29749 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII.DIN(:-El,ELT'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINI:-$IF:CIIANICAL 29749
BUILDING PROJEIT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
l03$& lyorwicifv A-vp G-f-Pt,, h�D , (A R5-01q-
O!P'NEH' (AMG: PHONE CONIItACy>IfS NM1G_r..a/1 hIC NO:
L O/`�*+1\�Y1`��'yl\� NIC CONTHOLp
RCHITECTANGINMR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fats Paid by Applicant(Initial) BLDG ELECT P UMB Mrc}f
LICENSEDCONTRAC'IOR'S DECIARADON QTY. ELECTRIC PERMIT FEE
L hereby off ren that I am licensed under provisions of Chapter v(commencing JOB DESCRIPTION
WON with Section]000)of Division 3 oftbe Bmimssand Professions Code,avdmylicemscis RESIDENTIAL:
FOO in full force and effect. PERMIT ISSUANCE
al ❑SFDWL ❑KITCHEN REMODEL
<VU License Class Lics APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
N a W Date Contract
ARCHITECTS DECLARATION ❑MULTIUNIT [I STRUCTURAL
F O m PANELS
zcoz Iundcmmndmy plain,lull be used as public records MODIFICATION
OZ4—a Oil 10200 AMPS L1 IN'] [2 CHIMNEY REPAIR
d.I-u1 Licensed P..fesSlonvl 20LRMXtAMPS IMPROVEMENT
WyP,.l OWNER-BUILDER DECLARATION
Use ATH REMODEUREPAIR ❑DEMOLITION
affirm C 6'Q I hereby am that 1 am exempt from the Contractor's License Law for the
K0ti following reasan.(Section]831.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL DOTTER
3(L which requires a permit to construct,alter,improve,demolish,or repair any Immure
0 prior In its issuance,also requites the applicant fmxuch peailto file a signed statement SPECIAL CIRCUIT/MISC.
trGG} that he is licensed pursuant to the provisions of the Comment's License Law(Chapter 9
1-100 p, ameneing with Section 7000)of Division 3ofthe Burvir.ond Profession,Code)or TI?MP.METH OR POLE INS'L COMMERCIAL
6 d e y mat bu is exempt thercl'mnt nad me basis far thu Nle,ed exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEM01.1'I'ION
by
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES ❑THNANT ❑FOOD SERVICE
HZ� <.,c than five hundred dollars($500). IMPROVEMENT
�= awnrrofthe pm,ry,o,mycmployees with wages as theirseclecompcnsation, SWIMMING POOL ELECTRIC
yF. order work,and the stracmrei>notimendeJ or offertdfor sale(gtt.]DW,Business ODTHER
41 mand Professions Cale:The Cmemseme,License Law does not apply to an owner of \ OUTLETS-SWITG S-FIXTURES
6 3^ property who builds or improves thereon,and who does such work himself or through
his own employers,provided that such impravcmems are not intended or offered for NEW RESIDENT X CLEM R SQ Fr.
sale.llhowever.the hit dingoriopnwenvnr is said vilharone year of compliermr,the SQ.FT:FLOOR AREA $/SQ.Fr..
owner builder will have(lie burden of proving that hr did nor build or Improve for pur-
prac of talc.).
