29008 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIIII.DING-ELECTRICAL PERMIT NO. 29008 O O H
IIUILDING.DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDENTIFICATION
ILDING ADDKF_SS: 'm SANITARYNO APPLICATION SUBMITTAL DATE
p 1S o PRLo US's Trir Ru -qG y' e
WNER'SNAME: PHONE )NIRACk" G: LIC NO:
1• C `
NIC ^ CONTROL#
4 CHITECTMNGINEER: LIC NO: UD L S: L ❑"Ill 1 (d�0
S` L U
CONTACT. PHONIC- b BUILDING PERMIT INFO
\ Ol ❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MF,CH
o An 9 3-i B ?r
I --
LICENSI!D CONTRACTOR'S DEf YARAT ON QTY ELECTRIC PERMIT FEE
I hereby affirm mal l am licemed under provisions of Chapter 9(commene ng JOB DESCRIPTION
la OZ with of Division 3 of the NminessadRnlbssirn dray license is R_FCIDENTIAIr
{^100 wt PERM IT ISSUANCE
full force and effeq^ q
tY�� in B d(Q ❑$fDWL El KITCHEN REh1ODF.1.
QVL14'g APPLIANCES-RFSIDENTIAI. 1)UITI0N ❑PLUMBING RGPIPE
QW tc Commdor ! -
F A HITECTS DEC R 1 14
❑MULTI-UNIT []STRUCTURAL
Z 1 underaaoJ l, 1 %hall be used its biic cords PANELS
ZO ypans eta UPTD200AMPS
OZ�O ❑INTERIOR ❑CIIIMNI!Y REPAIR
F•rnh(y Llceraui Professional 201-1o11(IAMPs IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IIXM)AM ❑BATH REMODEUREPAIR 0DEMOLITION
S�O U 1 hereby ufrom that 1 am exempt from the Conaacbn's License Law for the ❑OTHIiR
kk 6 following reason.(Section]1131.5,Business and Professions Cesi Any city or county SIGNS IiLEC AL
W 3 a y which rectums a permit to connwct.uher,improve,demolish,nr repair any suuewrc
E"�0Q "mrwitsismance,also reqsire,mcapplicont forsuch permit...flcasignNsmmment SPECIAL CIRCUIT/MISC.
yy, that he is licensed proureant in the provisitari ofthe Contractors License Low(Chapter 9
'dQ0 Rommeoring with Section Milo at Divia6rn 3ofine Business and Profession.Code COMMERCIAL:
)or TEMP METER OR JNST.
a S o C thm he is exempt mercfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEM0LI'LOSE
^m
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of MW17R DEVICES ❑TENANT ❑FWD SERVICE
not more than five hundred dollars(55(X1). � RIMPROVEMENT
p=60 ❑ Lus owner of the pmpeny.or my entployces with wages as their sole compennntion, SWIMMING M30I,ELECT
dF• will do the work.and the structure is not intended or offend hostile(Sec, ❑OTHER
Wm_ and Professions Code,The Contamors License law Jas not apply to an owner of OUTLETS-SW'ITCUES-FI% UR
property who build.,or improves thereon,and who does sum work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECUE 'Q FT.
sale.IL however,the building or imprnvemum issold withmone ycurnf em,1ction,the SQ.PT.FLOOR ARCA bISQ.FT.
w
mrhuilder will have the under of pausing thin he did nor build or improve far par-
exast ofoxh.). TOTAL: 11.
