29914 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO` - BUILDING.ELECTRICAL PERMITNO../���. 11..��
5
BUII,DING DIVISION t APPLICATIONAPERMIT PLUMBING-MECHANICAL L 1
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:. I I SANITARY NO. APPLICATION SUBMITTAL DATE
1 Lo4b I MDkipudx. A
OWNERS NAME: PHONE: " CONTRACrOR'S NAME: LIC NO:
'�' C,B� sz-�tea t -r '. - Q 3 '?ZD. N/c CONTROL is
\RC HITE(T/I!NGINEER: LICNO: O ADDRESS: ❑ t��
M T�we,�� 1 0 7H 'S.3' 'l Z YI+AT/f
CONTACT: PHONE: I ILDING'PERMIT INTO
' n ❑ Consultant Aces Paid by Applicant(Initial) - BLDG ELECT PLUMB MECH
• C1LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
.I heron,affirm Nat Into licensed under provisions of chapter 9(commencingJOB DESCRIPTION
'qaz with Section 7")of Division 3 of Ne Businessund Pudesions Codc.and my license is
�00 PERMIT ISSUANCE - RESIDENTIAL, ,
W in full eurea and effen. 1
p�.0❑❑❑❑ License Class ' Liaa W3� []SFDWL El KITCHEN REMODEL
yQ Doe - Comout �1•E•\MA�— - APPLIANCES-RESIDF.NI'IAL ❑ADDITION - O PLUMBING RE.PIPE
,;Don ARCIU]ECT'S DECLARATION PANELS ❑MULTI-UNIT '[]STRUCTURAL
z Otn4 [..delimit Pla ss 1 sed a. blit rccood MODIFICATION -
OZ4a - uP'1021XIAMPS ❑INTERIOR [I CHIMNEY REPAIR
r4F� Licensed l'mfesion 20L100(dAMPS IMPROVEMENT
��+ � OWNCR BUILDER U[ChAHA'TEON pyEµIfXX1AMl'S 0 BATH REMODELTEPAIR []DEMOLITION
j I hereby o that 1 am exempt from the Contractor's License Law for me
K O p,U following reason.(Section 9031.5,Business and 1'rolessinns fide:Any city or county SIGNS ELECT RICA.'+ ❑[]TILER
41 1+• which tNuims n permit to construct.alter,improve,demolish,or repair any sWcture
prior to its issuance,also requires the applicant for such permit to file a signed smtamtmt SPECIALCIRCUIT/MISC. 2
eW$2;!lad auuheis licensed pursuant o the provisions of No Connector's license Law(Chupler9
OC (commencing with Section 7")of Division 3 ofthe Business and Professions Curtin, TEMP.METER OR POLE INST. e1:1MMERCIAL if
Its�m m thm he is exempt Ihcrefrom and IM1c basis for the alleged exnnption.Auy violation of FDNEWB]LUC ION ❑DCMOLITION
Section?031:5 by anyapplicam far.pttmitsubjenx thcapplicanno.civil pewlty of POWER DEVICES,.non mare Nan Eve hundred dollars(E500). T []FOODSERVICH❑ I,os owner of the propeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC VEMENTwill do the work,and theswcture is not intended or offered for sale(See.7044,Business
and Profusions Code:The'Cnm nclueal License Law does not apply to no owner of OUTLETS-SWITCHES-FIXTURES
propeny who builds or improves thereon,and who does such work himself or through A t
his a employees,provided that such inrpmvemen.arc not intended or offered for NEW RESIDENTIAL EI.EC'rR S
s.a.If.mwevcr.ma building or improvement is sold within one year ofcomplelion,the SQ.FT.FLOOR ANG $6Q.FT,
owner-builder will have the burden of proving Nat he did net build or improve far par, ��� ��
peso of We.). � 1996
1,as owner of the Property,am exclusively contracting with licensed contractors to
construct the pnsject(Sec.90k4,Business and Professions Code:)The Contractor's Li-
cerse Law does net apply to an owner of property who tatilds of improves thereon,and QTY PLUMBING PERMIT FEE. Ul- � f
' whocometsforsuchprojectswithacontractor(s)licensedpursuanttotheCommcmrs /U
LIiIINU
License Law. I \ PERMITISSUANCE I
❑ 1 oto exemyt under Sec. _ ,B&P C fur mis'renwn
Owner DamALTER-DRAIN&VENT-WATER(P,AI VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby uffinn under peraly of perjury one of the following Jalarmions: J
•I]I have and will maintain s Certificate ofConacm to aelllinsara for Workers Compen. DRAINS-FLOOR.ROOF,ARIA,CONED. STORIES TYPLCONSTRUCIION
sdon,as provided for by Section 3703 of the lobo Core,for the perfommuce of the a
work for which rhi.+permit is i.vsued. FI%TURES-PERTRAP
1 have and will maintain Workers Compensation Insurance,us �
ruirad by Section
9')LUofthe Labor Code,formeperfnforactof the work By which thi,imint is issued. GAS-EA.SYSTI!M-1 NC.4(BUT
LGfS (3cc.GROUP APN
My Work y Qe9�aranJ Policy FJ be�pre"
Cartier.-r/L7=f1>VIA Policy No: IC_3 GAS-EA.SYSTEM-OVER 4(13A)
CHRTIFICA'rE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIRSDUSTRL WASTE INTERCEPTOR
(Thlssectom need not he completed if the penult is for one hundred delta.IS IFF) - - - BUILDING DTVI. )NPH
m1esJ GRPASE TRAP
• Isend ry thin in performance of the work for whi.h this perPGNCHECK FEEmit is issued, -
of employ an SEWER-SANITARY-STORM F.A.200 FT.
p y y person in any manner sen as ec�Re 51T Neenn she Workeri Compact- ENERGYFEE
Z sarion Laws of Cul ifom((t11R ~l/fTOO WATER HEATER W/VENr/ELECR
7Q 2 Applicant�f.lc GRADING FEE
r7 r4 NOTICE TO APPLIC I:1�,after mokmg thus Certificate of Exemption,you should WAI'IR SYS]EMA REA'1'ING
a ; become suhjecnn rhe vker's Compensation previsions of the Labor Code,you must SOILS FEE
{IJ fEly I
onhwithmmply with such provisiomorthis permitshall he deemed«voked. WATER SGRVICE
ow
�z CONSTHUCI'ION LENDING AGENCY NEWRESIDI!NTIALPLMB, SQ.PT. PAID
V 0 Ihereby efirm(hnuhem is a conseuction lending agency for the peroarmanexor - - DV e TFt»
rhe work for which this permit is issued(Sec.300.Ci,C.)
Q ULender's Name 'TOTAL: h-
U Lender's Address 1.
LL 1 certify Nnr I have mad his ap11iewina and slam that the thnve information is BUILDING PEE
777
Vi corrtcilagreens comply wire all city and county oNinances and stem lows relating to QTY, MECHANICAL PERMIT FEE
U building construction,and hereby nuthorine representatives of this city it)enter upon the SEISMICITE
abnve<nemioned propeny for inspection purposes. PERMIT ISSUANCE!
'(We)agree to save,indemnify and keep hamdess the City of Cupertino against ELECTRIC FET.
Imbiluies.judgmenrs.visas and expenses which may inany wayaccmc against said City ALTER OR ADD TO MECH. r
in asequence of the grunting of this permit. PLUMBING .E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 IO,0XI0CFM) - '-
SOURCE REGULATIONS. MECHAN .AL FEE
AIR I IANDLING UNIT(OVER 10,(0(1 CFM) CONSTCTIONTAX
Signature of Applica 'Use E%HAUSTHOOD(W/DUCr) HOU,.G MITIGATION FEE
I' ' HAZARDOUS
US MATENIALS DISCLOSURE
' Will the applicant or future building aceupam sone or handle herallous material I BEATING UNIT GO 101.000 BTU)
as defined by the Centro.Municipal Cole,Chnpor 9.12,and the IInJlh unJ Sudety
Cade.Section 25532(a)9 HEATING UNIT(OVER 100.000 BLU) ,
❑Yes E]No
VENTILATION FAN(SIN RFSID) PAID Dam Recciptp
Will the applicant of future building occupant use eAior devices which BOILER-COMP(311P OR 100,000 BTU)
/11
1—it humorous air contaminants us Jetined by the Bay Area Air r Quality Management
Disnriet
❑Yes, ❑Ne < 110IL17R-COMP(OVER 10X.000 RTU)
' r
I have d;he huzmilm,mnmrinlx rcyhirenanu under ChupmrfiJS of the Cnli- AIR CONDITIONER - NC DATE
faros Health&Safety Cae,Sections 25505 25533 and 25514 1 undessnd that if Ne NEW RESIDI!NTIAI.MECH. SQ.FT '
building does not currently have a mann,than t'.my fcsrym+ih l ty o notify the occupant,if me urumen whs oust bq met in t. ante ofa Certificate of Dix`;y.
Owner or Data TOTAL: ISSUED BY:
OFFICE