29671 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPFRTINO BUILDING-ELECTRICAL PERMIT NO,
BUILD
DIVISION APPIICATIONIPERMIT PLUMBING—MECHANICAL 29671
BUILDING.PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
10 3 0 z .20-4
'R'S NAME: �I'(iOyyw�E: CONTRACTOR'SNAME: LIC 'O'
EnJc'$Toc 'lb ' s °� A IAIET C AFY rv/c colgTRol.a
�1RCHITECf/ENGINEER: LIC NO: ADDRESS: // // ❑
Trf 9(„f a`7 H I U BSc S�Ca 9 I?3
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ehpG Elr[eT, PLUMB MECH
LICENSED CONTRACTOR'S DECIARATION QTY ELECTRIC PERMIT FEE B DES IPTION —
I hereby orfirm that I am Reenxd under provLdonz of chapter v len tog JOB DESCRIPTION
0�7. wire section](XNBof 'vision3ofinel""'a wand Pr ea' Cnde licence is El SFDW_NTIAIu
W 00 In o PERh11'I'ISSUANCE
FW full forcennd eff , n ❑SFDWI. TCIiEN REMODF;1,
91z License a: hic.a APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
Qa U Contrenor
F> HITECTS DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL
Z
oni I undersand my plan.shall be used as public record. MODIFICATION
OZ—Q UPT0200AMPS [I INTERIOR El CHIMNEY REPAIR
Licenced l'mfeacimnal 201-10X0AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
CY _1 OVER 1000 AMPS BATH REMODEL/REPAIR El DEMOLITION
C Q 1 hereby affirm that 1 am exempt from the Cmdracmrzs License Law for the THER
k 3 6 U following mama.(Section 7031.5.Business ami Professions Cade:Any City or county SIGNS ELECTRICAL
which nmquirea a permit tit construct.alter,improve,demolish,or repair any structure
Ftitor
F. prionnits issmnce,alsn rcquirca me applicnm for such penninn fileasignnlsmement SPECIAL CIRCUIT/MISC.
Ethat he is licensed pursuant the provision%of the Conan 's License Law(Chapter 9
=W (commencing with Section]g0)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. MM $ !A
Q.dx c y that he is exempt therefrom and me basis for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W�H
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
rZy not marc than five hundred dollars($500). IMPROVEMENT
�Q (] Los owns of the propany,unmy cmpinycus with wngcs nv their sole com.Car on, SWIMMING POOL ELECT RIC
will do the work.and the smme,is not intended oroffcred for sale(Sec.9044,Business ❑Q ER
W 3 m and Professions Code:The Conovaur's License Use does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon.and who does such work himself or through
his own employees,Provided that such improvements are not mandod or offered for NEW RFSIDEMIAL ELECIR SQ FT.
ssle.lf.howcvcn me mildingor imp rovcntcnt issdd within one yCarofcoinplutis,me .FTF . RARER® s/SQ.FI'.
cr-builder will have me burden of proving that he did not build or improve for put- �U
pose of sale). FEB
❑I,az owner of the progco
eny.am exclusively contracting with licensed tmenars,m TO 21
Construct the projen(Sec.7044.Business and Professions Code)The Contmmo I W- l/
c Law cities not apply toanowner olpmpenywho builds orimproves thercon,and QTY. PLUMBING PERMIT FEE Y' 1996
who contracts for such pretests with a atmracsngs)liectvsed pursuantto the ComrveturS
License l.aw. PERMIT'ISSUANCE "I�`'rh 11Np
O 1 am exempt under See. .B&P C for this reason
ALTER-DRAIN&VENT-WATER WA) VALUATION
Owner Date
WORKI!R'SCOMP1iNSAl'IONDECI.ARATION BACK FLOW PROTECT.DEVICE OO
/ I hereby affrunder penalty ulperjury ane ofthe following declnrmers:
x]I have and will maintain a Certificate of Comentto self-insure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA,COND' STORIES TYPE.CONSTRUCTION
salon,as provided for by Section 37M of the Whr Code,for the performance of the
work for which this permit in issued, FIXTURES-PER TRAP K6 4C�
1 have and will maintain Worker's Compensation Insurance,res required by Section
37W of the Labor Code,fnr the perl'nn once of the work lbr which this permit is issued, GAS-EA.SYSTEM-I INC,4 OUTLETS OCC,GROUP APN
My Wor amp c tot sore rticrond Policy number are:
Career: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OFEXEMPIION FROM WORKERS' GREASF/INDUSTAL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This ac tion need nm he completed iDh permit is for one hundred dollats($100) GREASETRAP
or tax,.) PLANCHECK FEE
loaddy that in the perlinmancenfthc work for which this permit islamed,IxhnO SEWER-SANITARY-STORM EA.200 FT.
