29318 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. QQI(� 1
BUILDING DIVISION APPLICATIOWPERMIT PLUMBINC,-MECHANICAL 2 V 318
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: :SAPNITARYNO. APPLICATION SUBMITTAL DATE
O� E2NOWNERSN - lb
COIJIROI,t
RCHITECTENGINEER: LIC NO: ADDRESS: .
Q IaltA//�
CONTACT: PHONE I BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
GmaL 76, t ?;)k-LAIDD ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARADON QTY ELECTRIC PERMIT FEE
1 hereby affirm than I am rrenam ander pmvi,mr,of Conine,9 pmro.mcing 'JOB DESCRIPTION
"Z with Srefiu 17000)ofDi,isinn3ofthcliasincax and Provisions Codr,and myliccnsc in RESIDENTIAL,
F O ' fullfnrte and effort PERMIT'ISSUANCE - N
aUV �aiccn 1- list ❑SPDWL L]KIT REMODEL
FZlal )at. Canitvnor BESIDEor - []ADDITION C1 PLUMBING RE-PIPE
IN,py ARCHITECTS DECLARATION ' PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZOyZ I understand my plans&hall he used as public recaNs MODIFICATION
OZ-o UP TO 200 AMPS
E ti L W Li m od Professional El INTERIOR 0 CHIMNEY REPAIR
Clad _1 OWNFR-BUILDER DECLARATION '-01-I(pIlAMPS IMPROVEMEYI'
G C W 6 1 hereby vffinn tom 1 not escmp(fru.the Contractor's License Law for the OVER 1000AMPS BATH REMOD1g1/REPAIR 0 DEMOLITION
3 W F following reason.(Section 90313.Business and Profusions Cmc:Any city or county SIGNS ELECTRICAL. OTHER k`EAZ
O y which mia permit m canemmt,ober,mtpmve.Jemoiixh,or repair arty gmduor
fFes,N.. priorto its issuance,also m4uirex theappbcam forxuch perntinn file a signed state.em SPECIAL CIRCUIT➢MISC.
WY that he is licensed pursuant o the provixions afthe Contractor's License Law(Chtmr)
gJ C) (commencingwith Smuon9(0Bof Dlvision3of the Bualnessand Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
a a c d' that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑OF:MOLITION
NSection 703 LS by any applicwl for.permit subjens the rpplir.nt to a civil perany of POWER DEVICES
FZY of more than five hundred dollars($500). ❑TENANT [I FOOD SERVICE
f=G ❑ Las ownerofthe propcny,of myemployms with wagexas theifsolecompensation. SWIMMING POOL ELECTRIC IMPROVEMENT
W1: will do the work,and the structure is not intended oroffererl fnreile(Sec.70H 'Buninex& ❑OTHER
W m unit Pmfusiws Code:'ITe Contmaorx License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who built,or Inipmvca Ummoa,and who does such work onoelf nr Imoueh
fix own employees,provided lim such improvcmc.s arc not Intended or offered for NEW RESIDENTIAL ELEC'Ot S iT.
•ale.IL howm'et,the building or iropmmou,ntissolJ within one year of completionthe SQlf FLOOR AREA $/SQ.EL
owner-builder will have the bunien of proving that he did not build or improve for put- ay
osD
pe of sele
T,asownenerMthe Smpeny,oresinessand welcoming with:)Tlm Contractor's Li-
TOTA A
wmwcl the pmlcn(Sec.T(H4,Business and Profnsiom Cede:)The Contvn.r's Li- Q
c se law does not apply toanowner ofpropcnywho builds orimproves theteon,and QTY. PLUMBING PERMIT 1996
who commat for such process with o conlm
tactors)licensed pursuant to The Co ac 's //�
License paw. PERMIT ISSUANCE Vr L
I um exempt under Sec. ,B&PCfm Ihismaaoo (Jl'Cn�/1�1f
Owner U:nc ALTER-DRAIN&VENT-WATER(PAT VALUATION
/• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby&!Isere under penult,of penury one of the following declarations:
Ibave.od will.aintain.CenificareofConrent 1. If- ume for Worker's Co.,.- DRAINS-FLUOR.ROOF.AR G,COND,
scion,as provided for by Section 3700 of the labor Code.for the p m om once of Bar STORIES i TYPE CONSTRUCTION
work far which this Permit is iaxum. FIXTURES-PER TRAP
Fl I have and will maintain Worker's Compensation Insurance,as required by Section
39W of the labor Core.for the T noonsince of The work for which(his permit is issued. GAS-EA.SYSTEM-1 INC. OUTLETS OCC GROUP APN
My Worker's Compcosminn Imurance carrier end Policy nuotRr are:
Came, Poley No, GAS-EA.SYSTEMOVER4(EA) - ..
