29762 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 29762
BUILDING DIVISION APPLICATIONWERNI T PLUMBING MECHANICAL
BUILDING PBOJELT IDIONTIFICATION '
BUILDING ADDRESS, SANITARY NO APPLICATION SUBMITTAL DATI
/0 ,76 9 H I e1e� TUd� �
OWNER'S NAME. IAA V PEAS' Pt ONC W4G1QJ WNTR+A�C-fOR'S NAMG + LICNO' Y
1 a.•I.. i ��1 \ ,Ic
ARCIfITIiCTIIiNGINELR -" C_ N❑/C
CONTROL.
LIC NO' OR 1'W Q
CONTAC'C ra.sor`e PRONE Y06 l BUILDING PERMIT INFO
14. ,
�g•14�Q& ❑ 'Consultant Fees Paid'by Applicant(Initial). f RhpG ELECT MUCH
LICENSED CONTRACTORS DECLARATON QTY. - ELECTRIC PERMIT FEE
I hereby affian thin I dm hcen+,d unde..rm.eris, Chapher 9(cormucnclnj JOB DESCRIPTION
"Z with Sxuan TgO)of Diviainnlnf thelir5oness aml PmftxsoonsCodc,end my licerociv PRESIDENTIAL:
C2 PERMIT ISSUANCE
�UA~] Totemic Clan nd effeC Lot.# Q D ❑SPOWL ❑KITCHEN REMODEL
F�H Dam Can'r:mmr G API'LIANCIS-RLSBBNTIAL ADDITION ❑PLUh1BING RE-PIPE
1NF..pao ARCHITECT'S DECLARATION PANIiLS ❑MULE-UNIT - C1 STRUCTURAL
ZO 7a Irndemmnd my It ov,hnll lattice.,public accord+ MODIFICATION El oz-
a + UP ID 200AMi'S INTERIOR '�HIM1NEY REPAIR
F4E" Lncowd P..fmvonal - '201-1110.AMPS /� I IMPROVEMENT
OWNER BUILDER DECLARATION C1 BATH REMODEL/REPAIR ❑ h101.ITION
y�C I i herehy affirm the 1 an,exempt farm the Contrauor'a facene Law for the OVER 1000AMPS
x 04 U following ream. (Searle.7031.5,Bmmess end I'rofoaons Code.Airy city arcounty I SIGNS ELECTRICAL I ❑OTHER ��b9 /�nIP (wits
LLl a 41"' which rcya.re+n pennn ro construct.:drat,improve,Jtmrhvh,or repair any sWCrurc
poor tons..mane,dui airport,Ile applicant fonuahpmm�m Idea signal sratemeI ISPECIAL CIRCUIT/Af15'
y Nat he o+licensed pursuant mthe provrs.on ofthe Contrnemr's License Law Whapter9
OaG Rmamemmng wah Sector p00f1)nfDrvocwn3afthe Busines+end End..mnsCMgnr 'fF.Af l'MIETER OR POLE INST. I COMMP.RCIAL:
4�o n, that he iv exempt therefnnn and the basis for the alleged exempuan.Any violation of -- — - I C M BLDG/ADDITION ❑DEMOLITION
+ --0 Scotian]031.5 by any applicantfor a permit.blcats the nppf.card,,a mvd penalty at POWCRDIiV vS - 4
}��<O I g --- ❑TENANT ]-
FOOD SERVICE
am than Give hundred dollars($5((
❑I.az awnerofthe p ror army em p t Y s w we B es as mm pea se Ion, IMPROVEMENT
xJl dothewons,andth TheCmersnmmtenense Law dry not pplyit)1,eu+meas v OTHER
al 3 and property who GNr The Connector's License Lew Jr.e+not apply m arrow net of 00'ILEI;S-SW ITCH' FIX'I URCS
property who hn.lds or improves thereon,and w M1n don such work himself or through
his own employers,provided that+ach improvements are nm intended as offered bar NEW R[SIUEN'1'IA � $Q PI'.
,- safe.If,however,the huildungor improvement is sold within oneyarofcompletia.,the � / SO FTFLOORAREA SJSQ ET.
owner-timlder will hove the burden of proving that he Aid not build or improve for par- Aq
posy af.ale.) '` - � fC
❑1,as owner of the property,am exclusively contracting with hccusal contractors to J/n TOTAL APR
construct IM project(Sec.Own,Business and Prole++ions Code)'The Contractor's I..- � r
cans,Law does not apply to an owner ofpmperty who huildsin improves thaean,and QTY, PLUMBING PER 1717E /c
who contracts for such projects with a mntmmngs)licensed pursuant to the Contractor's I �� I C��'y 1996
Lateral Law. .
