29447 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY •
CITY OF CUPERTINOBUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT 'PLUMBING-MECHANICAL _ n(] /I /I —7
BUILDING PROJECT'IDENTIFICATION L J 4 4 1
UI-DING ADDRESS: 'SANITARY NO. APPLICATION SUBMITTAL DATE
�q 730 E?t, T Date WAR2 . RkMAIN61
WNERS PHONII: C N'TRiCfOR'S NAME: LIC NO: NIC - CONTROL#
VV MM AM
RCHII'ECf/ENGINEER: - LIC NO: DDRISS: ❑
I G
CONTACT': PHONE.: G - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECNRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of,Chapter 9.(conain mang JOB DESCRIPTION
Da'Z with Section 9ly)II)ofDivivon3of the Business and Prnfcsaions Code,and my license is RESIDENTIAL
DENTIAL_
f� PERMIT ISSUANCE
tar in fall forceund effect. ❑SNDWf. ❑KITCHEN REMODEL
U License Class Lic.#
Z UUj pate '�•Ig-� Comrxmr APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RR-PIPE
Ian¢a �— _r-r—
ARCHITECT'SDIiCLARATION + ❑MULTLUNIT ❑STRUM'URAL
P.
PANELS
Z O N Z I understand my plans shall he used us public'rcatNs MODIFICATION
OZ4- UPT02W AMPS ❑INTERIOR []CHIMNEY REPAIR
[•.` W Liceowd pedes, sal 201-1000AMPS IMPROVEMENT
06G OUC aj OWNER-BUILDER DECLARA'I[ON OVER It1lN1AMPS ElBATH REMODEUREPAIR ODEMOLITION
1 hereby afF..a that I am exempt from the Canttacmr's Licence Law for the
igyxS�LV following tcason.(Section 7031.5.Business vad Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to construct.aIle,improve,demolish,or repair any structure
F'� ¢ prior to its issuance;alko requires the applicmu for such perrinn ide v signed woorem SPECIAL.CIRCUIT/MISC.
that be is licensed pursuant to no provisions of the Contractor'sLicense Law(Chapter 9
W�00 (commencing with Section 7001 of Division 3 of the badness and Professions Code)or T'EMP.MCI'IiN OR POLE INST. COMMERCIAL:
6 o e+ that he is exempt thercfrgm and the haste for the allege)exemption.Any vielminn of ❑NEW BI.DG/ADDITION ❑DEMOLITION
.. Section 9113 lS by anyapplirna fin a permit sohice,the epplicmd ,,u civillmmalty of POWER DEVICES
Mm ❑TENANT ❑FOOD SERVICE
�6t mare than five hundred dollars(SSW). IMPROVEMENT
0 Lethew Lame themnctur my krat,mnyceswithwugrsas their sok c044.finedon. SWIMMING POOL ELE
4 0 will do fesiork.Cdt:'lle, �rc is notinmi.rwe aw dJsnot.,1,1.(no wrane.cs ❑OTHER r..
m unJ Professions Qde:The Cnntmemrs Liwmc Low Jnes not apply m mi owner of 011'ME IS-SWITCH E URES
n' .r property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such impmvemems are not intended or offered for NEW RESIDENTIAL ELECI'R 110 Q IT.
sale.14 howeveg the Fuilding ur intprnvemem is uilA within one ycmof completion,the S!),I;T.FLOOR AREA $/SQ.IT.
pcaner-builder will have the bonen of proving that he did not build nr improve far pur, MAR l g
osenfaale.l 1996
C]1,as owner of me property,am exclusively contracting with licensed contractors to TOTAL: (�
ti n of the project Sce.7(44, .,mant Prefesslmts Code:)'rhe Contractor's Li- Cid r V-
cemeLawit,.not apply to anowner ofpmpery no miles or improves thrown. it QTY, PLUMBING PERMIT FEE QV' �h(Itku
who commce,for such injects with a comuanorg)licensed pursuant o the Comramols
License Low. ' PERMIT ISSUANCE.
