29830 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO . . BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. nO 0
BUILDING PROJECT IDENTIFICATION J
BUILDING ADDRESS: OSANITARY NO. APPLICATION SUBMITTAL DATE
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OWNER'S F,: PHONfs: CONTRA. Oft'S NAME: ^ LICN
q Q1� NIC CO ROLM
\RCHITE UMBER: LIC NO: �� ADDRT
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CONTACT: - - pit S(p BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL .. ELEg: PLUM MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{�B1pZ with Section 701X11 Of Division Sof the Bminessunl Professions Code,andmy license is
F0k-0�j in full farce road dad. (((���� �—s� PERMIT ISSUANCE R -ID NTI L
UW License Class t- Lic.p � FL..L' _L s� ❑SFDWL ❑KITCHEN REMODEL
tiro boy Date Conroe,. YYRU^KW�Afg APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
1..7sn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
Z o!!z� I underneml my plans shall be used as public records MODIFICATION
0Z%4 UP TO 2W AMPS
r4lFq iil Licensed Prommi...I 11 INTERIOR ❑CHIMNEYREPAIR
Y2 OWNER-BUILDER DECLARATION 201-1000AMPZ IMPROVEMENT
p,�•Ca]6 1 hereby affirm that 1 ten exempt from the Connector's License Law far the OVER I"AMPS ❑BATH REM EPAIR (]D M t+xT-I�ON/��
pe L U following reason.(Section 7031.5,Business and Professions Come:Any city or emmY /rte-'',"�TNER fN7(�L
L'{sp`l a p,F SIGNS ELECT
W which requires v Aran I.construct,alter,impmve,demolish,or repair any structure t—y prizatoits imanare,alsoreimmstheappBerri(orsuchPermittofileasignedstatement SPECIALCIRas�a that he is licensed pursuant ro the provisions ofthe Commcor',License Law(Chapter 9
al'. 00 (commencing with Section 70(X))ofDivision 3ofthe Business and Professions Cde)or TEMP.METERd a o that he is exempttherefrom end Ne basis for the alleged exemption.Any violation of ❑NEWBLDG/ADDITION ❑DEMOLITION
Section 1th L5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVInot mote than five hundreddollars($51 ). ❑TENANT ❑FOODSERVICECEl I.asowner of Ne pmpcnyor my emloces with waethilSWIMMING PIMPROVEMENT
will"the walk,and themuchow is not imerdaloroffered forsale(SIN.7044,Business 0OTHER
and Prufesslons C re:The Cartmeam's License Law does not apply to an owner of OUTLETS-S
property who holds or improves thereon,vad who does such work himself or through
his own employees,provide)that such improvements ere not intended or cqI m E for NEW RESIDGN DAL ELEC R PT, gT A 11.
IT
tele.If,however,the building or improvement is sold within uneyear,demopletion,the SQ.FT.FLOOR AREA ySQ.FT.
owner-budder will have the burden of proving that he did not build or improve far par-
sasown. {�pY 14 1996
❑1,as owner of the Sm. n)F am exclusively asmmetimg with licensed contractors m
construct the project(gee.o an Business and Professions Cade:?The Corrosion's Li
cense law does not apply m an owner of property who builds or improves Comme and QTY. PLUMBING PERMIT FEE /s fry
Liumicwho meta for such pmjccts with ecommdogglicenuJ pursuammth<Comr4cmrs y,11 OF vLO LTII IIVV
License exempt
` PERMIT ISS NCE
❑.1 am exempt under Sec. ,e A P C for this reason
Owner Dare ALTER-D All VENT-WATER HIA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FI. ECT.D. ICE
I hereby mffimn underpanalty ofpefjmy one ofdw following dxlamtinnc❑ "'] '
E have and Will maintain r Cenificamof Conuatto seL6insum for Workpete 2
eYs ComDRAINS- COR, OND. — LJL�IJ'
sation,as provided for by Section 37M of the Labor Cade,for the perfommnce of am STORIES TYPE CONSTRUCTION
work for which this permit is issued FIXTURES-PE RAP
0 I have and will maintain Worker's Compensation Insurance,az required by Section
37W of the Labor Cade,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 .40 EfS �� OCC.GROUP - APN
My Wor Coco mpensaion lnsurancc caller and Policy�t berere
Cartier:4Sr1I1 11A1A41'�pC tip_ olicy No.i Ka�xWy A�l- .T{D GAS-EA.SYSTEM-OVER 4 )
CERTIFTCATEOFRXEM IONFROMWORKERS'
COMPENSATION INSURANCE. GREASMNDUSTRL WASTE INTERCEPTOR
('Nis section need nm be completed ifthe permit is forms,hundred dollars IS I WE BUIL ISION FERS
or less) CREASE TRAP PLA CHECK
Loy any Natinthe Perforanyarnimet&0ce the work for subject
bjech thto pmarit the Workers
Compen-I shall SEWER-SANITARY-
O 0 not h Law any person in any mannenn as to become subject to the Workers'Cnmpem STORM EA.21X1 FL ENERGY FEE O
sation Laws of Califomiz.Data WATER HFATER W/VENT/ELECTR
O Applicant GRADING E
fq N mine I.OAPPUCANT:If,ober making this Certificate of
Exemption,you should WATER SYSTEM?REATING
UJ became s comp y id Workers Compcnsad s previsions of the Lehr Cade,you man SOILS h
Forthwith comply with tech previsions or this permit shall be JttmcJ revoke).
L�Lq Q NATER SERVICE
.7Z + CONST RUCTION LENDING AGENCY NEW REST DENTIAL PLACE. SQ.PE PAID
L) 0 l hereby affirm that is a construction lending agency for the performance of On Receiptp
IIr E•' the work for which this penom is issued(Sec.30)7,Civ.C.)
p U Lenders Name TOTAL:
yyy Lender's Address
G I minify Not I have read this application and nate that the above information is BUILDING E 2 �+
EVE cores.I agree m comply with all city and county ordinances and stare laws miming to QTY, MECHANICAL PERMIT
F
Ll� building construction,and hereby authorize representatives of this city to enter upon the SEISMIC E
r move-mentioned property for inspection purposes. PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless the City of Criammo against ELECTRI FEE
liabilities,judgmems,costs and expenses which twyin zany way mccme against smiJ City ALTER OR ADD TOMECH.
in consequence of the granting of this permit. - PLUMBIN FEE
APPLIC •• oS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(TO 10,0)0 CFM)
S I,REGULAT
• MECHANICAL D
AIR HANDLING UNIT(OVER 10,q(10CFM) CONSTRUCTION TAX
gig to Apphimutumamctor Date EXHAUST HOOD(WMUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FE
Will are applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I ER."BTU)
v defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
Code,Sermon 255320)? HEATING UNIT(OVER 100.000 BTU)
❑Yes No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Data Receipt
emit hazardous it civarom unrs ms defined by Ne Bay Arca Air Quality Management BOILER-COMP OUT OR 100,000 BTU) -
District? TOTAL:
OYcs No BOILER-COMP(OVER 1011"BTU)
I have real the hazardous materials requiuments under Chapter 6.95 of de Cali- AIR CONDITIONER
forma Health&Safety Code,Sections 25505,2533 and 25534.1 understand that if the ISSUANCE DATE
buildingdoea an
currently hvveeterent,Nand is my responsihilitym nrnify Ne occupant NEW RESIDENTIAL MECH. $Q.FT.
of the requirements which must be met prior to issuance of v Certinume of Occupancy.
Owner or vuNortzed a gent Date T T ISSUED BY:
OFFICE