29907 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMxINO:MECHANICAL
BUILDING ADDRESS: DII� (]O
BUILDING PROJECT IDENTIFICATION G J
SANITARY NO, APPLICATION SUBMITTAL DATE
W PR'S NAME: /�.�� PHONE: CONTRA OR'S NAME: , LIC NO:
\` NIC CONTROLa
RCHITECT : INEPR: V LIC NO: ADDRESS:
CONTACT PHONE:
{ate— BUILDING PERMIT INFO
"a°�+� ►��� �y�) I-595v Consultant Fees Paid by Applicant(Initial) BLDG .ELECT PLUMB MECH
LICENSED CORMACTOR'S DECLARATION QTY ELECTRIC
� with Sea
I hereby affirm Nat 1 On licensed under provisions of Chapter 9(comrneneing PERMIT FEE JOB DESCRIPTION
� cti-Ii7fl )of Division Jof the Businessand Professions Cmlc,amdmy license is
CWI- infullfmceaadeBect. PERMIT ISSUANCE RESIDENTIAL -
QUU License Class Lica EISFDWL
W DKITCHEN REMODEL
Date
Contractors. APPLIANCES-RESIDENTIAL []ADDITION[]ADDITION ❑PLUMBING RE-PIPE
[F 5�� ARCHITECTS DECLARATION
Z PANELS 11MULITUNIT ❑STRUCTURAL
Oz=.Z, 1 understand my plans shall h used as public records
UP TO 200 AMPS MODIFICATION
Lmenxd.....simnelOWN [I INTERIOR [I CHIMNEY REPAIR
,4 WISER DECLARATION 281-Ig18 AMPS IMPROVEMENT
y Q I hereby affirm shut 1 inn exempt from tm
he Coracusr's Littmse LuOVER 1000AMPS
w far the OV [I BATH REMODEUREPAIR [I DEMOLITION
x 3 d F- following moxa.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Yl y O which inquires a pemtit to const..d,ahcn improve,demolish,or repair any succmte
prions its issu:mce.elsonsliires thevpplicuot for.xch permit tofile a signed smtement
SPECIAL CIRCUITIMISC.
2�a� that he is licensed pursuant to the provisions of Ne Contractors License Law(Chapter 9
O (commencing with Section 7")of Division 3 ofthe Business and Professions Costello TEMP.METER OR POLE INST. COMMERCIAL
dpi5�o y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
W^w Section]031.5 by anyepplicam for a permit subjects the applicant to a civil penalty of POWER DEVICES D NEW BLDGIADDITION CI DEMOLITION
Z} not mom than five hundred dollars($5000. DTENANT D FOOD SERVICE
C6� Dl,asownerof the propedy,omny employees with wall,as lbeirsolecnmpcnsatimt, SWIMMING POOL ELECTRIC IMPROVEMENT
d 3$ wdldothe work,and the structure is not intended or offered formle(Sec.]044,Business ❑OTHER
and Pmrexaions Cade:The Contractors License Law does not apply to an owner of OIffLETS-SWR H - -URES
pmpeny who builds Of maneves thereon,and whit does such work himself or thum,h
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENTIA R SQ FI'.
sale.if.however the building or improvement is sold within One year ofcompletion,the SQ.FT.FLOOR AREA SISQ.ET.
owneo-huilder will have the burden of proving that he did not build or improve for par- r� r
pox of sale.). L
❑1,as owner Of the Progeny.am exclusively convecting with licensed commctors to TAL:
conalmn the p Ject ISw,9044,Business and Professions Coda)The Convacon's U.
cense Law does not applymm owner of Pmpcny who builds or improves thereon,and QTV PI 1 PI: IT FEE MAY 30 ]996
who convects for such pmjtt¢with a contmctogs)licensed pursuant to the Contractor.
