29938 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
l CITY OF CUPERTINO BUILDING•ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL. 29938-
BUILDING PROJECT IDENTIF'ICATION-
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
OWNER'S NAME: ) �! PHONE: COp CfOR'S�AME: LTC N a
r V/ G eCT 7 g/C�l•"-ss N/C CONTROLM
sf R ITECF/ENGINEER: LTC NO. AUUR�SS:
u S
CONITACT` ../'
PHONE: BUILDING PERMIT INFO
JO� / '�` SSsb ❑ Consultant Fees Paid by Applicant(Initial) ABI ELECT PLUMB MECH
CAM Z7P- El ElLICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 'P
1 hertby affirm Nm I ern licensed under provisions of Chupmr 9(commencing _ JOB DESCRB'CION
0fcZ with Section 7")of Division 3 ofthe Business and Profenal Code,and my license is
�00 PERMIT ISSUANCE. RESIDENTIAL:
full force and a t.
ts—Il: E 1° ❑SFDWL ❑KITCHEN
t;ULiccrLse v Lic.p e.�._ APPLIANCES-RESIDENTIAL ❑ADDITION - ❑PLUMBMG RE-PIPE
Vs QZ u�l Dvm � Comate s]��7
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
PANELS
Z py Z • 1 understanJ my plws shall be used es public rcnmrds MODIFICATION
UP TO 200 AMPS
O Z Cf O ❑INTERIOR ❑CHIMNEY REPAIR
g, F' Licensed Professional 2111-1000 AMPS - - IMPROVIiMENT
�'d OWNER BUILDER DECLARATION
C ..1 entry affirm that 1 am exempt from the Centramals License Law for the OVER TIMID AMPS ❑BATH REMODEIIREPAIR DEMOLITION
.Mowing anon.(Section 70JL5,euainess and Professiorm Code:Any city or coumy SIGNS ELECTRICAL ❑OTHER
LL O w,.g regga a permit to consumer,alter,improve,demolish,err repair any suu<mm _
poonits�ast annce,alsu tremulous the applicant for such Permit file a signed statement SPECIAL CIRCUIT/MISC.
} that he Hican'Ta l pursuant to the previsions of Ne Conttacm/s License Law(Chapter 9
0O (commeeing'vim Section]W0)of Division 3 ofthe Business and Professions Code)or TEMP.MUTER OR POLE INST. COMMERCIAL:
L ¢ that he i'a n therefrom and the bmis for Be alleged exemption.Any violate.of El NEW BLDG/ADDITION DEMOLITION
'4m R• Section 9111.5 v myapplicnnt fora pcmmitailents theapplicam m a civil Acuity of POWER DEVICES
mat nrn mote tiara fiv hundouddollars($500). ❑TIiNANT ❑FOODSERVICE
I.Z.
❑I,uowsanf ,Ipropery,oe my employees with wages as their sole compensation, SWIMMING POOLELECTRIC IMPROVEMENT
will do the sank,rel the sanctum is not inmmded or offered foreale(Nor.]044,Business pil [)OTHER
O and Professions Coale.The Central License Law dues nm apply to an owner of OUTLETS-SWITCHES-FIXTURES
a' property who ouildv or improves thereon,and who does such week himself m though
his own employees,'provided that such improvements ore not intended or offered for NEW RESIDENTIAL ELCCfR
sale.IL hawever,the building or impmvemem is sold within one year of completion,the \� SQ.FT.FLOOR AREA $/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve for Pur-
Tiomofaile,.