CERTIFICATE OIr EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRE,ASOINDUSTRI,WASTE IN'T'ERCEPTOR
(This section need not be completed if the permit Is for one hundred dollars 01Off BUILDING DIVISION IEES
or lcsxJ GREASE'fRAP pfANCHECK FEEni
I rectify that in the perfommirance awork for which this Permit is issued,i shall
not employ any pen in any manner so as T.beton heel to the Workers'Com SIiWER-SANITARY-S'fORM EA.200 FT
_ 1 Pen- ENERGY FEE
zZ xainn laws�u CaliOrmia.Use q�1�' _ '{�+•�I�L-�•�
O Applicant �jFwl'f C—_ IN } WATER HEATER WNPM/ELECTR GRADING FEE
.Nr NOTICE TO APPLICANT,If,&her,making this Ccnificme of lisemptioi,you should WATER SYSTEMOREATING
a > become subject to be Workers Cnm(r n,.fion provixianv of the Labor Code. .it must SOILS THE
D-1 forthwith...ply wilh,tch previsions or this permit shall he damned revoked WAIVER SERVICE: -
oz C(l n'mis.c ON LENDING AGE NEW RESIDENTIAL PLMIL SQ.FT. PAT])
V O 1mrsbyvffirm that there isummawction lending agency for the performance of Date Receipt
r- the work for which thh permit if issued(See.3197.Civ.C.)
Lender's Name TOTAL:
} {Il 1<Wet's Addrcas TOTAL:
f•' 0. T certify that I have mad This application and state that the.bove information is BUILDING FEE
h ntrect.1 agree m comply with all city ane county oNinances nnJ atom laws rcmting to QTY.. MECHANICAL PERMIT IEE
V z building construction.and hereby authorize representatives of this city to enter upon The SEISMIC FEii
above-mentioned property far inxpcctian purpmes. PERMIT ISSUANCE So
(We)agree(o,aavo.Indcionoty and keep harmless the City of Cupertino against ELECTRIC IME
liabilities,judgments,costs and expense whichln,inany wa,amruemgmina,aid City gLTER OR ADD TO MECH.to mmecquence of the gaming of(hit perms. PLUMBING FEE
APPLICAJRT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00)CFM)
SOI'RCF EGULauPO MECHANICAL FEEii fl_ y AIR HANDLING UNIT(OVER IO,OpD CFM) CONSTRUCTIONTAX
Signaturcof AppllcmVC. tractor 1 Date EXHAUST HOOD(WNUC) HOUSING MITIGATION FEE
HA' RDOUS MATERIALS DISCLOSURIi
Will theupplicia,orfuture buildingrccupant,nor nr handle hamolo.,minimal HEATING UNIT(TO I W.0y)B'LU)
rx deGncd by The Copemoo Municipal Code,Chapter 9.12,and(hc IealTh and Sufcty
Code,Section 25532(u)'1. �...111/ I(EATING UNIT(OVER 100.AX)BTU)
Cl Yea T[INo PAID
lav R VENTILATION PAN(SINGLE RESID) Date Receipt 0
Will the applicant infuture building bthe occupantuse equipment Qu or dMana Management
p
:mit hazardous us air comomiwmsuJefinW by the Bay Arca Air Quality Management BOILER-COMP pHPOH 11X1000 BTU)
DixtrimP TOTAL:
El Yea No
BOILER-COMP(OVER IBB100,001) N
H ),'I
I have mad The hazmdrh�i.,huncriuls requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fornix health&Safety Cade,Sections 25505,25533 and 25534.1 undcrnand that if the NEW RESIDENTIAL.MECH SQ.rL
building does not currently have a moral,that it i,try respx.sihlliq to notify ton ouvpam
o1'the"siren tins which Fruit he reel priori Issuance of a Cenil icate of Occupancy.
Owner or authonzed agent Date TOTAL: 0
ISSUED If Y:
OFFICE