29767 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
1'•� BUILDING PROJECT IDE.TIFIC\TION
BUILDINGADDRESS: / / of ` Qtr ft"AU — /) 1 O / ��/� SANITARY NO. APPLICATION SUBMITTAL DATE
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OWNER'S NAME:.. 1�1T `���pU 1 p PI MINI?:r (/x-4aV�M CON'I'kACI'OOR'SN'N-AMME`I-l/Oj'/1\I_1, LICNO: OYD N/C �CO IL l
V •�Y'1P0
ARCH[TECT/ENGINFE`_ =.IC NO: ADDRESS: �� I Q e r {aW ❑
CONTACT: 'Y _Y PHONE: L J /a-f BUILDING PERMIT INFO
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1 , � (�y� a ) El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
V LWlVn .9 EJ 11 ❑
LICENSED CONTRACTOR'S DECLARNTI N QTY. ELECTRIC PERMIT FEE
1 hereby affirm me Inn,bacaaad under provialon,of chapter v(commencing JOB DESCRIPTION
p.Z� to11e11 force and ef. 4� Business and l'rofeeeions CuJe,onJ my license l.v pFRMIT ISSUANCE RESIDENTIAL:
aZ lhSenior 7WO)ofD
�O w ❑SIV WL ❑KITCHIiN kEMODEL
aV License Class Contractor ffY�y APPLIANCES-RE,SIDIi IAL ❑ADDITION ❑PLUMBING RH-PIPE
Commnor_
F=y ARCHITECTS DECLARATION PANELS ❑MULThUNIT ❑STRUCTURAL
Z O rn'Z 1 understand my plans that[lie used as public records MODIFICATION
OZ�-M UPT02WAMPS ❑INTERIOR CHIMNEY REPAIR
F vsF W Licensed Professional 20I-I000AMPS IMPROVEMENT
Q $'� OWNER-BUILDER DECLARATION
a� J OVER I(MIOAMPS ❑BATHREMODEI/REPAIR EIDE OLITION
xry�a a 6 I hereby affirm that 1 ten exempt from the Consorter',License Law for the
py 3 G Ug. following remvm.(Seetinr 9031 5,Ravine,and Perfevsions Code:Any city or county SIGNS ELECTRICAL. ❑OTHP. On..
W (L N which requires a permit to construct,almr improve,demolish,or repair any smueuraa!2' - �.��
O� prior to its Issuance,also requires the applicant for such permit to file'signed statement SPECIALCIRCUIDMISC.
pede, that he is licensed pursuant in the provisions of the Contractor's License law(Chap¢r9
1a1�00 recommencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METE � POLE 'ST. COMMERCIAL:
a L oy thus he is exempt therefrom sod tine basis fm the allege)ucmplion.any violuion of ❑NEW BLDG/ADDITION ❑DEMOLITION
kaMN Section 7031.5 by any applicant for a permit subjects she applicant m a civil penalty of POWER DEVICIS []TENANT ❑FWUSERVICE
no more than five hundred dollars(S500k
1- my wages not OTHER IMPROVEMENT
6 wiLas he work.and pfestray,oe i,no, loyeeswiWened formltheir(See 0ILL Business
SWIMMING POOL ELECTRIC
will donessi work.ande The antra not intended orow do Tema apply t)an Business ❑OTHEN
W and
properly
who
Cadc:The over tin un'e License Law docs not work
hi nr an owner of OUTLETS-SWITCHIi5-PI%TUkG
his own
who builds or improves t such improvements,and who Jam such work dee or or through
his own employeese provide[that much ssold arc not intended or oRuW for NEW kL'SIUENTIAI.GLBCTR I SQ PI'.
mlc.If.however,the building orimprovmncm is sold wiihinnne ycarofcamplalion.the SQ,P.FLOOR AREA §ISQ,FT.
