29526 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES--USE BALL—POINT PEN,ONLY ;y
CITY OF CUPERTINO ,BUILDING.ELECTRICAL ,'s, PERMIT NO: 29526',
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BUILDING DIVISION' APPLICATION/PERMIT" • - PLUMBING-MECHANICAL. ,r t - 2 9 5 2 6',
BUILDING PROJECT IDENTIFICATION r '
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
' NER'S NAME: PI{pry@ CTOR'S NAM LIC NO,
iA♦ I� - NIC CONTROL#
R ITECf N NEER: LI O: ,..
ry
CONTACT: HONE: .� - - BUILDING PERMIT INFO
spy @.••�.��
❑ Consultant Fees Petd by Applicant(imhal) BL LF@ .Cp PLU #CCH
LICENSED CONTRAC FORS DECLARATIONTT ELECTRIC PERMIT FEF /ly`Q'`• -
I hereby affirm that I licensed under pr n'-f Chapter 9(commencing - JOB DESCRIPTION
O0Z with Sectron]o00)of D" "" 3 flheBic ssond Prof esslore Cnde,andmylw se+s '
BOO PERMIT ISSUANCE _ -RESIDENTIAL, "
FWD is full force and affect \``.� ❑SFDWL r.,❑KITCHEN REMODEL'
�UH License Class - Lia# gpI11ANCF.S-RESIDENTIAL
InQ 1 e Carmelo, „ ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MUI.TbUNIT ❑STRUCTURAL
PANELS
•Z
,=.7
y 1understand my Pions hell be usul "p M-records X v- MODIFICATION
OZ- OPTO-?WAMPS - '
rr.VJ E'Q Licened Promaional El INTERIOR El CHIMNEY REPAIR
'fi�dd OWNERBLILDER DECLARATION 2Ub1a10'AMPS IMPROVEMENT
�i l lc I hereby affrr n that I ant exempt from the Contractor'sL L far the OVER HXA AMPS - ❑BATH REMODEUREPAIR ❑DEMOLITION
{i�5 O y U following reason (Seal n]031 5 R end Professions Code:Any e ty r county SIGNS ELECTRICAL ❑OTHER
u+al+lF whmh w, mu p n r r h' p d m I',h r cla y hicmie
�y Poon itsissuance,also hectaresthe ppf l for suchTarrant Fileasg dntment. SPECIAL CIRCUtl'/M18C.
9+ (hath .1'cn.edp uatt th p fid C B t I' L (CI pter9
00 (commencing with Section 7000)of Division3 of the Rusinessi d Professo+s Code)., TEMP METER OR POLE INST. COMMERCIAL: '
14 y o e' that he is exempt therefrom and the basis for the alleged exemption.Any Jiclation of ❑ W BLDG/ADDITION ❑DEMOLITION
Section]03 56yanyapplmantforapermt M1jea th ppl rt a I it, alt,of POWERDEVICES �`` a
F Z N not more than five hu+dred dollars($500) Elsi ., ❑FOOD SERVICE
d ❑I,as owner of the property,or myemploy with wagesas their sole pe ettan, SWIMMING POOL ELECTRICQ,, OVEMENT
will do the work and theswdure is not me d d Re eJ fo nl (S 7044 Business ❑OTHER
,3 and Professions Code The Contractors license Law does not apply to an ownerofOUTLETS-SWITCHES FIXTURES+`, "
property who builds or improves thereon,and who does such work himself or through -his own employees,provided that such improvements ura not intended or offered for NEW RESIDENTIAL ELECTR' ?SQ FT.
sale.If,however the building or improvement is sold within ane yearof completion,the SQ.PC FLOOR AREA $/SQ.IT.