1,as owner of the propeny,am exclusively contracting with licensed contractors to MAR 181996
containerthe project(Sec.1044.Business and Podc.innz Code:)The Cantracmrs Li27 5P-
censeLawdoesnotapVlS'to an owner ofpropeny who build or improves thereon.and QTY. PLUMB ER FEE
mmm
who contracts for such projects with a cocrts)licensed puua
rsmto the Carburetors ;!lY ur klul C.fTI Inv
License Law., PERMDISS ANCE
❑ loo exurk
under Sel .B&P C for this..,on
ALL'IiR-I VENT-WATER(EA) VALUATION
nor Data
WORKGN:S COMP NSA'ION OECLARATION BACKF OW PR .D ICL
I beer affrnunder penalty of perjury mmol rhe following dudaratin..s:
❑Iheve an ill maintain eCenifcme of Commnuo.alf-imurt for`abrkers Compcn- DRAINS-FLOOR, O .A.COND. STORIES TYPE CONSTRUCTION
.tion,as died for by Section 3700 of the IsMr Csde,fo the perfomnnee of the -
work for which this permit is issued. FIXTURES-PER TRAP
I have and will omimain Worker's Cmapensiumm Insurance,as required by S«tion
3]00ofthe Labor Cale,for The performance ofthe work for which this perand is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Comperiona n lnsumrcc carrier and Policy number am:
Carrier: Policy Na: GAS-EA.SYSTEM-OVER 4(GAJ
CERTIFICATE OF EXEMI'1'ION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be rompinrd ifthe permit is forom hundred dollars($100) GRT:ASETRAP
nr less) PIANCEIGCK FEE
I certify that in the performance either work for which this permit is issued,l shall SEK'F.H-SANITARY-S'rOHM EA.201 FT.
net employ any person in any manner so va m become subpNt mine Workcn'Cemprn- ENI7RGY FEE
Z cion Lawsof Culltumiu.Dam WATER HEATER W/VENT/GITCTR
0 Applicant GRADING FEE
NOTICETO APPLICANT:IL after making this Certificate of Exempnon,you should WAI'F:R SYSTEM?RI:A'L'ING
F' N become subject m he Worker's Compensation provisions of the Labor Cole,you must SOILS FEE
Wforthwith comply will provisions ar this Armen shall is deemed revoked. WATER SERVICE
0
CONSTRUCTION LI!N])INGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PATO
L)0 Thereby affirm that mere is aconstmninn lending agency for perfonnancc of Dae ReceiptM
F rhe work for which this permit is issued(Sec.3(PJi.Civ.C.)
0 U bender's Name TOTAL:
D1 lender's Address TOTAL:
a I certify mm I hove real this it,lientar and slam Naothe above inforamtien is BUILDING FEE
V) correct.I agree to un
comply with all city and county ordinances and state laws mlminm
g QTY. MECHANICAL PERMIT FEE
�.) Z building construction,and hereby authorize rcpesvounives of Nis city to enter upon me SEISMIC FEE
aheve-mentioned property for inspection purposes. PERMIT ISSUANCE
(WO agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities judgments,costs and expenses which may in any way accrue against mid City ACrER OR ADD TO MECH. PLUMBING FEE
in O
consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO 10,066)CFM)
MECHANICAL HE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0N0 CPM) CONSTRUCTION TAX
I} SIILnamrc of ApplicarVConm«or ])ate EXHAUST HOOD(W/DUCD HOUSING MIITGAIION HE
ff HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupumsmm orhandle hazardous material HEATING UNIT(TO 100,000 BTU)
f as defined by the Cupertino Municipal Cale.Chapter 9.12.and Ne Health and Safety
Cad,,Sermon 2553200] HEATING UNIT(OVER 100.000 BTU)
❑Y. ❑Na PAID
V13N'IHATION FAN(SINGLE RESID) Doc Recripk
Will the applicant i future building occupant use .Air Qu or devices which BOILER QHP OR I W,Igg)BTU)
emit hararduus our«mtuminems as defined by rbc Bay Arca Air Quality Management TOTAL
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
I have read the hamalcus materials mquircm,nts under Chapter 6.95 of Ne Cali AIRCONDMONER ISSUANCE DATE
forms Health&Safety Code.Sections 25505,25533 and 25534,1 understand that if the NI7W RESIDEM'IAL SUCH. SQ.IT.
huilding does no earmi ny have a tenant,that it is my responsibility m notify the o«mpam
of rhe requimn ars wMch muse ed rant priuno issnnme of a Certifnur ol'Ouupuncy.
Owner or auNortreJ agent Date
ISSUED BY
j OFFICE