29753 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29753 9 7 5 K
BUILDING PROIF,C'r IDENTIFICATION J V V
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI'13
v200T"J'42G 5-3- %
OWNER'S NA B:
PHONE: CONTRACTOR'S NANIE: �'n LIC NO'.
�I'h -5Er/G 57o C.r- e-b&A/ CW-41ENIC CONTROL If
ARCHITEYNGINEER: LICNO: ADDRESS. ❑
FJpixo$ W04 L-7P
CONTACT: PHONE: BUILDING PERMIT INFO
11409 `^/A ❑ Consultant Fees Paid by Applicant(Initial) BLDG EET PLUMB MECH
``� ^'e 44+ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
MZZI hereby i ffiml Thal I am licensed unJer provisions of Charm,9(commencing JOB DESCRIPTION
'00 tio
with Secn 71NNq otDin 3visioofthelyminco,mad don
Pndcas C de,and my liaFERMI I'ISSUANCIi RESIDENTInscis AL:
F-ad.. in full force and dlaa, ❑SFDWL ❑KITCHEN REMODEL
HuL to Cont
License Class Lie.N
I. U S-!'I7ZT� Armee^ APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
N6 Da _Jif r ra-- ras
F•D y
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL,
Z O a `JI+"JJewmid my plat s II be used n puhl' Jv MODIFICATION
OZ O �// t �i(�.•(}�y}� UPT0200AMPS
.( El INTERIOR CHIMNEY REPAIR
a1 Oce wJ fess0on l 201-1000AMP$ IMPROVEMENT
ggOWNER-BUIER DECLARATION El BATH RI!MODEIJRI!PAIR UF;MOLITION
C = LD
I hereby affirm that 1 um exempt from the Contractor's License Law for the OVER Inn AMPS
X0 a.U following reams(Section 7131 5,Business and Prow,sioas Code:Any city or county SIGNS ELECTRICAL ❑OTHER
3 u.�¢ which requires is permnit to cotruce,alter,improve,demolish.or relmif any swnum LLi4K�I1Y
F�OJ prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
fW that he is licensed pursuant to the provisions ofthe Contractor's Licence Law(Chapter 9
p0 (commencing with Section 700(dof Divisi..n3ol he Busine,¢and Professions Code)or TEMP.MIT UR OR POLEINST COMMERCIAL:
6 2X00: that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W�h Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than rive hundred dollars($5011). IMPROVEMENT
�aQ Las owns of lac norm In
props y yemp Ywx with wmgus m0heir sola nempcnsaeinn, SWIMMING IsOOL HI-EC'TRIC
FO will do the work,and lrestructure is nut imendedoroftered home bee.70Wf.Business ❑OTHER
a 3 m and Pmfcssi.ns Code:The Contractor's License law Jots not apply to an owner of OUTLETS-.W IES-FIXTURGS
p o,rd,who builds or minuses thereon,and who does such work M1rmself or through
his own employees,provided that such Improvements arc not factional or offered for NEW RESID T?[IiLF R SQ FT.
g orbnp year.' p S IT FLOOR AREA S/5 FT.
sale.IL holder will have
the mvcmengisat he fid none improve
Imine.the Q Q'
owner-builder will have the burden of proving that he did not build m improve fur par-
pose of mle.l.
I,as owner of the property,am exclusively contracting with licensed commcmrs 11 TOT
construct the project(Seo.70,41,Business and Professions CWe:)The Contractor.Li.
