29782 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO Bull, NU-BLELIRICAL PF.RMI'I'NO. 29782
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BUILDING DIVISION APPLICATION/PERMIT PLUM RODEG. TIDENTIFIC L 4J / l}J( L
BUILDING PKOJECI'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, AI'PLICA'1'I(1N SUBMITTAL DAT[
A i -
W ER'. NAME: FHONE: CON'IR C'1 OR'SN ME LIC NO:
BIC CONI'ROLM
%RCHITECT/ENGINEER: LIC NO:' ADDRESS: ❑
So .I�e bane
FwithS=tim7�)
PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ 67 ❑
LICENSED CONT'RACTOR'S DECLARATION QTY. ELECTRIC P17RMIT FEE
ffirm that 1 am licensed under provisions of Chapter 9(commencing JON DESCRIPTION
OaZ )af Division 3 afthe Business and Professions Code,and my license is PERMIT ISSUANCE
ffect. �9O ❑SFDWL ❑'KITCHEN REMODEL
155
Lin.k
Q U M APPLIANCES-RI5IDF.NTIAL []ADDITION ❑PLUMBING RE8IPR
Z{q Ilme Comraaor
tis Q 0. ❑MULD-UNIT ❑STRUCTURAL
.ARCHITECTS DECLARATION
Z~O ti 1 understand my plans shall be used as public records PANELS MODIFICATION
OZ—, UP10200AMPS El INTERIOR [I CHIMNEY REPAIR
� Iy Licensed Pmfessiunal 201-10010 AM PS IMPROVEMENT
OC Oat I a.OWNER-BUILDER DECLARATION C..t ION OVER RW AMPS ❑BATH REMODEL/REPAIR DEMOLITION
1 hereby uffrm hal 1 am eacmpt from the ConwcmFs License Law for the 1p
X00. fallowing mason.(Section 7031.5.Business and Professions Cash:Any city or coaly SIGNS ELECTRICAL. [I OTHER _
W a W fcq which rcqulras n permit m construct.vIm,improve,dcrnollsh,nr reynir any slarana
prior to its issuance,also requires the applicant for such Permit o rile a signed statement SPHCIAL CIRCUII'/MISC.
ythat he is licensed part to the provisions of the Comlacmrs License law lChamer 9 COMMERCIAL
00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP MET ER OR POLE INST..
L q C the he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Iz•
Second 7031.5 by any applicant for a permit subjmis the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
yyyyh nm mora than five hundred dollars(85(10).
IMPROVEMENT
� Q ❑I,as owner of the property,or my employees with wages as their sale cnnpenmtioa, SWI M M ING POOL ELECTRIC []OTHER
Sa will do the work,and the structure is not intended mousiest forule(Sec.]W4.Business
W and Pmfessions Gds:The Convector's License Law does not apply to un owner of OUTLETS-SWITCH ES-FI%TURES
0. property who briilds(it improves thereon,and who does such work himself or through - J
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECT' SQ
side.IL however,the building or improvement is sold within one year ofcompletion,the _ SQ.En FLOOrRy ARBA $/SQ.FT.