not employ any person any manner anner sir as m hcm
oe subju
eeo the Worker:Compare- ENERGY FEE
OZ summ Laws of C.I.fimitt.Data WATER HEATER WNENT/ELECTR GRADING FEE
0 APpliliao
NOTICE TO APPLICANT,If.after makingthis Cenifit Exemption,you,should WATER SYSTEM?REAPING
f's become suhjcct to the Worker's Contlrcnsntinn provisions til the Labor Code,you must SOH hS FU
�> forthwith comply with such provisions orrhixpennd shall hodocmed invoked. WA'T'ER 517RVICE
0
Data Receipt a
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.bm PAID
=
V z I hereby affirm that there is a construction lending agency for the performance of
me work fur which this permit is maul(Sec.3097]Civ.C.)
u" Lander'%Name TOTAL:
U Under',Address T L:
D.1 BUILDING FEF.
I certify that I have read this application and nate that the above information is I�
0a/1 commit.I agree mcomply with all city and county ordinances and state laws almingm QTY. MECHANICAL PERMIT FEE
UZ boildingcnnnmction.and hereby authorize represcandivcsoflhiccity mentcr upon the SEISMIC FEE
abuvorroolu ed propcny lire i napation faa,ws. PBRMI'1'ISSUANCE
(Wm)upme to save,indemnify and kap limitless the City of Cupertim agviust \ I?LEClRIC PEE
mento..,and expenses wh'mh may in ony way accrue against sail Ciry ALTER OR ADD TO MECH. PLUMBING FEE
mnuquence Ids,mming olthis permit.
APPLICANT DERSTANDS AND WILL COMPLY AIR HANDLING UNIT 0010,000 CIh1) MECHANICAL TEF.
SOURCIi UL
Z AIR HANDLING UNIT(OVER 10,001 CFM) CONSTRUCTION TAX
Sigwt 'of Appliwn onweor D c EXHAUST HOOD(W/UNCI) HOUSING MITIGATION FEE
HAlARDOUS MATIiRI DISCL05URF
Win the applicenor future building recupants le hwtudnus material HEATING UNIT GM 100,000 BTU)
as deli ted by the Cupertino Municipal Gxle,Chapter 4.12,tad the Health and Safety
Cole,Section 25532(0'! HEATING UNIT(OVER HAOCO BTU)
❑Yes C)No VENTILATION FAN(SINGLE RESID) PAID
Data Reccipta
i
Will the applicant or future building occupant uno,equipment or devices which
(i mit haeardous air contaminants as def ncJ by the Bay Arca Air Quality ManagementBOILER-COMP(JHI`OR 1 Car,"B'TU) TOTAL:
'swat l❑YO, ❑No BOILER-COMP COVER 100,000 BTU)
I have most the harznlousmaterials mquimmem,under Chapter 6.95 nfthe Cali AIR CONDITIONER ISSUANCE DATE
forms Health&Safety Csdc,Sections 255(15,25533 anal 25514.1 understand that if the NEW RESIDENTIAL MECH. SQ.pT.
building does nm cerently have a tenant,than it is my resrymsibility ret notify the occupors
of the requirements which mus be met prior to k na me of a Cam ficme of Occupancy.
Owner or amhorized agent Dote I ITOTAL ISSUED BY:
OFFICE