looser builder will have the burden of prming that he did not build or improve for pury '�,+
Imam of sale.). u" / i<
❑I,as owner of the property,a exclusively contracting with licensed cement to TIL:
ino mrua the torpet(Sec.TDHL Business and Profeaions..de:l'Dm Canmacon,Li- rr
cense law does not apply to an owner of property who builds m improves thereon,and QTY. PLUMBING PERMIT FE H 90
who corrects for such projects with a comocmHs)licensed pursuamt to the Contme oa s a
License Law. PERMIT ISSUANCE CITY 1996
❑ I ten exempt under Sec. ,e&P C for this reason �r 1
ALTER-DRAIN&VENT'-WATER(EA) see VALUATION
B O � su
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE � � '75, 06
1 hereby affirm under penalty of perjury one of the following Jeclaretions: /i�
(have and will maimaina Certificate of Consemmulf-insure for Worker's Coope"- DRAINS-FLOOR,ROO RE .0 STORIES TYPECONSTRUCTION
union,as provided for by Section 3700 of the Lahr Cole,for the Peritoneum,of tine
work for which this permit is issued. FIXTURES-PER TRAP f 1e�3
I have and will maintain Workers Compenmlion Insurance,uz rcyuircd by Section /
37g1 ofthe Labor Code fordo,perfemarrceof the work far, GAS-G.SYSTEM TIN:.4 LGTS OCC.GROUP APN
My Worker' rte nsalinn1-lrnxuranc carrier and Puliry number ora yy)
Carrier; �e gIUK�Policy No.' GAS-F.A.SYSTEM-OVER 4 EA) / /�(
CERTIFICAI li 01'EXEMPTION FROM WORKERS GREASF/INDUSTRI.WASTG INTERCEPTOR �/
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed lithe permit in Torun hundred dollars(SlOin GREASETRAP
nr bill.) PLANCHECK I:EE
I certify that in the Nrformanceofthe work far which this permit is issued.Ishal[ SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner s r is to heroine subject o the Workers'Compen- ENERGY ME
iZ scion laws of California.Use WATER HEATER WNENT/ELECfR
Z
Applicant GRADING FEE
NOTICE 10 APPLICANT:If,after making Nis Cer iticae of Exception yam should WATER SYSTENUTREATING SOILS FEE
(-' become no,.tm the WorLet,Campensaltoo pon,mi na ul the Labor Code,you mu.a
lothwith comply win andiprov,,iono,in,permit,loll he deemed revoked. WAI'1ik SERVICE
Q
n' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID
V 0 (hereby affirm that there is a constmetion lending agency for the Performance of Dam ReceiplM
the work for which this permit is iswW(Sec.3097.Civ.C.)
E•' Lander's Name
O
r ul Lenders Address TOTAL:
0. 1 certify that 1 have read this application and slate 1ha the above information is BUILDING FEE
.F.UI correct.1 agree to comply with all city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT FEE
(.) ,Z, ohorim building eonstctiom.and hereby mnrepro,ankives of this city to enter upon the SEISMIC FEE
aboveonerho red employ lin iespvclina purposes. PERMIT ISSUANCE
(We)agree losses,indemnify and keep nature,the C'ny of Cupertino against ELECTRIC TTI?
limit...u,judgmere,costsord espcmeswhichmay irony way uccmcaguinsts.iJCity ALTER OR ADDTO MECIL PLUMBING ItEF
in omequeace of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO[Alpo CFM)
MECHANICAL HE
SOURCE REGULATIONS.
AIR HANDLING UNIT(AR .WO M) CONSTRUCTIONTAX
Signamecof ApplicanUCuntrammr Data EXHAUST HOOD IW IC HOUSING MITIGATION FEE
HA9ARDOUS MATERIALS DISCLOSURE
Willthe,tilitem or lnerchuilJing ixcupum store or bundle h.,amms material HEATING UNIT(T ,I ).W(I TU)
uv dcftnrJ by the Cupertino Municipal Coda,Chapter 9.12,and the Bruhn and Safely
Code,Stalin.25532(0'l BEATING UNIT(OV:R I(90,01p BTU)
i]Yes �'fNo VENTILATION PAN(SINGLE RESID) PAID
( Will Jre a licam or future building ecu M1 use c t ter devices which Data Receipt M
PP g e "Airne^ BO ILER-COMPpHP OR Igl,lpo BTU)
emit M1azanlous air contaminoms as Jefimd by the Ray Arca Air Quality Management
District? TOTAL,:
Yes q} BOILIiR-COMP(OVER Iq),gp BTlll
M1Y•`n .
I have read the hca
ordoun mine mals requirements under Chapter 695 of me Cali AIR CONDITIONER SUANCE DATE
fnmin Ilealth&Suf^ry C,Je,Sections 25505,2553)and 25534.I understand that it the NEW RESIDENTIAL.MECH. SQ.II'.
building Jocs not curcn0y hove u nnwn,thus it is my rcnM'nsihility In molly theoxcupam
of the requirements which mus Ire zaimm ity acenitirmuf0 upancy
Owner or authorie agcn Dam TOTAL: ISSUED BY:
OFFICE