29293 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 29293
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'1TAL DATE
,4n,2A Scv V_>
OWjHYi'$NA _Zf3=HONE: _ 4- CONTRACTOR'S NAME: LIC NO:
`{l•A�^4 `/�'mVgL NIC CION'1'ROLM
RCkHITE /FUEL EN ER: e_,rZ Gq2_ ADDRESS.
CONTACT. LQ wT0.•TINT (I,HOOSN4E:
BUILDING PERMIT INFO
72/ 334to ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH
LICENSED CONTRACf0R'S DECLARATION QTY. ELECTRIC PERMIT FEE Iry{I►
1 hereby affirm that I-am licensed under provisions Of Chapter 9(commencing JOB DESCRIPTION
O0Z with Section0000)of Division 3 Of the Business and Professions CWe,ard my license is RESIDENTIAL:
�U O O PERMIT ISSUANCE
FW Ltfoil forceandeffect.
❑SFDWL - ❑KITCHEN REMODEL
li U Dual' Class Li,.b t
4 Dote Comment APPLIANCES-RESIDENTIAL. ❑ADDITION [D PLUMBING RE-PIPE
y ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O�q dem ny p 9Y seJ rb is r ro PANELS MODIFICATION
OZ c • UPT02MAMPS [I INTERIOR [I CHIMNEY REPAIR
'4,Hp L' sed Pr el 2(11-IIXD AMPS IMPROVEMENT
S%Z 0
5 R-BUILDERDECLARATION OVER 1000 AMPS ❑BATHREMODEUREPAIR ❑DEMOLITION
G C 1 h y affirm thea I am exempt from the Contractor's License Law fur the
O6 U f reason.(Burton TOl LS,Busitrcss and Professions CWe:Any city or county SIGNS ELECTRICAL ❑OTHER
CF' whicw requires n permit m cornmct,alter,improve,demolish,or repair any swnore
prim to its issuance.also requires the applicant for such permit file o signed stm,ment SPECIAL Cl RCUIT/MISC.
�vW�vW�s} thea he is licensed pursuant to the provisions oftha Cmdatel ',License Law(Chapter 9 COMMERCIAL:
4'p0 (commencing with Section TOW)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.
4 p,M K thea be is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X 2 Secuon]01Ll by any applicant for a permusubjects the applicant ro a civil pemlry of POWER DEVICES
WAN NANTP000 SERVICE.
t more than five hundred dollars y employees
ZO ❑Lu the wrofthe pro psirtymmyemployeesw.fWages us leeit,, ftheirS sideCompensation,Bsatinn, 'SWIMMING POOL ELECTRIC IMPROVEMENT
OOL
will dr the work,and The hedroacom,Concis not inrondedoro w do far sale pply to ten,Bminaas Cl OTyER
4 and Professions CWe:The over thereon,
License Law does not apply to if owner of UTLBTS-SWITCHES-FI%TURES
..
property who builds or improves thereon,and who rices such work himself or through ✓ ..
his awn employees,pnrviJW that such mentis old w nm not intended u offered for NEW RESIDENTIAL ELECTR SQ NT.
sale.IL however.the building or improvement is sold within One year of completionJhe EQ.FT.FLOOR AREA E/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- �+0� +
L
Ease of tele]. -`7
❑1,es owner c f fl a property,am excursively committing with licensed convectors to TOTAL: `
construct the project(Sec.NAL Business and professions Code:)The Convnc,.rs U. _ 8 p,/
cense Low does not apply too.owner of property who builds m improv,,thereon,and QTY. PLUMBING PERMIT FEE
who contracts for sock projects with a co n rcmns)licensed pursuant to the Contractors pre
License I..w' t PERMIT ISSUANCE ,i
max under ,B&PCTorthisrtason ^ 199
ALTE
IN
VEN
Owner Dam BACK F OW PRO ECT.D ATER(EA) �red IAT1
ON
OI R'S COMPENSATION
on DECLARATION BACK PLOW PROTECT.DE*_j;,.
