29301 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILIIING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNfa!)NAME. �PII^(l � 6� �Z CONTRACTORS NAM t: �/r. LIC NO:
`D � ' NIC COMI'HOLp
H CT/ENGINEE : LIC NO: DDR ES ❑
9 r s� C.A.,iu_au- roe,r✓e
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ;K ❑
LICENSED that I in iterkACfaRB DECLARA'T'ION Q•pY. ELECTRIC PhRMIT FEE
1 ionhereby701 affirm that 1 oro licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Cbz with Section IIMMOaf Division3nhhe Business and Profession Code,and m licenseis
DO y PERMIT ISSUANCE' RESIDENTIAL:
In full farce and effect.
��� ❑SFDWL El KITCHEN REMODEL
F.UZU License Class Cal APPLIANCES—RESIDENTTAI. ❑ADDITION UMBING RE-PIPE
NGS Dam mDELL
I„py ARCHITECTS TS DECLARATION PANELS ❑MULTI-UNIT STRUCTURAL
ZO'o? IundersfenJ myplans shall be used m public records MODIFICATION
pZ C UP TO 200 AMPS [I INTERIOR ❑CHIMNEYREPAIR
��t{y Licensed Professiowl 201-IIXMIAMPS IMPROVEMENT
O'{ay,Z•ai OWNER.BUILDER DECLARATION
U I hereby off rte that et l oexempt Income Convactar's License Law for the OVER IfNM)AMPS C1 BATH RF,MODEIJRF.PAIR ❑DEMOLITION
36 following reasnn.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL cs,
[]OTHER
Owhich requires a Permit to construct,alcor,improve,demolish,or repair any income
y prior to its issuance.also requires the applicant for such perming rile a signed ornament SPECIAL CIRCUIT/MISC.
P that he is licensed pursuant in the pna,kiasof the Contractor's license Law(Chapmr9
p0 (commencing with Section 70016 of Division 3 of the Business and Professions CMe)or TEMP.METER OR POLEINST. COMMERCIAL:
III. c C that he is exempt Iherefmm and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
n Second 7031.5 by any applicant fora permit subjects he applicanun o civil penalty of POWER DEVICES
m ❑TENANT ❑FOODSERVICE
�,
nal marc than five hundred y,orm($SM).
< � ,nshe wit of the pestructremyemployees with wages rsalei(Sec.compcnsiness SWIMMING POOLI?LECfRIC IMPROVEMENT
will dmhework,and the a,ComosoavLicens.Lowiit(.antell,tomarea 7044,reamer
❑OTHER
and Professions Cash:The anew thcmfs License Low sac oro apply les if owner of OUTLETS—SWITCHES—FlXTURFS
his o
property who builds or improves thereon,and who docs such work himself f Through
his own employees,e provided trim such impros sold within arc nm inter otc or oleate,for NEW Irl?SIDFNI'IAI.HLECTR SQ
rr
wk.Ilh.weveull have the buren ofpemem it sold idon wild or improve
the SQ.FI'.FLOOR AREA E/SQ.fcl'.
ncof saildcr will have the batten of proving that he Ns not build or improve for par
pose
❑1,as owner of the proper,,mu exclusively cnmmctinwird.i ....W contractors to TOTAL:
construct the project(Sec,7I94,Puxiness and Professionss Cod..)The Comm�etnr's Li.
cera Lw does not apply to an owner ofpmNny who builds or improves lhereod,unit QTY. PLUMBING PERMIT PEE
who contracts forsuch projects with a constructors)licenced pumuard m the Contractors
License law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for this rcawn
Owner Date ALTER—DRAIN&VENT—WAT17R E/Q `�1f^q
V�U1996
WORKER'SCOMPENSATIODECLARATION BACK FLOW PROTEGE DEVICE.
1 hereby effrm under penally of perjury one wrote following dedamtiaro
❑ 1h.ve.nd will moimainu Certmenteof Cadsem Inself-iormoo for Worker's Comped- DRAINS—FLOOR,ROOF,AREA,COND. T •S nTYpI..CONSTRUCTION
union,as provided fr oby Section 37M of the Labor Code,I'or the performance at the Orth lJ/
work for which this permit is issued. IFIXI URES—PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as requirW by Section it
37M afthe Labor Code,for the perfomtnc,of the work for which this permit is issuW. GAS—HA,SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
nrkel'zCaptrlenwtipu 4,,carrier and Policy num r
ortie0 a Policy No.: GAS—IA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WO KERS
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEESGlim section need..,bee.mpletW ifrhepernit is for one hundred Mllam(SIM) GRGASIi'TRAP
or less.) PLANCHECK FRE.
I cerifythal in the performance ofthe work forwhich this Iscmilis issued,l shall SEWER—SANITARY—STORM EA.201(1 FT.
not employ any person in any manner so as m become subject to the Workers'Conoco- ENERGY FEE
,Z natio Laws of California.Date WATER HEATER WNENT/ELECIR
7�7 O Applicant GRADING FEE
r7 N5 NOTICE TO APPLICANT:If,after making this Ccomalac of Exemption,you should WAPIik SYSTEM?RL'ATING
a F4 become subject to the Worker's Compensation provisions of the Labor Code,you must SOUS PER
forthwith comply with such Provisions or this permit shall he deemed revoked. WATER SERVICE
�O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR SQ.PT. PAID
I hereby air,.that there is a construction lending agony ftothe parliurance of Data Receip,p
f the work for which this permit is issued(Sec.3097,Ci,C.)
0 landcrs Name TOTAL:
LUkI Lender's Address T
Lod
y I certify that 1 have read this application and store that the above inom.mioe is BUILDING FEE
TA correct,l agree to comply with all city and county ordinances and stare laws relating to QTY. MECHANICAL PERMIT FEE
U Z building concoction,and hereby authorise representativesafthiv citymenteruponthe SEISMIC FEE
.bnvemendnnW property for inspection puHwas.
(WO agree to save,indemnify and keep homeless the City of Cupertino against PERMIT ISSUANCE. ELECTRIC ME
Tiubililie,spdgmems,contend exper,es which may intent way nccrueagnincl oud City ALTER OR ADD TO MECH.
in consequence of the ground,of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY NONLPOINT AIR HANDLING UNIT(TO Ul"CFM)
SOURCE . .ATIONS. MECHANICAL FEE
GI
AIR HANDLING UNIT(OVER I0,090 CFM) CONSTRUCTIONTAX
Sigmuum adApplariRlarTrameatir Uma EXHAUST HOOD UVMUC1) HOUSING MITIGATION PER
MATERIALS DISCLOSURE
Will theappliendorfurm laiddin,acuponrame.,handle havminos met HEATING UNIT(TO](to"BTU)
as defend by the Criterion Municipal Code.Chapter,9.12,and the Healon end Safer,
Code,Section 25532(10'! HEATING UNIT(OVER 100.000 BTU)
E]yes L]No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant ns future building occupied use equipment or devices which Date Receipt p
�
qit hazardous air aiwm
ntro s as defined by the Bay Area Air Quality Management BOILER—COMP UUP OR 100,00 BTU)
District'! TOTAL.:BOILER—COMP(OVER Hat BTU)
❑Yes ❑Na
I have read the hevvduus materials ream¢moms under Chapter 6.95 of dm Cali- AIR CONDITIONER ISSUANCE DATFL
Loans ITealth&Safety Code,Sections 25505.25533 and 25534,1 undcrsmnd @m if the NEW RESIDENTIAL MECH. SQ.IT.
building hatenot emandly have a road,Ih.,it is any responsibility to notify the necupant
of the requirements which must he met rider to issuance of a Certificate of Occuponey.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE