29176 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CCfY OF CUPERTINO BUILDING.ELECTRICAL. PERMIT NO. 29176^ �S
. BUILDHiiG DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL •2 kJ,J a � {6
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 3 SANITARY NO. APPLICATION SUBMITTAL DATE
a3� ��if� -��S
OWN R'S NAME PHONE: CONTRACTOR'S eNNAi� LIC NO: �.�.,,/ NIC CONTROLg
i'se
RCH1TEICTANGINEER: LIC NO: AllOft Sa � 9. ( ^A❑ V m
cONTACI! PHONE: BUILDING PERMIT INFO
6/I /� / 7 L/�O ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB pfFC.�y
LICENSED CONTRACTOR S(DE7CfARATI QTY. ELECTRIC PERMIT FEE eDgl(• 'IJJN`
I herchy affirm that I um licensed under pmvisinns of Chnpmr 9(a.mmencing JOB DESCRIPTION
a s7: wiN Section]f1I10 of Divisian3 of the Business and Professions Cotle,mWm license is
00 ) y PERMIT ISSUANCE RESIDENTIAL:
Bill force end effect.
F In 14 rat) CSFDWL s.[CCITCHFN REMODEL
t<UQQQG License Class Lic.p 6
Date Contractor APPLIANCIS-ftfSIDENTIAL ❑ADDITION PLUMBING RE-PIPE
1F...D ran ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT 05TRUCTURAI.
yp 7� understand my plana shall he used as public rccoNs MODIFICATION
0z UPTO 2W AMPS
D ❑INTERIOR ❑CHIMNEY REPAIR
P la Licensed Professional 201-I0II0AMPS - IMPROVEMENT
C6 OWNER-BUILDER aten DERDthe ARATIONCommerc OVER 100GAMPS ❑BATH REMODEL/REPAIR 0DEMOLITION
yp� 1 hereby affirm than 1 vn exempt from the Convenors License Low for the
W 3aU following mason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
LL which.quires o permit to construct,almr,improve,demolish,or repair any swcla.
�4y prim to its issuance,also requires the applicant for such permit o file a signed statement kSPECIALCIRCUITIM1SC,
Y Nm
at he is licensed.......1.the Provisions of the Coanacr's License law(Chapter9
(commencing with Section 7")of Division 3 of Ne Business and Professions Code)or TEMP.MITER OR POLE INST. COMMERCIAL:
a o LL
that be is exempt therefrom and the basis for the alleged exemption.Any violation of 0NEW BLDGIADDRION 0 DEMOLITION
la• Section 7031.5 by any applicant for.permit subjects the applicant to a civil penalty of POWER DEVICES
nN nm atom than five hon dr ed dollen($500). ❑TENANT [:1 FOOD SERVICE
O0 Lasowneroflhe property,or my employees with wages as their vele compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the swaure is not in.ndeJ aroflbrcd for eine(See.]1144,Rosiness DOTTER
1 end Professions Code:The Contractor's License Lew dues not apply to on owner 01UTLETS-SWITCHES-FIXTURES a—
pariamy who builds or improver,thereon.and who does such work himself or though n
his own employees,provided that such improvements om not intended or offered for NEW RESIDENTIAL ELECTR SQ PT..
sale.If,however,the building or improvement is sold within ane yemofcompletion.the SQ.PT.FLOb{tARL%i 5/SQ.ff.
owner-builder will have the burden of parsing that he did nm build or improve for put. •I IV
poseofeale.), L� 41V 8
0 1,as owner of the property,am exclusively contracting with licensed convectors 1. ♦ n ,1I�T
construct the prmj.t(Sec.7044,Business end Prficesiom Cod_The Conlmnars Li- ���` r
cense Law does not apply than ownerofpropvey who builds mimproves thereon,and QTY. PLUMBING PERMIT FEE 996
who contracts forsuch projects with a contras odod licensed pursuant to the Contractors `�yNC
License Law. PERMIT ISSUANCE hf//`.
❑I am exempt under Sec. ,B&P C for this reason U
Owner Date ALTER DR VENT-WATER(EA) VALUA'1'ION`�
WORKER'S COMPENSATION DECLARATION BACK FL OT BVICE 1 {1 1
I hereby ams.trader penalty of perjury one of the following declamtlons: U
I have and will maintain.CertiGcamcfCons,m.self-insure for Workers Co.,.. DRAINS R RFA.CON).
stood,as provided for by Section 37W of the Labor Code,for the Performance of the STORIES TYPE CONSTRUCTION
work for which this Permit is issued RRTURES-1'E P 150
0 I have and will maintain Worker's Compensation Insurance,as required by Section
37Wofthe LuNtr CWe,fortheperfmmance ufthe nrkfor which this Permit is issued. GAS_EA SYSTEM-I INCAO S OCC,GROUP APN
My Wmk d 3 ^-wlicy number me:/ tee
f Cartier. li No.: �y1 r— GAS-EA,SYSTBM-OV ) '
/ RTIDCATB OF E)FMPTION FROM WORKERS' GREASEnNDUSTRL WAS E R
COMPENSATION INSURANCE BUILDING DIVISION FRES
(ThMartionneed not bocomPr
leted if the peril la formic hundred dol lms(SIM) GREASETRAP
or less.) - PLANCHECK FEE
I certify that in the performance ofthe work Rnwhich this permit is b,ted.I shall SEWER-SANITARY-STORM PA2W
not employ any person in any mann,,so as m m N
Isccon..ubject e Workers .
Co.,.. ENERGY FEE
Oz cation Laws of Califomia.Date WATER HEATER WNENTIELECIR
O Applicant GRADING FEE
VI NOTICE TO APPLICANT.If,soar hulking this Certificate of EaemPlimn,you should WATER SYSTEMRREATING
become subject to the Workers Compensation provisions of the Lnlwr Code,you must SOILS ME
UF forbwith comply withsuch Provisions or this permit shall he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDBNTIALPIAIB. SQ.PT. PAID
UO
I for
which thi Nauhe.issued( action len ding agency for the perfonnetrceaf Date Rettiptg
{Tr t•+ the work for which this permit is issued(Sec.JW],Civ.CJ
U Lender's
No 'TOTAL:
Lender's Address
f�" a I certify thm I have read this application add sate that the ahrve infnnnauon is BUILDING FEB �a
IA ,tercet.I agree to comply with all city and county ordinances and state law.reltam". QTY. MECHANICALPrRMIT FEE
U 4 building construction,and hereby authorize representatives of Nis city to emarupon the SEISMIC FEF. 6
above-comahmed property for inspiration purposes SPERMIT ISSUANCE
ELECTRIC FEB
(We)agree to save,indemnify and keep hleas the City of Cupertino against
armQ
liabilities,jodgmenls,costs and e.pensea whichnwy in any woy accrue ugsinstssid City ALTER OR ADO TO MF.CH.
in comequence of the granting of this p aunt. PLUMBING FBI
APPLICA 1NDNDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00()CFM)
SoREG LA S. ' q MECHANICAL TLE
_je AIR HANDLING UNIT(OVER 10,00I CFM)
g, CONSTRUCTIONTAX
reof ApplimnU amramor Date EXHAUST HOOD(WMUCT) ` HOUSING MITIGATION FEE
�) IA5=10U5! TRIALS DISCLOSURE
Will theapplmurt.r tato.bu dingaccupant soneorhindle haz.Nousmemrial HEATING UNIT(TO 100,0311 BTU)
as defined by the Cupmino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Seen.25332(a)? HEATING UNIT(OVER I W,000 BTU)
GYn ON. VENTILATION FAN(SINGLE RESID) PAID
Data Receipt g
sindll theapplicantorent.a building by the rt Buse equipment nrdeviceswhich BOILER-COMP QHP OR I W710U BTU)
list Maardous sir conmminunw as defined by the Bay Area Air Quality Mnnegement TOTAL:
District?
GYa Fl No BOILER-COMPIOVER 100,0001111H
I have hand the transations.,ad.[.requirements under Chapter 6.93 of the Coli- AIR CONDITIONER ISSUANCE DATE
forma Health,$Safety Cole.Sections V5505,25533 and 25574.1 understand that if the NEW RESIDENTIAL MCCH. SQ.PT.
building Jos not mrramly have a mnsdt,that it is my respnnxibility m notify the occupant
of the recuirements which must IN,met prior m issuancents Certificate of Occupancy.
Owner or authosiced agent Date
a. ISSUED BY:
OFFICE
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