29448 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 29448
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Io BG 1`40VF-" Bl�p r�,l(t-q6
OWN17R:SNAME: PHONE. CONCH TORS NA LIC NO: N/C CONTROL#
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r0 Kis—i�6'3 2519. �r
)RCHITECETNGI,NMI: LIC NO: ADDft S: ❑ \
not 1(� '� - AI C-'1 3?6 U-;tv-
CONTACT PHONE V F BUILDING PERMIT INFO
i--AVI (3 R�f� 446- ❑ Consultant Fees Paid by Applicant(Initial) BLIP ELECT' PLUMB MECH
\J 3�7(� 1st—�Y• *
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 heresy anion root 1 ant bee ad maser pmvisioae ar,Cuper 9(wanaer,e is ]OB DESCRIPTION
I- in fall 7000) Division ohne BusinessanJ ProfessionsCnsc,and mYlicenscis
W O p PERMIT ISSUANCE RESIDENTIAL:
=—i- License
Cl.d,fiat. ❑SFDWL ❑KITCHEN REMODEL
FCUU Littnsc Clu Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION EI PLUMBING RF;-PIPE
to G 6 Dam Contractor
ARCHITECTS DECLARATION ❑MULTI-UNIT [:]STRUCTURAL
Z O fin PANELS
Z 1 understand my plans shall he used a.Public mmrds MODIFICATION
OZ- a UPTO 201 AMPS ❑INTF,RIOR a) nn [3 CHIMNEY REPAIR
[Fa 4F-u1 Licensed Professional 201-IM)AMPS IMPROVEMENT
C �-z Oat I a.ma m,t R DECLARATION OVER Pain AMPS ❑BATHA1"M EUREPAIR ❑DEMOLITION
C a I hereby off rte that 1 am csempl from the DECLARATION
license Law lin the
gxOiU following reasrn.(Smtion10315,Business and Professions Cade:Any eilyor coumy SIGNS ELECTRICAL ❑OTHI?R
which requires a permit to construct,alter,improve,demolish.or¢pair any slrvcture /`/r. Moil
Prior to its issuance,also unuies the Applicant for such Permit to file a signed statement SPECIAL ttCIRCDIT ESC.
} that he is licensed pursuant the provisions of@ter9 e Contractors Licenselaw(Chap
GAO (enmmrneing with Section l(XMp o(DivisionJ of the lsusiness mod l'mfeoinns CuJe)or TEMP.METER POLE(NST. COMMERCIAL,s rh�f)0
6qi5 c e' that he is exempt therefrom and the basis for the alleged exemption.Any vinhaion of ❑NEW BLDG/ADDITION 61)HPAOLITION
WM Section 7031.5 by any applicant for a permit subjects the apPlicanfm a civil penalty of POWER DIiV ES []TENANT ❑FWD SERVICE
not more than five hundred dollars($500).
F Z} IMPROVEMENT
p0 ❑to the work,the propcactur is emptended or offered for
rsale((See.
compensation, SWINISH '. LELELTRIC
andl do the and the structureisnet i License lzwdoes rmlclply to an Business DOTTER
ars progeny
who
Cole:The Contractors License law Jces not apply m an owner of (IDTLI: SWIT -P TURES
hisw who busess or improves thereon.and who does such work himself or mbrough
his own however.
he provided But such menti,sold wine.
are not intended!o. or oRereJ for NEW RESIDENTIAL EL SQ FT.
own If,-lower will have the bur imp mvement ithaehe lid nonmed or improve
eforthe SQ.FT.FLOOR AREA SISQ.PI'.
