29571 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CITY OF CUPERTINO BUT],)ING-ELECTRICAL PERMIT No.
BUILDING DIVISION APPLICA770NQ'F,RMIT PLUNIIIINC-MECHANICAL nC
BG P1,I
UILDINEIIkI
CT INrIFICATION J J
71
BUILDING ADDRESS.' SANITARY NO. APPLICATION SUBMITTAL i)xri.
L� 6
0 NL'R:SNAM INVtl \ r Q� PIIUNIi: At C 'IRAGI'OR'SN E. -� LIC NO11 : N/C ONTHOhp
A C I'ECT/EN INEER: LIC DURESS: .LJ!-l^
❑
e\grECIDENh r N 1 4
CONTACT 4 PHONE: BUILDING PERMIT INFO
,IM qec (!'I nb"r 4ft-CQp'✓o .-44(# ❑ Consultant Fres Paid by Applicant(Initial) BLDG ELE T PLUMB MECH
ItT1 OO�Z
LICENSED CONTRACTORS DECLARA'T'ION QT'y, ELECTRIC PERMIT FEE
1 hereby ulfrm tlmt 1 am licensed under pmvi,ions of Chepmr 9 eman ereing JOB DESCRIPTION
with Section 7")of Division 3ofar Blederssand Pmfe,si...Coda,andmy1womoeis RESIDENTIAL:
FI.lull force and effect. PERMIT ISSUANCE
LL= r %Q,f' -DWL ❑KITCHEN REMODEL
aUU Licenec Class Lie. APPLIANCES-RESIDENTIAL ❑rDDITION El PLUMBING RE-PIPE:
BZW Dme Contrast-
'Doo,
4 ARCHITECT'S DECLARATION ❑MULTI-UNI T [I STRUCTURAL
ZO`7I materialist ndetoy punished]he cocoas public records PANELS MODIFICATION
OZ— UP TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
F
L,4W Licensed Professional 201-1000AMPS IMPROVEMENT
Y OWNER-BUILDER DIiC1,ARAl'ION - OVER I00OAMPS ❑13K1'H REMODEUREPAIR [I DEMOLITION
CL Q 1 hereby effort that 1 net exempt from the Carruthers Liemoc,Law for the
xa a U following reason(Section 0031.5,Business and Profession,Calc:Any city al county SIGNS ELECTRICAL ❑OTHER
1+13 LL y which profiles a permit.construct,alter,improve,demolish,or repair any structure
g (mina its ismanve.also require,the applicant fmsuch prodit o file a signed statement SPECIALCIRCUIT/MISC.
} that he is licensed proman olhe pnni.annnof the Comrnaor's License Law(Chi acres
—OO (ecomencingwith Section TNq)nf Division 3oObe Business and Prnfessinm Code)ar TEMRMI TERORPILE INIT. COMMERCIAL:
116 a that he is exempt therefrom and rhe basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
N
Sciences 0031.5 by any applicant for a permit subjects the applicant to a evil Penalty of POWER DEVICES
m mom than five hundred dollar,($500). []TENANT ❑FOOD SERVICE
IMPROVEMENT
q Q ❑Laxowner ofthe mcpany or e myemployees with wages rsale( ec.7(mpensmion, SWIMMING POOL Ii1,liCfRIC
2�1 will dorhawodr,anal he Contractors Licorded ense
Laoffiw
red dos of a(Slytoan Boniness ❑OTHER
tail m and Pny who
Csde:imp Contractors License Luo saes not apply m if owner of OUTLETS-SWITCHES-FIXTURES
3 his o ny who Fuels,or improve thereon,and who dies such work himselfef through
his own employees,provided that such improvements are not emended or offcrcd for NEN'RESIDENTIAL ELECTR SQ IT.
sale.IL however the building or improvement is sold within one year"to h onlay,rhe �^ SQ.Pf.FLOOR AREA $/SQ.IT,
cwm,b.hdcr will have the burdenorpreving thin he did nm build or impnrve for par- G a� pep
poscofsale). I�`Z
geny, 0 0
❑1,as owner of the proam exclusively contracting with licensed contractors to TOTAL: 1 Led).
