29839 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL - 29839
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRCSS: SANITARY NO. APPLIC TION SUBMITTAL HATE
'-7/035/ penJson Avc
'ER'S Amyx PHONE: CONFR OR'S NA r. IC NO:
ser{( ; /&e sl 2S-195 70 c. S er"� G r002' NIC co.TRol.a
ARCHITECF/IiNGINEER: LIC NO: A RCSS; ❑
22 FOSS �_
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B ELECT PLUMI ME.H
El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 north,affirm that I am licensed under provision,of Chapter 9(commencing JOB DESCRIPTION
W0Z with SectionJ(N0)of Division Td the Business and Professions Code,and my license,.,
W O O PERMIT ISSUANCE RESIDENTIAL:
a=-F` in force and ��Ms��=—_z
UU LmeJtc - _ ca f0yJf_� ❑51'UWL ❑KITCHIiN REMODEL
iZzw }MCc Contrstnr AvvL1ANCE5-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
in f- r�r ANCIi1TRCTS DECLARATION PANELS ❑MUI.TI-UNIT (]STRUCTURAL
OvinZ I understand my plans shall he mad.spubl,.crecords MODIFICATION
Z^- UP T020)AMPS '
[. F-W Licensed Professional
kINRR ❑CHIMNCY REPAIR
OWNERHUILDER DECLARATION 2(11-1000AMP5 EMENQ 1 M1ercby affirm Nal l ar exempt from the RATI lt)rs Liccnsc Law forthe OVER UCIIAMPS MO iUREPAIR DEMOITION
3dfollowing teaser.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICALOT
W vFi whiah renuine,a perms 1.mnomin,she,,Intpr ve,dcmWNb,or ,paan
ir y,micutrc
F'L�C) 5 prior to its issuance,also requires the applicant for ouch Permit o rile a signed statement SPECIAL Cl RCUIT/MISC.
F.n> that he is licensed pursuant to the provtsions of the Contractor's License law(Chapter9 as
� (commencing with Section 20Jo)af D,.vision 7ofthe Bus,.nes,and Pndacsinns Cada)m TEMP.METER OR POLE INST. COMMERCIAL
:
la.M that he is exempt therefrom and the basis In,the alleged axetnpuon.Any cadmium of ❑NEW BLDG/AUDITION ❑DEMOLITION
V�-� Saurian]631.5hy,my applicant far a annul subjects the aludemm too civil penalty of POWER DEVICES
not mann than five handled dollars(S500).
❑TENANT ❑FOODSERVICE
F=6 O I,as owner of Ne pmpenp or my employees with wages as their sole compensation. SPTMMINGPOOLELECTRIC IMPROVEMENT
aFa will do thework.rad thcnmaurc ixnotimoodedmo[fcteJfnr sale(Sec9(414.Businca R
W�m and F9ml'rs,ion,Coale The Contraao ,License law dna,not apply ,bt an owner of OUTLETS-SWITCHES-FIXT'URE'S -
�' property who builds or Improves thereon,and who dine,such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL F.LECTR SQ FT.
sale.IL however.the building or improvement is suldwilhir one year ofenmpletion.the SQ.FT.T1_OORAREA S/SQ.14.
erbuilder will have the burden of proving that he did nm build or improve for put- A �/ h
now ot'salc.).
❑ I,as owner of the property,ant exclusively contracting with licensed commaars to TOTAL: /1/�
construct the pro614
project(Sec.] ,Business and Professions Code:)The Com �/�
racmr's Li- (]
cerise....
Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE n 19
who commca 4,f,ncltpojca,wall aeommnmLl licenced pursuant to Ill,Conausiod tit/ II � O6
License law. L
L] PGRMIT ISSUANCE Vr I am exempt under Sec. ,B&P C for Nis reason t ('rlrll4•
Owner Data ALTER-DRAIN&VENT-WATER(EA) 1 VaAALUUAHON
WORKER'S COMPENSA1 I(1N DECLARATION B PROTECT.DEVICE
I hereby affirm under Penalty of perjury One Of the following declarations: 111 V
❑I have and w ill maintain a Cenificale ofConvmto wlLinsute for Workers Crimper- DRA1N5- .00R.ROOF.AREA.GOND. STO0.IfS TYPE CONSTRUCTION
sation,as provided for by Section 37M of the labor Code,for the perfnmwnce of the
k forw ch this prml J ES-PER TRAP
war Ix c t Is Imus .
