29652 . APPOCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY; -
CITY OF CUPERTINO - - BUILDING-ELECTRICAL. PERMIT,NO.
29652BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL,
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:. - - SANITARY NO. APPLICATION SUBMITTAL.DATE
/0910 ,Q Lbr'ration CO- ar. vc far '�—qto
i
OW�ryry.-R'S NAME: PHONE: CONI'RACIYIR:S NAME: LIC NO:
•He1-513 &8,1d-eo 7a2- 3li75 I N/C CONTROL
XKCHII hU11h.NOIl iR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: .BUILDING PERMIT INFO
❑ Commitant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
-LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMITCZZ PCG
I herchy to irm mot I am licensed under provisions of Chapter 9 fa minumelrg JOB DESCRIPTION
Woo win
Sl Pone uW chin Divixion3ofthe Busbms.and Profession Code,nndnry licenneix RESIDENTIAL'
F„�� - PERMIT ISSUANCE ❑SFDWL - ❑KITCHEN REMODEL 1,
�bV Dan, Class Limp APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING R17['[III.
F D� Unle - CnntDECL - _
Vl ARCHITECTSused to DECLARATION El MULTI-UNIT ❑MODIF'ICAl]O
F�yhy 'PANIe1.5 ..
URAL
Z O r4 F unJerstanJ my plans short be used as public records ' ^ •• MODIFICATION„
O44n - ` yp T0200AMPS (/ ❑INTERIOR ❑CH IMNHY RfiPA1R
FSE al Licensed Professional .2111-In(XIAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER INRAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
y�y�C Q 1 herchy amrm that I am exempt from the Contractor's License Low for the
I's l following mason.(Section 7031.5,Business and Profeaslon Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
m which requires a permit m consuri alter,improve,demolish,w repair any arumurc
F.u.G prior to its issuance.also retainer the applicant for such permit to file a signed artment SPECIAL CIRCUIT/MISC.
KQ that he is licensed punuam m the provisions ofthe Contmctorr,License Law(Chapter 9
FD�00 Dommencing with Section tBnion.fDivinion 3ofare Buemessand Professions Cotte)or TEMP.MISTEH OR POLE INST. COMMERCIAL:
64x C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�,,,,LLLLy.
Section 703 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES -
notmoamanLivehundreddollars(g5W). ❑TENANT ❑FOOD SERVICE
f=0 ❑Las nwnerofthe pmpcny,onny employees with wagered theinole compensation. SWIMMING POOL ELECTRIC" IMPROVEMENT
F will do are work,and the saucmre is am intended watered basalt,(See 90Ll Business OTHER _
6 as,3(4 and Probsaion Cale:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves thereon,and who does such work himself or through
his own employe'co.provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR' SQ FE
sale.IL however.the building or improvement is sold within one yew ofcompletion,the SQ.FT.FLOOR AREA SISQ.IT
owner-huilder will have the burden of proving that he did not build or improve for per-
pnmoLsule.). s -
❑L as ownertoLthm po pcny,ua,cnelusively concern,wire nwsw d Enntractors It, 1-
onxwet the ploi,sl(See 7044.Business and Pmroved ns Cede:)'The C vamorx A. ,
cenre Law does not applym an owner of pmpudy who builds or improves thereon,and. QTY. PLUMBING PERMIT FEE
nwhoc nm Is fnr sant ,,,jeers with a commeor(s)licensed pursuant ldthe Conmm�hn's
License Lu s. PERMIT ISSUANCE
❑ I am exempt under Sec, ,R&PC fou this reason
Owner Uwe ALTER-DRAIN& T- ALTER(EAG VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVAV
1herchyal... under penalty of perjury one of the fallowing Jeclamtinm.