mm
ao the pmjecr(Sec.2044.Business and Pmfessifns Calc:)The Cln o.....s Li- ✓ p�
crave low does not apply.an owner of propeo,w hn builds of Improves rhere:m,and QTY. PLUMBING PERMIT FEE
who common,for such probes with a contractions)licensed putsuanua the Contractor's
License law. PERMIT ISSUANCE
❑1 am exempt under See. .B&P C for this reawn
ALTER-DRAIN as VIINT-WAT17R(BAT VALUATION
Owner Dam
WORKERS Caltyof rjuq NDECLARATION BACK FLOW PROTECT.DEVICE ` /v11Y
1 hereby affirm under penalty of perjury one of the following dedmations: —r
❑I have and will maintain a Cenifcme of Comcnt.self-moor for WorkersCompen- DRAINS-FLOOR,RODE AREA,COND. STORIFS�o TYPE CONSTRUCTION
of ion,us provided for by Section 3]W of the Lubec Cale,lin the affirmance of the
ark lin which this psmn is issued FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation looreares,as required by Section
370oftha labor Qwle.fmtheperfomancelefline work forwhich Nis permit is issued. GAS-IiA.SYSTEM-]INC.4 OUTLETS CGROUP) APN
My Workers Compensation Insurance carrier and Policy number art: r
Cnnicc PolieCIiItTIPICATG OF Ii%CMI'TIONYI FROM WOR KF.RS' GAS-IiA,SYSTEM-OVER �I! Lr VUf'L^,, 1
COMPBJSSAOON INSURANCE GREASIVINDUsOIL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This sowlamnced not becroduredifthe pcmtit is Tomos hundred dollars(SIM) GREASETRAP /q
or les,.) ENERGYPLANCH
FLIT lw�.
Icenify that in the perfnrmancc.I,noole oek for
nnamwhich this ho Wiiico'Coued, sban SEWER-SANITARY-STORM EA.200 FI'. 4
not mupiny any person in any nmmeer so ax m banner xuhjed In the Workers'Compem GNEROY FF,E
,� onion lawn of Califomia.Date WATER HEATER WIVENT/ELLOR
z O Applicant GRADING FEE
z' NOTICE TO APPLICANT:If.after making his Cmifcalo of Exemption,you should WATER SYSTEMT`REATING SOILS IEE
a become subject m the Workers Compensation provisions of the Labor Cale,you must
0.1fonhwllhenmply with such pro,kionsonhi.penal l,hall he dcanedrevokWE.
. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
UQ in
IhcmbY a(Orm thmahere a is cnmtr ifn lending agency fm The performance of Data Receipt of
1-t the work for wash this of l rs i...ed(See.3197.Co.C)
ks Lender,Name TOTAL:
LUL1 Lender's Address TOTAL: «V
1«nit,that I have read this application and nam that the above infomlmlon o BUILDING FEE
.F+ VN correct.)agree .comply with all city and county ordinances and state laws coming to QTY. MECHANICAL PERMIT FEE
(..)� building construction,and heachyaothen,rrepresentativexofthis city mcale,,on rhe SEISMIC FEE
above-nrenrioncd propmy for inspection pmpa.m,. PERMIT ISSUANCIiBLECTRIC PER too
(We)agree to save,indemnify and keep hamdci,the City of firl,mno oguall
Iiahilits,judgmenls.toss and expenses which may in any any accrue against said City ALTE•RORADDTOMECH.
PLUMBING FEE
in nquence of the granting of this permit.
x
APPLICANT UNDERSTANDS AND WILL COMPLY WITH LL NO POINT AIR HANDLING UNIT(TO 10.001 CPM)
SO EGUI.n S' MECIIANICAL FBB
'/ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signatureof Applicua Com mor L•e at EXHAUST HOOD(W/DUCT) HOUSING MITIGATION ME
HA3ws�DOUS MATERIALS DISCLOSU E
Will denpplicant cratem hailch.1,11a1am,.re orhundlehroardous maadal HEATING UNIT(To 100,00h)BTU)
a,defined by the Cupanino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section SSRSU HEATING UNIT(OVER 100.000 BTU)
El Yes ❑No PAID
VENTILATION PAN(SINGLE R[SID) Dare Receipt X
Will the r,ho,mt or future huilding occupant use agnip arm or devices which
coal haaarms air coami
nnonb as defined by the Bay Area Air Quality Management BOILER-COMP OUT OR 1UB,0b)BTU)
d TOTAL:
District? BOILER-COMP(OVER 100.00)BTU)
[3 Yes ❑No
I have read the bavvdous mmcrials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE
fomia Health&Safety CWe,Sections 25505.8533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
built ingdoes std currently haven from.that it is my responsibility to ratify the rccupant
of the rtyuiremenu which must he met prior.issuance of o Crmrimte of Oacupmcy.
Owner m amhonled agent DJIC
TOTAL: ISSUED BY:
OFFICE
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