29535 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY r
CITY OF CUPERTINO I BUILDING-ELECTRICAL - PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBING.MECHANICAL.
BUILDING PROJECT IDENTIFICATION 2953
BUILDING ADDRESS: ' SANITARYNO: APPLICATION SUBMITTAL EA"
J
/c .f S S H,4 LL �� LES a
OWNER'S NAME GGG /P�N�OO 9 CON'1'RACTOR'SNAME: LIC NO:
NIC CENTRO L#
CHI ECT/ENGINEER: LIC NO: ADDRESS: ❑ '
e �:f 2 0
t CNA PHONE: - BUILDING PERMIT INFO
K —a O / ❑ CBngWtant Fees Paid by Applicant(Initial) BLDGCT P UM
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE X1 hereby affirm that{an lieeneed under provisions of Chapter 9(commencing J B DESCRIPTION
{Q{�WZ with Section 0000)of Division 3 of the Bisinessand Professions Code,enormity license is RESIDENTIAL'
FWD full force and effect. PERMIT ISSUANCE ,
F-W u rn TV5FDWL ❑KITCHEN REMODEL
UzV License Class Liam APPLIANCES-RESIDENTIAL, ADDITION '. El PLUMBING 11CPIPE
y64 Date Contractor°
p.,pm ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
1 understand m I PANELS p MODIFICATION
ZOryi- my shall be used as public recoMs
OZ-- UP T(3200 AMPS E31 OR
f - El CHIMNEY REPAIR
Licensed Profeasmnul 201-I000AMPS - IMPROVEMENT J
OWNER-BUILDER DECLARATIONheComani OVER lr(RAMPS ❑BATH REMODEUREPAIR El DEMOLITION
Ls 0'G 1 hereby affirm that 1 1 exempt front the Colicin o :License., Law for the
ippi5$� :d U following reason.(Section 903 L5,Business and Professions Code Any city bec.untY SIGNS ELECTRICAL ❑OTHER 1
t++ �I"' which qure: "num,l me" idea,i pm- diminish, p' any.[acture
peonwo itsl..0 Iso req se,thop.mlicomalretouch peit to file.sSeed:mlemert SPECIAL CIRCUIT/MISC. .
} that he licensedpursuu pursuant theprovisions of the Contractor's LteneL (Chapter9
yGy
(commencingwth Secti 9000) fD 'sin 3 flh B ss andP f ns C(do7 or TEMP METER OR POLE INST, AMS�AL'
G m C thin h pt theref d thebasis f Nalleged exemption,Any ioIaliun of r
a1 4 Section]03LSh brain fern JEW BLDG/ADDITION ❑DEMOLITION
by app pe,nnt objects the appl cam to a civil penally of POWER DEVICES ` TENANT ❑FOOD SERVICE
�. not more than eve hundred dollars($500). .
E]I.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure boner intended(unforced f.eeale(Sea 70L4,Business - ❑OTHER
L 3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES �O LIn Q IrA
property who builds or improves thereon,and who does such work himself or through
his own employees,prnvided that such improvements are no[intended or offered for NEW RESIDENTIAL ELECPR SQ FT. "
sale.If,however,Rebuilding orimprovement is sold within one year ofcompletion.rhe �LSPJIPI'. RpBEp� S/SQ.FT.
owner-builder will have the hander of proving that he did not build or improve for put-
❑L as owner or the property,out exclusively competing with Ilecrsed oontracers to TOTAL !x '
construct the project(Sec.1044,Business and Professions Code:)The Contractor's Li- !`
,fY(ou .
ease Law does no[npplyab owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE I_�IF�J./V1
who contracts for such projects with a contranor(a)licensed pursuant to Ibe Gmlpclors
License Law. PERMIT ISSUANCE '
1 oro exempt under Sec. •,B as P C far this reason
Oit--.1% ALTER-DRAIN&VENT-WATER(EA) ^ VALUA^TION
WORKER'S C PENSATION DECLARATION—�� BACK FLOW PROTECT:DEVICE
I hereby affirm under penalty(f pe jury no of the following declarations: �W a
I have and will#almaima CertificateConsent of Conseno self-insure for Worker's Compen- 'DRAINS-FLOOR,ROOF.AR[iA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3]00 of the labor Cade,for the per&nnnance of the
work for which this pa roar is issued. FIXTURES-PER TRAP y
❑I have and will maintain Worker's Compensation lime mnce:as required by Senior
370 of the Labor Code,for the performance of the work for which'his loomot is issued. GAS-PA.SYSTEM-I INC.4 OUTLET DEC.GROUP APN
My Workers Compensation Insurance carrier and Policy...her..
