29820 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO " - BUILDING-ELECTRICAL ^PERMIT NO. 29l�J('2^^ ^^O
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING MECHANICAL .. _
BUILDING PROJECT IDENTIF'ICA'TION
BUILDINGADDRISS:, s SANITARY NO. APPLICATION SUBMITTAL DATI
aas60e,rw S. 3a 9�
OWNER'S ME: �SS S CONT R'S NAM / L-/LIC NO:
NIC CONTROL#
CHH'ECT/ENGINEER: _ LIC NO: ADD ESS: / ❑
GOd 7 S Ah 12k-,(
t CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees.Paid by Applicant(Initial) _ BLDG ELECT; PLUMB MECH
❑ ❑ ; . ❑
fICCNSTU CON'1'RACTORSDECIARATION QTY ELECTRIC PERMIT FEE
I hereby Tfnn thin1 In.l eased under providonsof Chapter 9 lcommem'tg JOB DESCRIPTION-
QaZ with Section ToB lD 3 fthe Business end Professions Code,Dodo Icenmis
P 00 - y FERMI I'ISSUANCE RESIDENTIAL:
WU full farce and ailed. L EISFDWL - O KITCHEN REMODEL
a V w Data License Co.r APPLIANCES'-RESIDENTIAL, I
F�u] Data CrS DEmr ❑ADDITION �TLUMITURAL PIPIT
NOy ARCHITECFS DEC[ - - t,' ❑MULTI-UNIT t�$TRUCTURAh
F >> I'ANI?I ti t
ZO G lundcrstnnd my plans shall he used as public recnNs - MOUIPICAT'ION
O Z�O UI'TD 200AMPS ❑INTERIOR O CHIMN17Y REPAIR
FWN Licensed Professional '' 201-100IAMPS IMPROVEMENT
E 01 that I a exempt
DECLARATION OVER 1000AMPS - O BATH REMODEUREPAIR (]DEMOLITION
1 C W 1 hereby.(Sere that 1 ma eBusin from the Contractor's License Law for the _
4V followingmiss.permit
to
Business and Professions Co de:Any city or county SIGNS ELECTRICAL [I OTHER
which acquires a permit m construct,ahee improve.Demolish,or repair any swnurt
......111 prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
�} that he is licensed pursuant to the provision ofthe Contact Linnen Law(Chapter 9
141 �0 (commencing with Section 7000)of Division 3 afthe Busines std Professions Cale)or TEMP.METER OR POLE INST COMMERCIAL:
a y o K that he is exempt Therefrom and the basis far the alleged exempt nn,Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
.n Y. Section 1031,3 by any applicant for a Penni)subjects the applicant to a civil penalty of POWER DEVICES
,�..y tome than five hundred dollars 15500). ❑TENANT [I FOOD SERVICE
�=O Q I........f the depart or my employees with wages as their sole compensmion, SWIMMING POOL ELECTRIC IMPROVEMENT _
5aF willdsthework.andthestmcmm isnotintendedorofferedforsalc(Sn.70 ,Business OOTHER
uI m end Professions Code The Cnntrncm's License Law dos not apply to an owner of OUTLETS-SWITCHES-FIXT
property tubo builds or improves thereon,and who does such work himself or thmugh
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR - SQ FF..
sale If.however.the building or improvement is sold within one year ofcnmpletion,the - SQ.FTFLOORAREA $/SQ.FI'.