ceme law dons not apply m an owner of property who bui Ids or improves themon,and QTY. PLUMBING PERM I
whocommen for such projects with scontmcmds)licensed pursaanuo the Contractor's
License law. PERMIT ISSUANCE
lain exempt under See. ,B&P C for this reason
Owner Date
ALTER-DRAIN&VENT-WAIER(EA) VALUATION O O
WORKER'S COMPENSATION DECLARATION BACK FLOW PROT[CT.DEVICE 6 qoo
1 hereby affirm under penalty of perjury one of the following dedications:i.ns: l/V
❑ Ihavu and Provided
moinby Section
Bcamof be Latin,
ode.sure l'urerf ouce of the DRAINS-PhOOk.k(IOP,AREA.COND. STORIES '1'YPLs CONS'1'RUCTION
section,as which
hohi f.r by Section 3]W of IM1e Labor Code.for We perGnmance ur the
work for whichthisremit is.,kc. FIXTURES-PER TRAP _
1 have and will maintain Worker's Compensation work
hi a required by Section
37W of the Labor Cody for the performance of the work for which this permit is ism W. GAS-P.A.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
My Worker's Compensation houmace rumor and Policy mmcher arc:
Cartier. P.Iicv N..: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Phissection need not be contplumJ I tare permit is throne hundred dollan(SI(M) GREASE'I'RAPp
or less.) PLANCHECK PEE
l amity that in the Performance.(rM work for which this permit is ixsuW,l>hall SEWER-SANITARY-STORM EA.200 ler
not employ any person in any manner so ,Ut13��ubject to the Workers'Comrcn- ENERGY FEE
OZ swine Laws nfCalifornia Ualc b� WATER HIiAI'FIR W/VENT/ELECI'k GRADING TEE
z Applicant r �(�..(/]( /"�
N NOTICI3 TO APPLICANT:If.after making this Ccrtificutc of Exempti ,you should WATER SYSTEMITREATING
become subject o the Worker's Compenzrlon previsions(if the Labor Code.you must SOILS FEE
as forthwith comply with such prov....or this p<•rmil4mll he deemedwroked WATER S17RVICE
w
o 9237
7z CONSTRUCTION LENDING AGIiNCY N[WRESIDIiM5-?A'IALYLMB. SQ FT. PAID Date Receipt J
V 0 l herebyalliml mon them is a construction lending agency for the perfaroommeof
D. the work for which this permit is issued(See 3197,Civ.C.)
ULender's Name 'TOTAL:
Isnder's Address TOTAL:
r y 1 ecnify that 1 have mad this application and scute thin the salve information is BUILDING[TEE 107-0
ITN correct.l agree to comply with all city and county ordinances and state laws rclatingto QTY MECHANICAL PERMIT FEC SEISMIC FEE
U building construction,and hereby owhorim representatives of this city to enter upon the A
above-mendonnd prolcrty for impccaom parpoccc PERMIT ISSUANCE
(We)agree m rove.indemnify and keep hmmkss the City of Coliseum.againsl ELECTRIC FEF.
Iianilities,judgmenu,costs and expenses which may in any way acme against said City ALTER OR ADDTO MECH.
PLUMBING PEE
in APPLICANT
Nthe RSTAN Sthis permit.
APP6ICANT UNUIiI13'fANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNII'('10 IU.lNXl CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
��(�L/y/Js��L�'�T�L�'�(✓//(J���,,��,�/^� �/ AIR HANDLING UNIT(OVER 10,0,4 CFM) CONSTRUCTION TAX
Scg room nk fAppkcunVCnnvactor -new, I.XHAUSTHOOD(W/DUCT) HOUSINGMI'NGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE MAY '1 ,mss
Will the applicant or future building occupant store or handle hmandicsmaterial HEATING UNIT(TO IIXLg10 BI U) 1. IO�•�V
as defined by the Cupertino Municipal Code,Chapter 9.12,and the[health and Safety
Cade,Scow.25532(a)'I HEATING UNIT(OVER 100,000 BTU) "T.'
❑Yen *QIN,, ,... , -. — rr. PAID .J
VENTILATION FAN(SINGLE RESELL Date Receipt
Will the applicant or future building occuperm use cquipmem or deviecs which
coal hazardous aircontaminanrsasdefinedbytheBayAreaAirQualityManahasuan BOILER-COMP011POR100,000BTLU �,3o6r
Divult[? TOTAL
(]Yu ?1W BOILER-C(3MP(OV EN HNLWOIiTU)n
I have teal the harsMwrs materiulz mquimmenu-unJer Chapmr 6.95 of Ne Cali- AIR CONDITIONER ISSUANCE DATE
f.mia Health&Safety Code,Sections 25505,25533 and 25534.1 umlcrsm id that if the NEW RESIDENTIAL.MECH. SQ.ITT.
building own no0 cmrnnly have n tcnunl.lbm it is my rcepnnsihilhy m notify the occupant
of then menu whim then tpr mi wwc ofa Certificate0746
f y.
G we .f— gz/746 T
O crm euthorittJ a gent - TOTAL: ISSUED BY�,/ /�1ti7Js-tiCC-•
OFFICE