29929 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUpERTINO BUILDING-ELECTRIGAI. PERMIT NO.
6UILDINGb�:arISION APPLICATION/PERMITPLUMBING-MECHANICAL ' 29929
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNC ' PHONE: NTRACTOR'S NAMIi: LIC NO:
,\ Tf1'4 IOG . O NIC CONTROL#
SAE f ECT/EN GINE£µ: - LIC NO� URESS: T+ elle VV` ❑
IY` La
CONTACT: PHONE: BUILDING PERMIT INFO
�IG Jy y� �/Q ,� .��J ❑ Consultant Pecs Pald by dpplicant(Initial) LDG ,ELECT PLUMB MECH
Ol G� 'TELL / ❑ ❑
LICENSED CONTRACI'OR's DECLARATION QTY ELECTRICPERMIT FEE
1 hereby affirm that 1 nm fthe al under pmvisions of Chnpmr 9(commencing JOB DESCRIPTION
OWZ{{y�00 with Section 9000)Ifoivisian 3onhe Busineaa arta vrofesailnseee,ane mylicman is RESIDENTIAL,
as W Oqq in full force end effec // PERMIT ISSUANCE
aU❑❑❑❑t' _a. v Lica b ❑ADWL ❑KITCHEN REMODEL
�n a,� Da¢ Comrucnn APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RB-PIPE
CTS DECLARATION El MULTI-UNIT El STRUCTURAL
zIb{ rs
K - Iumdetandmy plans shall he medispublic records PANELS MODIFICATION '•
0z�L" a# UP TO 200 AMPS
C El INTERIOR ❑CHIMNEY REPAIR
Licensed Foraomad
201-1 WIIAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER EMOAMPS - ❑BATH REMODEUREPAIR ❑DEMOLITION
yy G I hereby affirm that 1 1. exempt from the Conlrns C h,Ad,c Law for Ne
ltd 3 C.V following mason.(Section 1o3L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
aB]]^LLO which its requires a a pentyl to conswct,alma improve,demolish, fi repwr any structure -
thathpoor oslcensemossorequirhe theapplicantfor such Contractor lLicesL.,(chapt em gPGC1ALCIRCUIT/MISC.
} thatheiscing wit purstion7 the of Division
of Ne Contractor License Law(Chapter9
aOC that he I,engwieh Sereno'/1100)of basis lot IleacegedIssmd Professions Code)or TEMP MBTIiR OR POLE INSi COMMERCIAL:
Ihne he is exempt eaerefmm and the basis for the alleged exemption.Any violation ofBLDG/ADDITION El DEMOLITION
,-y Section 2031.5 by tory applicant for o Permit subjects the applicant to a civil penalty of POWER DEVICES NANT El FOOD SERVICE
�Cat mom Nan five hundred dollars(8501). IN OVEMENT
❑1.asowner of Ne property,or my employees with wages as their sole compensation, SWIMMING POOL F.LEC'rRIC ,
will Jo the work unJ the Wmcturc is not imenJee Ir of&red for sale(Sec.7044,Basineaa [10 THER
mand Professions Cwk'.The Contracmes License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
q 66 property who build or improves thertnn,and who docs such work himself or through _
his own employees,provital that such improvements art not immmde ar offered for - NEW RESIDENTIAL ELECTR SQ F4.
sale.If,however,the building or improvement is sold within one yeemdcompletionJhe SQ.FT.FLOOR AREA $/SQ,FT.
owner-builder will have the burden of proving that he did not build or improve for put-
pose of soled. y
❑h as owner of the Property,am cfi
eaclmively conanng with license comrac ms to T AI ♦ 4t 4'1 B W
construct the project(Sec.21WQ Business amt Professions Code)The Contractors Li--
sense Law does not apply to sn owner of Property whit builds or improves thereon,and QTY, ,,UM C PERMIT FEE NA Y,2Z 9
who contracts for such project with a conbactor(s)licensed pursuant the Contractor's
License law. /�9. PERM IS -CE �II 9 u
❑�Iamexemptueer Scc. ,B&PCfmthi,.mmn "s7, .� r�/r .