DNAINS-F
avc and will maintain aCenifcate of Cnnsemmself-insurefnr Workch Compen- FLOOR, AREA,C STORIES TYP
❑IM1HCON."RUCTION
.anion.as pnrvided fnr by Section J7W of me UMr Code,for the performance of the
wvhforwhichffin,nmirokirood. - FIXTURES-PER TRAP
C] 1 have and will maintain Worker's Compensation Insurance,as required by Section
37Wafthe Labor Code,for the pedomaance ofthe work forwhichthis permit is issued. GAS-EA.SYSTEM-I NTL OCC.GROUP AI'N
My Worker's Compensation Insurance carter and Policy wwdti-'are:
Carter: Policy Nu: GAS-EA.SYSTEM-OVER 4( 7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE(NTE f
(This xeetiom need not he complexed ifthepermit is fm one hundred dollars p$I W) BUILDING DIVISION FEES
or less.) ' GREASE TRAP r @ rr.�
Icanil that in the famarrce oflhe work forwhich this PLANCHECKIFEE�
y per permit is issual,lshull SEWER-SANITARY-STORMEA.21X)FT.
not employ any lwnnn in any manna xo ns m become subjem m ate Workers'ComDut- ENERGY FEE
ZZ satiunLnwaolCulifraia.Date WAI'liµllfiA'I'IiN'WIVENT/ELECTR 1'a
A,Igbo,mt - GRAD
rA NO'I'ICR IO APPIACAN'I':IL nftar making mix Ccnificme'of Exmnptlon,you 0 Id WATER SYSTF.MRREAUNG
I"' become xuhjat to the Wmkcr'e Cinnpensotinn Drovisions of the larhi,r Cnde,you oma(
SHE
PEE
[aZl forthwith comply 110 each pmvi,, a,or this perand shall be deemed revoked. WATER SERVICE -'t, Ulf 1 11- r :L`r x'X. '
Q7.
z CONSTRUCTION LENDING AGENCYNEW RESIDENTIAL PLMB. SQ FF. PAID
IJP Iherehy eflirm that there isaamswmion lendingagency for the perfonnanecnf Date Receiptq
W. F the work for which this permit is issued(Sce:3097,Civ.C.)
p'G Lenders Name TOTAL:
Udders Address ` TOTAL:' _
Fy 1 sentry that 1 have read this application and state that me above Infnrmmion is BUILDING FEE
W comect.Lagree to comply withal]city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEEU z building eonswetion,and hereby authorize representatives of this city reenter urywthe SEISMIC FEE
above-mentioned puPwry for impaction purposes. PERMITISSUANCE - —+
f We)agree m rave,indemnify and keep harmless the Cuy of Coleman,agitation ELECTRIC FEE
Iiabiliceejudgment.cost and expenses which may in any way areme against said City
in consequence mine gmmm,of this permit - I ALTER OR ADD TO MECH. PLUMBING FEE -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CF
M1U
SOURCE REGULATIONS /, MECHANICAL FEE
`����4//�� yp/XBO Z1131,710 AIR HANDLING UNIT(OVER 10,000 CFM)
ldAp,1, -f[y.t... y� CONSTRUCTION TAX
Signamrc of ApplleaHAZAmfiCmw DO Ilse EXHAUST HOOD(W/DUCl7 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will y the Cumant ou Tatum hpal ing Code,Chapter
912,handle Healm and ate, - HEATING UNIT(TO I W,WB ITT To ,
_
as de,Sed by me 32(a)?nn Municipal Coda Chopta 9,12,and the fleNm trod SN'my - t
Code,Section 255J2(uJ7 HEATING UNIT(OVER I00,000 BTU)
' ❑Ycx ON. VENTILATION FAN(SINGLERESIU) PAIU t
Will the indicator or future building occupant use equipment of devices which Dole Receipt p
pO1LER-COMP(3HP OR I W,000 BTU)
,it hazardous air contaminants as defied by the Bay Area Air Quality Management I'OIAI.
t District] -
❑Ycx F7 No BOILER-COME(OVER I0a"BTU)
1 have read the hamrdous materials p AIR CONDITIONER ISSUANCE DATE
rryuimments under Chapter 6.95 or the Cali-
Health&Safety Cr l Sections 25505,25533 and 25534.1 understood that Hong NEW RF_SIDF.NTIAL MECH. SQ.IT.
building dies not currently have a tenant,that it is my responsibility to notify the occupant
of the rtyuireme wxM1icb must t tui uanm nfaCrnificae !Occupancy.
Owneroramho Jngent Date TOTAL: ISSUED BY:
OFFICE