O^
3
,
1,ruowner ofthe property,
c.7104ammirmiv ad cu.coin.,with licensed Cm,...I m
construct the pnjM(Sec.]1144,Business and Pmfessirm'Graded The Gmtmcmrs Li-
e om taw does nm appy In an owner of proany who build,or improves thereon,and QTY. PLUMEI(G 11 IT FEE 11_2 hqa
sai
who contracts for such projects with a contractors)licensed pumoantto me Contractors L1✓L�
License taw. PERMIT ISSUANCE
I um esempt under Sec. ,B h P C for this reason
Owner Dam ALTER-DRAIN&VEST-W (L L VALUATION
WOR KER'SnaltyCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Q
at 1 hereby affirm under penalty of perjury one ofthe
telt following declarations Co
In.as add will for
neCenifca0 of Consentr Cat,for the Worker'sce of the
DRAINS-FLOOR,ROOF,AREA.GOND, ST0Rlli.S TVPIiC0NSTkULT1ON
seine,as hick this
for by Section issued. of the Who Css1e,for the performuncn of the
work forwhich this aintiisorker FIXTURES-PGR TRAP
I have and will maintain Worker's uompevamion Insurance,h his Per by Section
J]INl of me lahnCode,l'or me perforn nnecalme work for which this Permit is issued. GAS-GA.SYSTI!M-I INCA OIITLGTS OCC.GROUP APN
MyWork mns�iry1n Ivwq(aocartier and Polic)7um1wr am:
Carrier. L• f/fX(F/✓e/AS Policy No.:• GAS-EA.SYSTEM-0VEk4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASF/INDUSTRL WASTF.INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION ITES
(Thisscctiou need not hecoundeted ifine pemlilis unarm hundred dollars IS IW) GREASETRAVp P p /�
or I ,.)
ca
Lato
I certify mPerformance in the perfnmnce of the work for which this permit isimucJ,l shall SEWER-SANITARY-STORM EA.200 FT. PLANCHET P..'i
not employ any person in any manner so as m become subject ht the Workers'Compen- ENER Y FEE
Z .mina Lwsnf California.Date W'AT'ER BEATER W/VENT/EiXc7TR
ZO APFlicant GRAI N O 11 k,
z'y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTENYTREATING
f-' become subject to the Workers Com provisions of the Labor Cral,you most soyf9 FEtE -
Compensation Prost s t Al s
fnnhwith comply with such pnrvininnn nr this permit and be deemed revoked WATI!R SERVICE r Ln I(iU
a
CONSTRUCTION LENOINGAGENCY NEW kFSIDENTIAL PLMB. SQ.FT. PAID LAO
V 0 1 he
mbyeffirm that to.,,.communist lerdingagcncy frnhe perfumwnceofV. Dat° Rs r v
the work for which this permit Is issued(Sec.AN7.Civ.C.)
0 U Lenders Name TOTAL:
WLcndcrs Address 'TOTAL: BUILDING FEB
Aa I certify that 1 have read this applicuum and anal,that the alana information is
pp correct.l agree to comply w'nh all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
building construction,and hereby awhnri'ec representatives afthls city In cnlcruirm the SEISMIC FEE
alawe-mentioncA properly Introspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Capsmino against [LGCI'RIC PEE
ar
I ishilitics.judgments,coax and expemes which may i n any way aeauengainst said City ALTF,RORADDTOMECIL
PLUMBING FEE
in nurse ranee of the grunting of this lxrmit.
APPI ANT UN .RST D AND ILL COMPLY WIT I AL1.N IN-POINT AIR HANDLING UNIT(TO 10.000 CPM) MECHANICAL F
S 'E REGI' ATION' /�
l\ AIR HANDLING UNIT(OVER IO.00B CPM) CONSTRUCTION TAX
S' tawre Applicant/ t am >mo EXHAUST HOOD(WNUCF) HOUSING MITIGATI FEB
HA'ARDOUS MAI
DISCLOS RE
Will the applicant or future building occupant store or handle hazardous mammal HEATING UNIT(T0100,000 BTU)
us defined by the Cir a tiro Municipal Code,Chapter 9.12,and the Health and Safety
Coda Section 25532(0)] HEATING UNIT(OVER 100,000 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Orae Receipt x
Frit havmJon,air reals nants ns defined by the Huy Arco Air Quality Management ROILF,R-COMP(3HP0R 100.(100 BTUI
I.:
este] BOILER-COMP(OVER 100,00OBTU)
❑Yes [-I No
91
1 have and the hasmJons materials requirenmnts under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE.
brain Health&Safety Axle.Sections l!5505,25533 and 25534.1 understand that it he NEW RESIDENT Al.MUCH. SQ.F1'.
building does not currently have a tenant char it is my responsibility to notify the occupant
of the mltirements which must be met prior to issuance of Cenificare of Occupancy.
Owner or aumorizeJ agent Dam TOTAL: ISSIIIiD BY.
OFFICE