owner-builder will have roc burden nl proving the he did oat M1uiIJ or impmvc for par- 2 /1\
poserfs.IeJ. ��`� t��/ 0S
I,a owner of the pmpeny,am exclusively contracting with licensed contractors to
constructhe project(Sec.1011.Business and Professions Cel The Contractor's Li-
canse Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a varbactur(%)Ilcunsed pursuant mo the Contractor's
License lass, PERMIT ISSUANCE
E]IvptunJer Se .n@I'C for this reason
ALIEN-DRAIN @VENT-WATER(EAI VALUATION
r Date � q—qR 14
ORK R'S COM YENSA' NUIiCLARATION BACK FLOW PROTF.CT.DEVICF,
and
dwill mai unser Certificate
erticof Coyonuofelf-insure for Workers o —`
I.,to provull forty Sunimf37M of the Lidur Cod.far the
Workersce of he DRAINS-PLOOR.RWRAREA,,QND. STORIE, TYPE CONSTRUCTION
smirk, r provided for mi Section 3100 of the IabiY Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I nava and will maintain Workers Co ec ofthe w rkfor Insurance,ti required by Section
3180 of(he hvhn Code,l rlM1cYpctlbrmmrceof the work[lir factious is lssucd, GAS-EA.SYS'IEM-I INC.AOUTLGTS OCC,C, P ANN
MyWCater:r a IrX(—Pandy No.:numhcj fcj/OL?� GAS-FA.SYSTEM OVIiRi(EA)
cr and 11 1
CERTIFICA'&F Of L=XE7vI"ION MOM WORKERS'
COMPENSATION
GREASFJINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE, ILD G (VISION MES
(This swnnn need nom beentptried itWepernit is for arm nundreddoll...HI(M)) GREASE'I'RAP
or
lass) PLANCHr:CK FE
I cenif am,inlM1e pcit.nam.reof the work for which this pemtim is issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any pe.a in any manner so as ro become subject m the Worker;Compel- ENERGY PEE
DZ anion Lows of Cullinane.Date WATER HEATER W/VF,N'rTLECTR GRADINGP
Z Applicant
.N-. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYST OTItHATING
h , beeime.subject to the Workers Compensation provisions of the labor Cade,You must SOI(S PER
sisi
foMwith comply with such provisions m this permit shall be deemed marked. WATER SERVICE
UJ
Q
oro CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.FT. PAID Da Receipt#
I hereby affirm That there i,.constmchum lana ing agency for the, of
the work far which this permit is issued(Sec.3091.Civ.CJ
I-" lenders Name TOTAL
y,U Lender's Address io
C W 1 certify that I have rend this application and state thin the above ndormntion is I BUILDING F.E
•'^ N cane 1.I agree to comply with all city and county ordinances and stale laws ramming m QTY. MECHANICAL PERMIT FEE
U building construction,andhembyauthodu repmuntmivcsafthis city tracer upon the SEISMIC FIr B
above-mentioned Mopcny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Carrion against ELECTRIC E
Iiuhilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO M ITCH.
in asequence of the granting of this permit. PLUMBIN i FEE
APPLICANT U. STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO to."CPM)
SOURCERE MECHANI'
AIR HANDLING UNIT(OVER 10,0010 CFM) CONSTRUCrIONT11
SiSnamre fir A,bellnVCnntmeter Date F,XHAUS'1'HOOD(W/DUCT) HOUSING MITIGATION IT
HA'URDOUS MATERI SDISCLOSURE
Will she applicant or future building occ nam store or handle havartlous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cole.Chapter 9.12,and the Health and Safety
Gds.,Scairn 25532(.)4 _ I[EATING UNIT(OVER 100.000 BTI)
❑Yes ❑Nr VENTILATION FAN(SINGLE RESID) PAID �-
v Will the applicant or future building reorient use cquipmem or devices which Date Rcecipt#
t Emoudous air conterminous as defined b the Ba Area Air Quality Management BOILER-COMP(3Hp OR 100,000 BTU)
'� Y Y TOT'Ah:
arnvicfl Yes E]No BOILER-COME(OVER 100,000 BTU)
I have¢,the harmdous moerialzet
muuMe,Chapter 6.95 of the Cali- AIRCONDHIONER ISSUANCE DATE
farm.Health @ Safety Code,Sections 25505,,2 255 at, mJ re"mi
,,uemath dict if the NEW RESIDENTIAL MLCII. SQ.FT.
huilJing Jws not curten
ntly have.Innn that it ixs mY msihilimy notify the itccupant
of the requiremensv which must be mer prior to Issuance of a Cenieicate of Occupancy.
Owner,,andorized agent Dae T J ISSUED BY. \\V1�1/V�l
OFFICE
1087 NovembRi-AN L
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR BUILDING PERMIT
Tract NoA 3 4......Lot No...../g...............
9/23
Date---------------- •---------------•.................. 19.-.fr.'.4.- Q Permit
Application is hereb-y�{made for a permit to .-Y.0J_L-j�..................................................
a-----1-• story, Type.._Ka. ..S' d _a '°' +/i'R✓
----'---� -------------..... Building
at A0.5Z---RAVF— .B.-E - .RLQ Use Zone-----E-i
to be occupied only as ....L__F �M_!'�. .�.✓��� Occupancy.........i-.........
- Parking Space.........71......
--
in accordance with Plans, Specifications and Plot-plan filed herewith.
V
Estimated Value of Improvements,$.....�`��.D �................ — 71) 3'��
It is hereby agreed that the requirements of the San Jose Building and Zoning Ordinances and all other laws
applicable to the construction, location, and use of buildings within the City of San Jose, will becomplied with.
I certify that in the performance of the work for which this permit is issued I shall not employ any person in
any manner so as to violate the workman's compensation laws of California.
Owner.. :.f_�UN-rE2 As5�.....Address../4k.5�.......Sd � 9
-- f"• ---
Contraet6 "" .l
ByAge�rt..� `/ -_= �• ������----- Address......-----�,.IY/.cJo3t �4UF
l/ -
I •
RECORD OF INSPECTION
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Form
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