Owner Data ALTER-DRAIN& ATER ) sVALUATIgN!'t
WORKER'S COMPENSATION DECLARATION BACK FLO OTECT
I hereby elEmn under penalty of pserjory one of the following declarations: `
El Ihaveand will maintain nCenifieateofConsentmulf-insure for WorkasCompen- DRAINS-FLUOR,RO 11A,C STORIES TYPE CONSTRUCTION
virion,es provided for by Senimn 37M of the Labor Code,far he perfmmunce of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workets Compensation fiv urmme,as mi that by Senor, .11
37M ofehe Lehr Code.forthe afffomume of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
OCC.GROUP APN
� My War 1 n nsumncecarrier and Policymyrobef itrwlsaia. [' GAS- - R4(EA)
Cnrticc Policy No.: Ci)) Vs.�la7 '
"L EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRL WAST RCEPfOR
UILDING T11VISION FEES
(This section need not be completed if Ne penin is for one hundred dollam 1$100)
or less) GRCASETRAP PLANC FEE 5
I certify that in the performance ofthe work for which this permit is issue,IshallSEWER-SANITARY-S CA.200 FT.
not employ arty person in any manner vn an m become subject to the Workers Contain- ENERO .E
O Z section Laws of California Dam WATER HEATER WNEM/ELE
.
C Applicant GR DI E
Vy NOTICE TO APPLICANT.If,after making this Certificate of 13sempeion,you should WAFER SYSTENUTREATING
a [' become subject to the Workets Compriu mion provisions mine Labor Cee,you muse
{J7 {may forthwith comply with such pmvisions or this permitmall be deemM resulted. WATER SERVICE
0. Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. S PAID
U 0 1hereb;.drimrtNm there isamnslruction lending agency for the performance of Dam RaciptIf
the work for which this permit is issue(Sec.3097.Civ.CJ
E' Landels Name' TOTAL:
U Larders Address TOTAL:
>iL1a 1 certify Ihml have read Nis application and same tbm the above information is IL G FEE
..I.l agree to comply with all city and county ordinances and some laws relating to QTY, MECHANICAL PERMIT FEESMIC FEE
U building construction,and hereby auNorim representatives of this city m enter upon the
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless[be City of Cupertino against ELECTRIC FEE
linhilieien,judgmena.costs and expenses which may in any wry necme against safJ City ALTER OR ADD TO MECH.
in asequence of the gmrdm,of this Fennie. PLUMPING FEE
APPLICANT UNDERSTANDS AND WILL COM PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL
FEC
SOURCE REGULATIONS.
/N I7 w}�a„- 5 /1-4
11 AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCf10NTAX
Signal�licaugComramr ] Date -11[f EXHAUST FOOD ONfOUCT) HOUSING MITIGATION
HAZ.M DOUS MATERIALS DISCLOSURE
Will the ,he.,or it..building occupamsmm nr handle hamolous mmenal HEATING UNIT(TO I010,000 BTU)
in define by the Cupertino Municipal Code.Chupecr 9.12,and the Health and Safety
Code.Section 25532(a)! HEATING UNIT(OVER 100,000 BTU)
C)Yes ❑No VENTILATION FAN(SINGLE RESIDE PAID
Will the applicant or future building occupant use eyuipmem or de it.which Dam Receipt X
mit hazardous air cnnmmimaats as defined by the Boy Area Air Quality Management BOILER-COMP(3HP OR 10k001 BTU)
TOTAL:
District?
BOILER-COMP(OVER 100,000 BTU) '•
❑Yes ❑No
AIR CONDITIONER
I have read the hazardous mmmals requirements under Chapter 695 of Ne Cali. ISSUA
humin Health At Safety Code,Sections 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MCCH. SQ.FT. '
building does not currently have a manor,that it is my resp romiliey to notify the tmcuponl,
of But refinements which must ba met primmIssuance ofaCertificate of Occupancy.
Owner or authd onmagent Use TOTAL: - ISSUCD BV:
OFFICE.