun nweJ lScc.ifi9],Crv.C.I � t
U.U Lender's Nam- 3pl'AL: '
Lenders Addr- I• TOTAL
aI cemty than 1 have read Im+applkalma and Gate that lie xbuuc mh....tatlon is BUILDING PEE x
rA cormcl.l agree mcomply withal]aby and muntyordi...cc,anastaamwsrtlamgm QTY. MECHANICAL PERMIT FEE �IVV/
fJ building cersomeirn.and hcmbyauthome reprcsemetives of thiscoy tocaterupon the (SEISMICF
nhovennentioned property for inspection Plitposee. - YEkhtl l'ISSUANC[
(We)agree io save.indemnify and keep harmless the City of Cupemno against - ELEC'I'kl�'ILL'
liabilities judgments,costs and expenses which may in any way accrue agdmn said City AI-TER OR ADD TO MECH �PLUhIBINC TEE
in cnnscyuerice of Ne gnmian of this Penn UNDE STANDS AND 1' L .IMPLY WITH ALL NON-POINT I AIR HANDLING UNTF(TO Iq(Kp CFM) MECHANICAL F :
OURCE Y OSS
�$ AIR HANDLING UNIT(OVER 1 8000 CFM) CONSTRUC'II/NTAX
9g aurt ofAppOCaMcom n Date EXHAUST HOOD(W/DUCCI HOUSING S/TIGATION HE
HA OUS MATERIALS DISCLOSURE I
K`dltbeapplian ,future hmldingoccupam nitre nr handle haurdow material HEATINGUNI'I'(f0100.0009TU)
as derined by,the Cu ants Municipal Cade,Chapter 9 12,and Ne Ifi allh and Safety - - _ - - I
Code,Section 25532x0! HEATING UNI'C(OVER 10l 13TU1
❑Yes ❑Nn VENTILATION PAN(SINGLE RPSID) ` (PAID
�+ ^ _ Date Re, N
Will the nppLcan[or future building o&aparl use equipment or devices which Ii01LER-COMP(?HP OR IUB.IIIIU BTU)
;i In mrdous air...ammanly as defined by the Bay Are.Au Quuhty Mnnagemcnt TU'IAL:
.,.,nm°❑Yea 0 N x BOILER_COMP(OVER 100,003 BTU)
(have read the hawdous materials rtquirtmcnls under Chapmr695nfthe Cali AIR CONDITIONER ISSUA CE DATE
fo ,a Health&Safety Conde,Sections 25505,25513 and 25534 1 understand that If]tic NEW RESIDENTIAL MECH. SO FI'
building does not contently hnc a mnann damn,my respnlnthJrty m notify the lecupam
miss,onto mma,which mua theme,prior m Issuance of a Cemficem ofOccupalacy.
Owner m ambnneed agcnl Dam • TOTAL-. (ISSUED BY'
— OFFICE