1,es owner of the Pnspedy,um exclusively contracting with licensed contractors to
conswct the project(Sac.96W,Business and Professions Code,The Coaradors Li- ftp us
calm law does not apply to an owner of property who builds or improves nation. QTY PLUMBING PERMIT NA
,FE 2 199
who contracts for such projects with a centmdnr(s)licensed pursuant to the Contmetols _
License Law. PERMIT ISSUANCE
p lameaemptunda Scc. ,B&PCfmthisoNum V4�r
ALTER-DRAIN&VENT-WATER(EA) VALUATIOl
Owner
Data I1
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICH a / (r-/•Y'S
1herebyaffirmtaina penalty of perjuryone nthefollawing Worker Co
Ihave and will forbyinetioCertificate700 ofComemmCar,mi File fin - DRAINS-FLOOR,BOOP,AREA.COND. STORIpS TYPE CONSTRUCTION
senora,ur Provided for by Section 3]W of the Labor Csde,fol the perinrmuncn of the
wok aveand this aintriis issued. FIXTURES-PER TRAP
❑1 have end will maintain Workers Compensationce,errw rkfor hi h required by Satin.
My Wo the LaboroIn Pedbrmenceofahvwork forwhichthis pemit is issued. GAS-EA.SYSTEM IINC.40ITIT,EfS DEC.GROUP APN
My Work Compensationlreurance curriervnd Policy a GAS-EA.SYSTEM-OVER 4(EA)
Conten ye R Policy FROM
CERTIFICATE OF EXEMPTION FROM WORKIiRS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE.INTERCEPTOR
(Thissection tined nal be campletud if thepemmir is for one hundmddollars(SI W) BUILDING DIVISION FF!ES
,it less.) GREASETRAP PLANCHECK FEE
I certify that in the performance otter,work forwhich this pemtit is issued,l shall SEWER-SANITARY-STORM EA,200 FT.
rip employ any person in any manner so m to become subject to the Workers'Compel ENERGY FEE
Z sedan laws of California.Dam WATER HEATER WIVENT/ELECTR
O Applicant GRADING FEE
ti NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEM,TREATING
abecome subject to The Worker's Compensation provisions of the Labor Code,you must SOILS FEE
W forthwith comply until provisions m this permit shall be deemed revoked. WATER SERVICE
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,PT. PAID
V Q Iherchy affim That them iso construction lending agency fonhe performance of Dam Rcceiptp
I.I. Pthe work for which this Permit is issued(Sec.31 Civ.C.) '
O UU Lender's Name TOTAL:
Ig2 Lender's Address TOTAL:
I certify that I have and this application and sate Not the above information is BUILDING FEE
.fir y coma I agree tocomply with WI city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
(,) huildingeonstmction,and herehyauthanze representatives ofthis city toenterupnn the SEISMIC FEE
about-mentioned property 6r inspection Final PERMIT ISSUANCE
(We)agree t.mor,indemnify and keep harmless the City of Cupertino against ELECTRIC FEL•
liabilities,judgments,costs and expenses which may in any wayaccme against said City ALTERORADDTOMECH.
in conry
sucnce of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WTI ,COMPL WITH ALL NON-POINT AIR HANDLING UNIT CIO 10,000 CFMI
SOURCE EGU HON1. CONSTRUCTION
FEE
S?t/ AIR HANDLING UNIT(OVER IO,IXNI CFM) CONSTRUCTION TAX
Signamm.1'AppliestraTbiterector, OF Dam EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupantsmreor handle hazardous maedal HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and time Tial and Safety
Code,Section 25532(a)? HEATING UNIT(OVER Iffil BTU)
❑Yus- Olin VENTILATION FAN(SINGLE RESID) PAID
Date Receipt It
Will the radicorcoantorfumre building byoccupant use eyo Qualint rJel Manaement BOILER-COMP I OR 100,000 BTU)
mit hazeNoue air contaminants as define)by the Hay Arte Air Quality Management
DTOTAL:Dill
0Yr,s ❑No BOILER-COMP(OVER 100,000 BTU)
'
I have readthe havadous matenals teyuirements miler Chapter 6.95 of the Cali AIRCONDITIONER I- ISSUANC ATE
. forma Health&Safety Code.Sections 25505 M533 and W534.I understand that if the NEW RESIDENTIAL Nt SQ.FT.
building doxy nm illy enmws nr,rh is my sib9itym notifythe oecupvm
of rhe re m to ass n aCe title. y.
Owner or authorized ag Doc TOTAL: ISSUED BY:
OFFICE