ownar-mildor will have the burden of proving that he did not build or improve for put. -
posoofsolo.). r - -
I;.v owner ollhe pmPcny,am as contracting with licensed contmcnors m - ' TOL' L A'
otnmmt the projnt(Sec.]014,13a.,i;m,,and Professions CedeO The Commaor's 1.1-
came,Law does not apply no on owimT of property who builds or improve;thereon,and QTY PLUMBING PERMIT F E
who contracts hasuch projects with a conuactood licensed pursuant to tho Contractor's
License Low. PERMIT'ISSUANCE j, O
O l am exempt under Sea. ,B&P C for this ratan _
Owner - Date
ALTER-DRAIN&,VENT-WATER HIA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herehy uform Out penalty of perjury one of the billowing• declarations O l have and will maintain aCenifiau
te ofComeno self-insure for Wmkcls Camper- DRAINS-FLUOR,ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
satiou,as provided far by Section 3]00 of the labor Cade,for the performance of the -,
work for which this permit is issued. FI%TURFS-PER TRAP I O
0 I have end will maintain Wsomex Compensation Insurance.u acquired by Section
3700 ofthe Labor Code,for the paforrounce ofthe work forwhichthis permitisissssuW. GAS-EA.SYSTEM-1 INC.4 OUTLE18 OCC.GROUPMy AYN
71-
Carrier o pcnse' sum ,caafterndCy No. GAS 1c' �J/ 2'"'/S GAS-EA.SYSTE•M-OVER 4(EA) ,
CERTIFICATE OF EXEMPTION FROM WORKERS"
COMPENSATION INSURANCE GREASFIINDUSTRL WAS3'E INTERCEPTOR _
ITho section need oat be completed iflhe permit is forma,hundred dollars($IUp t BUILDING DIVISION IT?F.S
or less) f , ORBASF,TRAY PLANCHECK FEE
Icemir that in the prrfonnonce al the work for which this permit is issued,I shill SEWER-SANITARY-STORM EA,200 FT.
not employ any person In any manner In as to become subject to he ON kers'Cnmpcn. ENERGY HE a
I _
Z smion Lwx of California Dat, WATER PIRATER W/VENT/ELF-CTR
7�7
Applicant - - GRADING FEE t
'a h NOTICE 31)APPLICANT If,n➢ermoking this Cenific to of Exemption,you should WATER S YS]EM/THE_ATING
become subject to the Worker's Compensation provisions of the Labor Code.you nisi - SOILS FEE
k7, forthwith comply with such provisions or this permit shall be deemed revoked. WATERSERVICF, t O
0
.CONSTRUCTION LENDING AGENCY NBW RE$IUENTIAL PLMB. SQ.FT. PAID
L) t7 l herebythat Permit i isacd(Sev.0G,Cleading
t,egenry for the Performance of Date ^ Receiptp
W.0 (•-' the work for which this permit is issued(Sec.]09],Civ.C)
lender's Name TOTAL:
IUT•I
Lardcr'�Addrxwxcavity
t TOTAL:
U y, 1 certify then 1 have !in this applicationac. and dam that xmmabove1 information is BUILDING FEE -
y building
l.greetocomply d with mldtynni rounsannativeso and dam mwsmlpingm QTY. MECHANICAL PERMIT FEE
U FZ•t building mnstmninn,and hereby amhsrimacpreunmtires of this city reenter upon the SEISMIC FEE
.bry>meuioned propmy for inspection purposes. j
PERMITISSUANCF. ' '
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
r liabililien,judgmenls,mstsandexpens'ws hmayinanywayaccmeagainlsaieCily ALTER OR ADD TO MECH. r 3V
in consequence of the gmmingof emit. PLUMBING FEE J
LICANT UND.It5TAN1 ; )WILL OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
:OU .EI ,UL TIONS MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX[ r,
Si arc fAfflicitat/Cotilbret Uom EXI IAUST HOOD(W/DUC) '
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Wil lithe applicant tartourer,building occupant store or handle hozanlous manrial. HEATING UNIT(TOI00,000 BTI)) -
as define)by the Culieninn Municipal Code,Chapter 9.12,and the Hculth:red Safety
Code,Section 255320)7• - HEATING UNIT(OVER 100,((X1 BTU)
❑Ycst x ❑No VEWI LAI'ION FAN(SINGLE RESID) PAID
Data Receipt#
Will the applicant or future building deadpanuse equipmcm or devices which pOILER-COMP DHP OR 100,0(X)BTU)
mit
ehmardom,air commodious as defined mli
ed by the Bay Area Air Qty Management TOTAL: S �/
Lngd- oo
p- BOILER 100.(1(10 BTU)
❑No - '
mail the hmallous..most,acsfamments under Chapmr 6.95 ofare Cut. AIRCONDITIONER ISSUANCE DATE
&Safety CWe,Sections 25505,25531 and 25514.I urdemtand Nat if the NEW RI'SIDENTIAL MECH, SQ.FT. - R ry 1) 9 O 1O 1(�
nor currently have.tenant,that it is my responsibility m notify the ovcupunn Mf fY 3 I Jvments which must he met prim m isuana of.Cenifrcam of Occupancy, �� /imaim .gent Umc TOTAL: g .(` �1/V,
OFFICE