❑I in and will nmimma Worker',Compenoainn lncnrunce,as required by Socdon
3] nflhe1Lcl rCcsle.Jsfoor the pcffmmanceofthe work for which Nis Permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
Gamier oie- nr^'(P�l+'r aPRc3,No,:
nly��tpd�+gpp�)yy�� C
CLY///7,"/rGs GAS-EA.SYSTEM OVER 4(EA)
CRRI'IFICATL OF IiXEMPIdoN FROM WORKERS'
COMPENSATION INSURANCE GREASE/RiGus;ITL WASTE INTERCEPTOR
This section need eat be completed irthe Permit is for one handml dollars OD W) BUILDING DIVISION FEES
or less) GREASETRAP PLANCHECK FEB
(certify Natini a twiforomanymannrof lbs work for subjectdri,
permit isissuedlsven- SEWER-SANITARY-STORM EA.VIII 1"f
nm employ any Pecam in any manner so as in Iwcunm subject n+the Workers'Camper- ENERGY EEE
O Z ,sheen laws of Cahlorria.Date WATER HEATER WNENT/ELECFR -
Z O Applicant GRADINGFEE
y NOTICE TO APPLICANT.IL attar making this CeNfica,of Exemption,you.should WNFER SYSTI?MarREATING
a ? become subject In the Worker's CO..danumion pnomons of the Labor Code,you must SOILS FIRE
4L) fonhwith comply witbsoeh pmmslonsor this permit shall lwdttmed revoked. WNI ER SERVICE
aQ
7z CONSTRUCTION LENDING AGENCY NEW RFSIDENI'IALPLMe. SQ.PL PAID
U (hereby afffm thathem is vconswainn lending agency Teethe performance of a ce,.pod
F-' the work for which this permit is Issue l(Sec.3092,Civ.C.) -
0 Lender's Name TOTAL:
V Lender's Address TOTAL:
I reality that 1 have read this oppbcainn and Stam that the above information is BUILDING FEE
y const.I agree to comply with all city and county ordinances and state laws raising to QTY. MECHANICAL PERMIT FEE
V Z building construction,and M1ercby anlhnris raPrcmnmtivcx of this city to enter upon the SEISMIC FEE '
above mentioned property for infection purposes. PERMIT ISSUANCE Way agree to save,indemnify and keep harmdi
less the City of Cupener against ELECTRIC
Imbilities.judgmenss costs and expenses which may in any way accrue against said City ALIT OR ADD TO MECH,
in ttmayucnce of the granting of th is permit. PLUMBING TBE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINTAIR HANDLING UNIT(TO10.001 CFM)
SOURCE RF LA'rIONS. MECHANIC
AIR HANDLING UNIT(OVER 10,00 CFM)
�/- CONSTRUCTION TAX
mace Applicmn/Ci TrC r , TData EXHAUSTHOOD(W/WCL') HOUSING MITIGATION
f{ ',ARDOUSRIALS DISCLOSURP.
Will the applicant or future building occupant store or handle M1azanlou,material HEATING UNIT(TO 100.000 BTU)
a,defined by the Cupertino Municipal Cede.Chapter 9.12,and the Health and Safely
Crile,Section 255321st)! HHA'IING UNIT(OVER 101,100 BTU)
E3 Yes 0 N PAID
VIRNI'ILATION PAN(SINGLE RES HU Dae Racip x
Will the applicant in future building by the Bt use Area
Air Qu or device,which
Distant?
hueuNnus sir contaminants as defined by the Bey Arca Air Quality Management IiU1LER-COMP(3HP OR 10L00 BTU)
Di,Wn2 T TAh;
❑Yes ❑Na BUILHR-COMP(OVER I1N1.lN10 BTU)
I have read the harardous maerials rcquimmerm,ander Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATEfomia Health&Safety Code,Sections 25505,25533 and 25534,1 understand that if the NIRW RESIDENTIAL MF,CH. SQ.FT
handing Nu not errantly have it IcreaL in.,it I,nay noism,dility to mady the occupant
of Ne requ,.remen¢which most killer prior u,Issuance of a CeN6eae of(R,.,.y,
o vire"u authonecJ agent Dote TOTAL: ISSUED 11Y:
OFFICE