ow
ner-hullder will havo the burden of proving that ho All not build or lnhprove for par, tT_'s J`
pose of sale.). - a
1,as owner of the propertam exclusively contracting with licensed commands, TOTAL:
y,
construct he civil Ser.](M4,Business and Profexslons Code:)The Contractor,Li-
cense Ina,does not apply to on owner of property who builds or improvesthcreon,and QTY. PLUMBING PERMIT FEE APR 211996
xbo mmmcrs forsuch projecu wit a commnnr(s)Iicenred pumuanuo to Contractors
License Luw. PERMIT ISSUANCE
Ian exempt under Sec, -.B&P C funMsremrm CII Y.Ur wren L INU
ALTER-DRAIN&VENT-WATER(EA) - VALUATION
Owner Dam
WORKER'S COM PCNSA'I ION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
Q I have uad willuminuin v Cenificam of Comar,to self-imam far Worker"Carol.- DRAINS-110011,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
union,as provided for by Section 3700 of tc Labor Cade,for the p if a it name of to
work for which tis permit Ls issued. FIXTURES-PER THAI'
1 have end will mairram Worker's Compeniitian Insurance,as required by Section
17M.1 tire Labor Code,for the performance of the work fair which flus peril is ismed, GAS-EA.SYSTEM.I I HE,4 OUGETS OCO OROLF MIN
My an --Tom cation wancclarr er rarity No.;nu hp:40 /
Carries S 3V1/' h Pad tic 1-3
j Y GAS-LA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASPJINI3USTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be,completed ifthe permit is foram hundred dollars(Slg)) GRFASETRAP
or least PLAN •CK FEE
I terrify tar in the perforate nfthe work for which this peril is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner m as rah becomeu
subjeao be Wmkeriom
Cpel ENERGY FEE
OZ cation Laws of California,Date WATER HEATER W/VENT/ELECfR GRADING FER
Applicant `
NOTICE TO APPLICANT If,aper making tis Cenilicme of Exemption,you should WATER SYSTF.M/yREATTNG
a � became subject to he Worker's Compensation prnvieiain of to labor CWe,yoummt SOILS FEE
W I dwitb comply with such pr iuians or his pcan ilslull be deemedrevokad WATIiR SERVICE
Y
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL 1'LMB. SQ.FT PAID Date Receipt N
1 hereby affirm that them is s unde.10 lending agency far the performvnco of
LI the work for which this permit is i,.wcJ(See.3119],Civ.C.)lx� 1
0 Landers Name TOTAL:
1
C. Lenders Address TOTAL:
6Wi 1 certify thin I have read this application uad slam Thar the move infimnmion i 06D BUILDING FEE
t/1 cortecl,i agree to comply with all city and county ordinances and sum laws relating in QTY. MECHANICAL PERMIT FEE
V building cnsvunioo,and hemby.odurize represenutive, Instant t
s city Instant SEISMIC FEC
n
abovumentloned proper I'ar inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC THF.
liabilities,judgments,cost,and expenses which may in any way accme against said City ALTER OR ADD TO M ECH. PLUMBING THE C
IncooICA&Fhcgringoflhixpermit.
APPLICAANDS A ' WILL COMPLY WITH ALL NON-POfNT AIR HANDLING UNIT(TO 1B0k0 CFM)SOURS. MECHANICAL FEE
AIR HANDLING UNIT(OVER I0,00OCFM) CONSTRUMONTAX
Si a Appic nt/Conf nor, Dae EXHAUST H(%]D(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATE' LS DISCLOSURE
Will the applicant or future building cupartamre orhandlehazamous material HEATING UNIT(TO 100,000 BTU)
as defined by to Cupertino Municipal Code,Chapter 9.12,and the Health and Stably
can.,Scalia.25132m)T - HEATING UNIT(OVER 100,000 BTU)
E]Yea No VENTILATION FAN(SINGLE RFSID) PAID pate RecciplN
Will the applicant or far.building asvcupant use equipment or devices which
omit hazardous air conunhinuntsas defined by to Bay Area Air Quality Management BOILER-COMPLUVORIWOORTU)
TOTAL.:
District! BOILER-COMP(OVER 100,000 BTU)
❑Yes 71 No
AIR CONDITIONER
I have read the haWx .S s materials requirements under Chapter 6.95 of the Cell- ISSUANCE:DAT
folia Health&Safny ry N etalons 25505.2,toy and 25534,1 I.may m tat if the NEW RESIDENTIAL MF.CH. SQ.FT.
of'heng char te(.adhity Noes twat t.pent it ro ma c eof.Calilycism o fy to aceupchh !'
of to requirements which must be tun prior,m issuance of a Cenifcam of(kcupancy. '
Ow ner or amount ad.,all - Dam TOTAL: . IS ORD BY:
OFFICE