PERMIT ISSUANCE Ur L
❑ Into exempt under Sea � � ,B&PC for the reaxm
Owner n,.. -
ALTER-BRAIN&VENT-WATER(EA) VALUATION'IJ
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECP.DEVICE l/('/) &00.• 06•
• I hereby affirm under Penalty official,one of the frllowmg declarations-
E]
Ihaveandvidlntamwm aCemficn¢of Comcm to atlfamurc lnr WnrAer'a Campcn- DRAINS SOUP AR�yv,fOND. STORIES .TYPE CONSTRUCTION
satin.,as pomaded for by Section 37W of the Lahr Gavle,fir the peAormancn of the �'Vr �
w.,I for wh¢har,permit is e+ucd. FIXTURCS-PERT 1 /,/1
❑1 have and will maintain Workers Compensation Interancc,av regmreJ by Section - I V�'V
101X1 of the Luhn Code,for theperformance of NcwnrA tsar x�M1eichJrt�'hir+permn.srs,urd GAS-EA.SYS'IE INC 40UFLETS OCC CROUP APN.
My Cnmeark,r�s j'yP.��ar,�yT•Wc'Policy No:rural cars GAS-EA S)>TEM.OVER 4(EA) a I
CSC �•1N. ( t t
CERTIFICATEOF SATIONINSFROM WORKERS'
COMPENSATION INSURANCE. CkTWtlf!IINDl15TR1.WASTE INI'ENCCPTOR - BUILDING DIVISION FEES
Movectfrn need not be completed ifthe Pemew far..hundred dollars($10) GREASE -
or la, PLANCHECK I'HE
I CertdythCmthe performunceafthe work faro hock the perm.II ... ed,1 141 SEWER-SANITARY-STORM EA.2M FT.
nor employ any perwnm any.,..all so as to become .b,,CLothe Workers'Comlmn- aNERGY FEE
z0 Applaud.r of Cnbfomm Darc WATER HEATER WNENT/EI.ECIR � (GRADING FEH
Of NOTICE TO APPLICANT IL after making this Cenificum of F.xempunn,you should I WATER SYSTEM/aREA'1'ING
rl become subject m the Worker's Compensation provisions of the Labor C.de,you must SOILS FEE
� > forthwith comply with such pmv.Cannor his perm.Ill.[[he deemedrevokeJ ' WATER SERVICE
' Q
U'o rehye nn ha Nthere s.OSnucINDI drag icyfurthe darmuncc off NEW RF_}IDE•N ALPLAB SQ T. PAID Date, Recruit#
IIa H the work for which this pcemt is issued(Set YNT pit,C.)
U Lender's No. T(YTAL,
0 P.l Lender's Addre•• - - --— _ TOTAL.
1 1 cancy the 1 have read(his...licabun.md+tme,hat the above mhmmatin.l.s f BUILDING FEE
IA caneat.Id,are to comply with all any and county mdlnances and stare lows telling 1. QTY. MECHANICAL PERMIT FEE I + r•�r-i
U Z buddmgmnstmmm�,and hemhymOm. a,aewmumam facility to enmrupon the SEISMIC FEE `^IJ
abuse-memmned pmpeny for oo,aion purposes PERMIT ISSUANCE
'
(We)agree to save.indemnify and keep bonnie+n the City of Cupenma against I I ELECTRIC PRE
huhthdea3udgments,coats and expenses which may in any way accrue age.nsna.d Gty ALTER OR ADD TOMECH
in sequence of the granting of Nu pemut - I PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT I AIR HANDLING UNIT 010,�(Ip CPM� MECHANICAL.FEE -
SOURCE REGULATIONS. - "`�T0
, AIR HANDLING U (O ES�I,IN GPM) CONSTRUCTION TAX '
S.gnamac m'Applmaat/Cantmctm Date EXHAUST HOOD U HOUSING MIITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE ,
Will'he...Imam or future building occurred or handle heandaa+mscnai HEATING UNIT,It 000 BTU)
as defined by the Cupemno Muninpul Code,Chupmr 9 12,void the Hcolth and Safety'
Code,Section 25532(e)p HEATINGUNI' EVER
V7N
o '
iC- VENTILATION FAN(SINGLE RESIDI PAID I Date Receipt#
Wrethe air commitments ntsa derineg by theaB useea Air Club or devues which BOILER-COMP OR IOO110f1 BTU)
riaunu le,! u5 air comm�umnts m JefineA by the day Area Air Quality hionagemenr I I TOTAL:
'. -I
❑Yes "a No (BOILER-COME(OVER 100,100 BTU) X /
AIR CONDITIONER
Ihave read the hmerdnm meterieh ecquimmentn under CTepmr695 of the Culn- I ISSUANCE DATP '
fimua HealN&Safety Code,Seume,25505,25533 it 25534.1 andemit ad that.f the NEW RISIDHNTIAL MECH. SO IT t '
building dm.Mat Comely have a ones.that my tes[amaholny to nnufy the vacation
of the cast secure, nth mu.rMma m fa Cemlicote IOerul y. I' • -,
I — jyr -
Ownenrauthonc agent # Date _-' - _ —-- '.TO"1'AL ISSUED BY
— — OFFICE
t —