- ❑1 am exempt under Sec. ,B&P C for this reuaon
Owner Date ALTER-DRAIN&VENT-WATER(E,k) VALUATION
Wm underT
WORKERS DECLARATION BACK FLOW PROTIiC'P.DEVICE
affirmI hereby affirm antler penally of perjury ane of the following Jalvrutinns:
❑I have and will maintain a Certificate of Convent to self-insure far Worker's Comment- DRAINS-FLOOR,ROOF,AREA,COND.
svtiun,ab provided for by Section 3900 of the Lahnr Calc,for the Iserfntmance of meS"TORIES 11 TYPE CONSTRUCTION
work for which this permit is is sue d. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insamnce,as required by Sermon
3900of the LahrCode.fill the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40L LETS OCC.GROUP APN
Cy Work LSgnlgp5mionln.cutyy�ccanicr and PnlicYn rp� '
bT/i�CN1/ Policy Nn: � �3 n7'q�+ GAS-EA.SYSTEM-OV FIR 4IEA)
CERTIIyCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. OR GSUINDUSTRLWASTE INTERC R
(This section need not becnmpleted it the permit is for one hundred Itollors(SI W) BUILDING DIVISION FEES
or let .) GItL'ASE TRAP
PLANCHECK[TEE'
I,roily that intoe perfornnnce ofine work for which this permit is iamcd'Idmll ENERGY PEE
SEWER-SANITARY-STORMP .200 IT
not employ any person in any mannure
ner so as to become hjert to the Workers'Compe
OZ sultan Lawsnf Califomin.Date WATER HEATER WN EN'T/ErR
Z O 'Applicant - L " GRADING FEE
NOTICE TO APPLICANT:If,after makin this Certificate of Esentt should
i g pion,You s ou WATER SYS'IEM/fRIiATIN
I-' become subject, the Workers Cori IT
prmu shoo of the nt,d Code,you must SOILS FEE
fimhwith ennply with such provisions onbix permit.chull be deenmA revokrJ, 1 WA'fHR SERVICE-
CONSTRUCTION
mucivoDINGng ENCYagency
NEW RFSIDIiNT1AL YLMB. SQ.FT. PAID
VZ I for that pemereisveonstrectionlendingngrncy forthe perfonnvnce of Date ReceiptM
W lF�y+ the work for which this permit is issuul(Sec.1009,Civ.CJ
O U Lenders Name TOTAL+
W Lenders AdJreac TO
1 certify that 1 have read this application and state that the above information is BUILDING FIiE
(0.p carfen.I agree to comply with all city and county unbalances and state Iawc relating to QTY, M17CHANICAL PERMIT FEE
U Z building Onsttumien,and march,euthonee representatives of Racily to ante,upot the SEISMIC PEE
aMvcmcntioned property far inspection purposes. PERMIT ISSUANCE
(We)agree to sme.indemmify land keep harmless the Cityof Cupertino against ELE FRIC ME
Imbilities,juJgntenu,costsoad expenses which may in any way accrue against said City ALDER OR ADD TO M CCH. PLUMBING FEE
consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT p1µHANDLING UNI'1'(TO 10,000CFM)
MIiCHANICAI.PEE
SOURC�E�9U�-LATIONS,.�'/
7�L.t .�u�Lu, 3 /8 96 AIR HANDLING UNIT(OVER 10,(IWCFM) CONSTRUCTION TAX
Signmureof Applicam/Contractor Dam EXHAUST HOLD(W/DUCT). HOUSING MITIGATION FEE
HALAR MATERIALS DISCLOSURE
t Will the applicant nr furore building occupant smreor handle haaanoua material HEAi'INO UNIT(TO I DBOT)BTU) +
as debnel by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Care,Section 25532(a)'l - HEATING UNIT(OVER 1(10,00(1 BTU)
❑Yes ❑Nn VENTILATION FAN(SINGLE RESUB PAID
Will the eppllcain of future building occupant use equipment or devices which Date Receipt#
BOILERCOMP(3HP OR 10000 BTU)
emm
it hasallous air mamimmrs as Refined by the Bay Arca Air Quality Mnnagm ,- ,
e
enr To District?
❑Yes .t E]No BOILER-COMP(OVER 100,0110 BTU)
1 have rend the hm.nrJnus mnmriuls r is under Chapter fi 95 of the Cali- Ailt CONDITIONER
egwremen p ISSUANC D
humin Health&Safety Code,Sections 25505,25533 and 25534.1 umkrstand that if me NEW RESIDENTIAL MECH. SQ.ET.
budding does mu eurendy have a tenant,mat it is my respnnsibiliry to notify me occupant
of the requirements which roam be met prior to issuance ofn Cenficam of Occupancy.
Owner or aemmited agent Date TOTAL: ISSUED BY: r
OFFICE