11 aRnn under penalty of perjury one of the following declarations: V
Ihave and will muinminaCertiOcate of Cunsenuo self-locum for Worker's Cnmpen- DRAINS-FLOOR,ROOF EA,COND, S RIES TYPE CONSTRUCTION
cation,as provided for by Section 3]0)of the Wbor Code,for the performance Of the
work for which this pernat is issued. FIXTURES-PERTRAp 47
'C]I have and will m6intain Worker's Compensation Insurance,as required by Section
37Wofthe Labor Code.to,the performat.ofthe weak for which This permit is issued GAS-EA.SYSTEM-IINCs60UTLE
My Workers Compensation Insurance carrier and Policy number we: WC,GROUP APN
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 6(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GRIT SFANDUSTRL WASTE INTERCEPTOR
(This suction residual be completed time permit is Toronto himmeddollars(8100) BUILDING DI BION FEES
Ides,] - GREASETRAP - PLANCHECK HE
I certify that in the pedonnmaearfthe work for which this permit is issued,l shot] SEWER-SANITARY-STORM EA.200 FT.
Out employ any person in any manner so w.to become subject n the Workers'Compen- ENERGY FEL' `
C) Z .solium Laws of California.Date WATER HEATER WNENT/ELECFR FEF
Q Applicant GRADING
y NOTICE TO APPLICANT:If,after inking this Certificate of Exemption,you should WATER SYSTEM/1'REATING
yy become subject 1.the Worker's Compensation provisions of the Lahr CWe,you most SOILS FE
F-t forthwith comply with such provisions or this permit shall be deemed revoked. WATERSERVICE
0. G
CONSTRUCTION LENDING AGENCY NEW RESIpENf1Al.PLMB. SQ,FE PAID Receiptp
i V p, Ihertby affirm that here isaconswetion lending agency for performance of
the work for which this permit is issued(See 3097,Civ.C.)
W [ti Lender's Name TOTAL
VL,nd,rs Address TOTAL:
Lk7 I certify that I have read this application Waal state that the above information is BUILD G FEE 1-1
10./1 cancer.I agree,.,amply with.((city and county ordinances and sane laws relating to QTY, MECHANICAL PERMIT FEE
7
V G hui]dingeonstrucuon,and hereby enhorive representatives ofahis city counter upon the SEISMIC HE
.have-mentioned property for inspection purposes. IPERMIT ISSUANCE, 1
(We)agree m s.vq indemnify and keep harmless the City of Cupertino against ELECTRIC FEF `1
liabilities,judgments.costs ande,penses which may in any way accrue against said City ALTER OR ADD',,MECH.
in consequence of the granting of this permit _ PLUMBING E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM) MECHANICFEE
SOURCE REGULATIONS.
IL c
Zf&Z AIR HANDLING UNIT(OVER IO."CFMI CONSTRU ONTAX
odefiby
l' n onto , Ute EXHAUST HWD OVMUCD HOUSING ITIGATION FEE
ZAR r S MATERIALS DISCLOSURE
ppliesnt Or future building recupare..real handle haendoas material 14BATING UNIT(TO IW.WO BTU)
Cupertino Municipal CWe,Chapter 9.12,and the Health and Safety5J2(a)7 HEATING UNIT(OVER I00,000 B'U)
[3 Y" No VF.N'TILATION FAN(SINGLE RESID) PAID
Date Ruceip
Wille,air conn Tants building by the Blase equipmentordevices which
mit hazardous sir contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(JHPOR I(03,000 BTU) TALL
pisvin9 -
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU) -
I have read the homdo.,,.serials requirements tome,Chapter&95 of the Cali- AIR CONDITIONER ISSUA DATE
Room Health&Safety Code,Sections 25505.25533 and 255fL 1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr.
building does not currently have a tenant,that it is my anprmsiMlity 10 modify the r ecupant ,
of the requirements which must lx met prior,.issuance d.Cent scare of Occupancy. ,
Owneroramhorizedngem Date TO L ISSUED BY:
OFFICE