er-builder will have the burden of proving that be did not build or improve far ppr- - \�,�`•
• poseofsuLd., .. s
I,as owner of the porpeny,'am exclusively contractlng with licensed contractors mcon
dnswet the prajeci(Sas 9044,Business and Professions CkdeJ The Contreemr's LI- - 4
ve Law docs mtapplymvn owner of property woo nailda or improves thereon,and QTY, PLUMBING PERMIT y.;° .,,FEE
who contracts for such projects with a contractors)licensed parsuamto the Contmetor'sLicense e.e - -- PERMIT ISSUANCE -
' ❑lam exemptvudet Sec. ,B&PC 4irthisreason
?f- Owner �
ALTER- AIN&VENT-WATER Aja VALUATION
t-\\�"Date _ _ -
WORKER'S COMPENSATION DECLARATION RACKL
_ Fs\
Thereby offirmunder Penalty ofporjury one of The following declarations:
❑Ihave and will maintaloa Certificate of the I-man
therWorker's Compen- DRAINS nn eeSTORIES TYPE CONSTRUCTION
setion,as Provided for by Section 3]00 of the Labor Cale,for @e performmra of the p �01, -
workforwhichthispermt'is issued. FIXTURE 1S,Mx _
❑ 1 have cad will maim' Worker's Compensation Insurance, required by Seaion COI MIpI��.'
3]00 of The Leber Code,lotth performance of whichrkfrzth permit is issued - OAS-EA - IOp�CA GROUP' APN
My Workers Compensmmn Insurance tamer unJ Policy number me: 1, )CC
��- Cameo PoltuY'N . - GAS-PA.
CERTIFICATE OF EXEMPTION FROM WORKERS �,yx\
- COMPENSATION INSURANCE GREASEIINDUS R W STFI RCE OR '
(Thswelim need not be completed if thepermit is for ate hundred dollars IS1Ed - - ' T ' `'BIhLr DIVISION Fff8S
or less) - GREASE AP
' PLANCHECK FEE
1 certify that the pefmr of he work for hichthis p t edlshull s
SEWER
tempi y any Peoria in any in nae a.robe h3 a th W rkers Conifer- A E ENERGY FEE
O ,7. satioApPInLt fCal arD le � WA'IERIT GM/EEE /� GRADING FEE
fA NOTICE TO APPLICANT If, ft ak g this Catfificau,of Excinpai,n y hould WATER SYSTeMITRBATING
/
nocturne subject to theW liCompensation- p f Ibc Labs Omni;y most
mo
a '� forthwith comply with such pmvjnjams or this pemat shall be deemed revoked. WAT6 Sftabire
Zp * CONSTRUCTION LENDING AGENCY N RESIDENTIAL PLM AID
U O 'I I hereby affirm that there is v coronation lending agency for the per of Date: Date Receiptlt _
w ,theworkforwhichthlnpermitisi..vd(Seaf5
3 ],Civ.C,) t .
"Q E Lenders Name - TOTAL: 4
W Lenders Address _ TOTAL: �`
I certify that I have read thisppl 'ation and state that he m information Is °` BUILDING FEE'
�i IA correct iagree m comply with 11 'ry 'd county nation,ncesn d state laws relating to QTY. MECHANICAL PERMIT FEE
U building wnstiucuon and h by authorize representatves of this city to enterupon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE - If,
(We)agree to save,lndemnily and keep harmless the City ofCupertim,against ELECTRIC FEE'
liabilities,judgments,costs and expenses which may in any"way uwrm against said City ALTER'OR ADDTOMECIL -''
in consequence of the groming of this permit. I PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ,AIR HANDLING UNIT 10,000 CPM) a;
SO REGULATIO MECHANICALFEE
,i AIR HANDLING UNIT(EVER 10,000111), CONSTRUCTION TqX. '
Signatumof Applaint/Ctuttmcmr ` Date/ EXHAUST HOOD UVMUCf) HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material HEATING UNIT(TO I OR"BTU)' -
as defined by the Cupertino Mumanin Code,Chapmr 9.12,and the Healthand Safety
Cale,Section 25532(a)] HEATINO.UNIT(OVER IOg000IfTU)' .
❑Yea 0 N - VENTILATION FAN;(SINGLE RESID) ee PAID
.Date R 'pt#.
Will theapplicant r future building by them use equipment device.,which 'BOILER-COMP(HE OR 100,000 BTU)
emith d iccnnmm' 't us defined by the Bey Area Air Quality Management -
Diatriwp- a - . - TOTAL: ,
❑Yea - E]No BOILER
Inspection Query for a Specfic Permit 4/7/97
r9526J7iUS1 S �S ST NSt) S^ ESI e n a
20605 LAZANEO R ELECT 4/3/96 4/3/96 JB 3P
20605 LAZANEO R FRAME4/3/96 4/3/96 JB 4P 20605 LAZANEO T-BAR 4/3/96 4/3/96 J6 21 N
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