Entice: Policy NO: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREssSEIINDUSTRL WASTE INTERCEPTOR
(Thisseeti.e.ced not IN,completed if the peruchn,forone hundred dollars 0[ad) BUILDING DIVISION FEES
orleasJGREASETRAP -
s' - - - PCANCHECK FEE
Loy any Pershat on in
pelfiraany
the work for subjech tt to themit is okes Campioll
n -
" omen Law,any person in any manner so asmbecome subject to the Workers Campion- SEWER-SANITARY-STORM EA.200 FL '
0 O prion Laws of California.Da¢ P�n ENERGY 1'f,L P
Applicant - WATER HEATER WNENT/ELECTR GRADING FEE
y NOTICE'TO APPLICANT:If,after making this Cetificate of Exemption,you should WATER SYSTEM/TREATING
become subject to the Worker's Compensali(n provisions of the Leber Code,you most SOILS FEE.
Wti forthwith comply with such Provisions or this permit shall be deemedrev(ked. WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ FT. PAID
0 I hereby affirm that there is a consl111elion lending agency for e perman
bncx.f _ Date [m
;tsF+ the weak for which this permit is issued Clow.31)9],Civ.CJ
O F+ Lender's Name 'TOTAL:
V Lender's Address TOTAL:
y 1 certify that 1 have .it this application and.nate that the above information is BUILDING 13PI, f92.a..'a fn correct:1 agree to comply with all city and county ordinances and stale laws reliningm QTY. MECHANICAL PERMIT FEE
Z building construnioeand hereby aulhorzrrepms(ntaves of this city to enter uponde, SEISM E-mvbnveenti.ned property for inspection propos es' PERMIT ISSUANCE(We)agree l(save,indemnify and keep harmlessthe City of Catoctin.against ELE RI E
liabilities,judgmeals,costs and expenses which may in any way accmeagainst said City ALTER OR ADD TO MECH.
iac.nsequcnce.fthe granting of this permit, PLUM GFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH'ALL NON�POINT AIR HANDLING UNIT OD 1(1.000 CFM)
SOURCE REGULATIONS: ., MECHANICAL FF
AIR HANDLING UNIT(OVER 10,004 FM) CONSTRUCI'IO TAX
SignamreofApplicaUContrac'or .Dale 'EXHAUST HOOD(W/DUCT) HOUSING MI GATION FEE
HAZARDOUS MATERIALS DISCLOSURE .Ii
Will the applicant or future building rotation store or handle haeardoms mulntial HEATING UNIT CIO 100,0110 BTU)
es defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER IEQINIO BTU)
❑Yes No PAID.
VENTILATION PAN(SINGLE 111111) PAID
Receip[m
Will the applicant or future building occupant use equipment nr devices which BOILER-COMP EIHP OR 100,000 BTU)'
mit hezard(us air c.maminanl5 as dermad by the Bay Area Air Quality Management
District? TOTAL:
❑Yes ❑No BOILER-COME(OVER 100,000 BTU)
I have readSubtly
Institutions Se materials requirements under .1 Chapter6.95d11.1 Cali- AIR CONDITIONER ISSUANCE
fomia Health ac Salary Cale,Sections 25505,25531 and 25534.1 understand Ihil if the NEW RESIDENTIAL MECH. SQ.FT. -
building does nm is which have came.p that,,is my c re
sponsibility Cerdf a notify Ne occupant
of the requirements which must be mel pri(rmissuancc oda Certificvm of Occupancy.
Owner or authorized agent', Dae q TOTAL: ISSUED BY:
OFFICE