License l.aw, yy V
D Iamcmmpt under Sec. ,B&P C forthis reason PERMIT 'SUA CE Cil 1 UI. 41 Lss111YV
Owner ALTER-DRAIN&VE -WA (EA) S
Date VALUATION
WORKERS CO, ATIONrfurym DECLARATION BACK FLOW PROTECT.DE
I hereby alarm under penalty oeperjury one of Ne following decimations
.,:(have and will forhy' aCeni ficmeof the elan Care.fortfur Workers Compen, DRseaAINS-Ft. R.RODEARP.A,C D..
as pmvid d for by Section d. of the Lahu Code,for the performance of the STORIES TYPE CONSTRUCTION
work and this maintain
issued FIXTURES-PER TRAP
❑ 1have Of
will mainminheWorkers
performance
me ion
hi as required by Section
J]W of the Labor Code,for performance of the work far which this permit is issued. GAS-EA.SYSTFM-1 INC.40IITL. 5
My Workers Compensation Insurance center and Policy number are: OCC GROUP APN
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASERNDUSTRL WASTE INTERCEPTOR
(This section need not he completed Elbepormit is forone hundred dollars( PIE - LDI IVISIONF :S
Or leas.) GREASE TRAP
Inudity that in the performance of the work for which this permit is issued l shall PLAN 11 K 'E
not employ any person in any nommurso as m become subject to the Workers'Cnmpc . SEWER-SANITARY-STORM EA,200 FT.
action Laws of California Date ENERG E
O O Applicant WATER HEATER WNF.NTIELECIR
C a' NOTICE TO APPLICANT,If.vfmr making this Certificate of Exemption. GRADI
a become subject m the Worker's Compensation pmvisions of the Labor Code,you must WATT7R SYSTEMOTI GATING '
fhwith comply SO E
ort
p y wird such pmvisions or Nis permit shall h domed revoke]. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. SQ.FT. PAID
UO (hereby affirm that there is a comundinn lending agency for the performance of Dine Rttciptp
w the work for which this permit is issued(Sec.309],Civ.C.)
O Z Lender's Name
Lenders AddressTOTAL:
TOTAL:
G I certify Not I have read this application and state that the shove information is BUILDING FEE
W m mm l agree m comply with all rdy iu d manly intimi nces candidate laws rclvting to QTY. MECHANICAL PERMIT FEE
U z buildallicammaion,end hereb,miduMimiae repof this citymenmr uponthe SEISMIC FEE
above-mentioned property for inspection purposes.
(We)-go-to save,indemnify and keep harmless the Cit of Cu ninoaainst PERMIT ISSUANCE - -
liabilities,judgments,costs and expenses which ma nen y d ELECTRIC FEE
in consequence of the granting of this permit, yr my against said City ALTER OR ADD TO MITCH.
PLUMBING FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT DYl 10.008 CFM)
SOURCE REGULATIONS. MECHANICAL FE
AIR HANDLING UNIT(OVER IB,BfXI CPM) CONSTRUCTIONT
Stgnmum m Appcermulmovacmr Date EXHAUST HOOD(WIDUCT)
HAZARDOUS MATERIALS DISCLOSURE - HOUSING MITIGATION
Will flue applicant orfumrc boildingoccupam smrearhvndlehmarJous material HEATING UNIT(TO I00,00-BTU)
as defined by the Cotentin Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)^ HEATING UNIT(OVER 110,000 BTU)
❑Yes EINo
VENTILATION FAN(SINGLE.RFSID) PAID
Will the app onto it ficants building by the tt Use equipment or devices which Date Receipt a
emit hazoNoos air cantaminamsu Defined by the Be,Arca Air Quality Management BOILER-COMP(3NP OR 100,000 BTU) •
District? TOTAL:
❑Yes UNo BOILHR-COMP(OVER L00,00011TU)
I have..it the hmallous materials ash immems under Chapter 6.95 of the Cali- AIR CONDITIONER
foods Health&Safety Code,Sections 25505.25533 tied 25534.I understand that file ISSUANCE DATE
buildingdmsnoteu ntlyhaveatcnuLNat it is mymponsmilitytonoufytheoccupant NEW RESIDENTIAL MECH. SQ.IT.
of the requirements which must be met prior to issuance of a Certificate of txrupaocy.
Owner Or outhonxdagant Dam s TOTAL:
ISSUED BY:
OFFICE