29052 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-ELF.C]AICAL PERMIT N029052
. a.a ^O a.a
RUILDINGI)IVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL L�JJ L
BUILDING PROJECT IDRIS TIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICAHON SUBMITTAL D;M
21 O (0 3 TRIOT #-Yanip'T140, � ciri01-F la_ S
OWN R N M^ PI(O C RACTOR'S NAME LIC No
NIC CONI'R^OL aaa.���$F,/•�
kRCHITECT/ENGINEEI IN . ADDRESS: ❑ �(/L/1
Opp
CONTACT. `PHONE: ,s '� BUILDING PERMIT INFO
( e I I)`L V4601> /yll G 1 I(jl l—I A'//o ❑ Consultant Fees Paid by Applicant(initial) B{pq ELE(T PLUMB MECH
TlG1yM^'L T ` 147✓ w Ii✓^Y/' !3�(I` ❑ ❑
LICENSED chat Ia CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm thn I am licensed under provisions m chapter 9(commencing JOB DESCRIPTION
O�Z withI. ll open]000)of DivizionJof the Business and Pmfcssiom Code,and my licenses RFSUDENTIIAI
�O O PERMIT ISSUANCE
�UF
Lice Classnd cff uc.M _gSFDWI- ❑KITCHEN REMODEL
sF�a Dam Contractor API'LIANCIi$-HT;SIDEMI'IAL �6 pIlUH'ION [I PLUMBING KF,PIPF:
ITECCS D[CL N MULTI-UNIT 0 STRUCTURAL
Z O Z I un J m pl...h he records PANELS MODIFICATION
OZ—Q c. UPT0200AMPS ❑INTERIOR OCHIMNEY REPAIR
F.N, neat t al 20LHMAMPS IMPROVEMENT
OWNER-IIU DERUI!CLARA]'ION
05 C R I hereby affirm that I am exempt born'
rom the Contractor's License Law for the OVER I WUAMYS BATH REMODEUREPAIR 0 DEMOLITION
OLV following teasen.(Section703IS.Business and Professions Cole!Any city or county SIGNS ELECTRICAL DOTHER
K
3 t fn which requires^permit m Lmiamel, In,improve,demolish m repair any smicame
.F.LL0� prior to its issuance,also requires the applicant knomb word ,,Bleasignedamemcnt SPECIAL CIRCUI'1'IMISC.
it, n thatampricurg with
pursuant 7W)).fDisiens of the Co milics's Llcenu Law 1,CapterY
it, no (commencing with Scaion]IXMB of Divisi�n3ofthe Bosincss and Pmfcssiore Cone COMMERCIAL:
)or TEMP. OR POLE INS .
a W n C thatSec he is exempt therefrom and the basis for the subjects
the esempnt to Any l Pen ion of ❑NEW BLDG/AUDITION C FOOD LITION
SERVICE^m Section than by anyapplicantfor epennit subjects the apPlicanunncivil penalty of POWER DEVICES ❑TENANT OFDGD ST;RVICE
nm more than five hundred dollars I85IXB.
FROIMPROVEMENT
Sat Dl.sownerof the Pmpcny,ter my employees with wages ax lheirsolc compenmtion. SWIMMING POOL ELECT n
fF0 will dothe work,and the structure is not intended or offend for sale(Svc.7044.Business El OTHER
W 3 w and Professions Gore:Tho
Tb,Contimmea License Lew does not apply to an wner, of OUTLETS-SWITCHES-E R
property who builds or impmvcw thereon,and who dues such work himself ter through
his own employees,provided that such impmventents are not imended ter offered for NI?W RESIDENTIAL ELEMR
sale.If.however.the building or improvement is sold within one year ofcompletion,the SQ,FT..FLOOR AREA $/SQ.Fr.
caner-builder will have the buNcoofproving that Inertial not buildnimpmve initial-
"ref sale.). uY S wq
I,as owner of the property,ata exclusively contracting with licensed mmracmcs m T ,
construct the project(Sec.7044,Business and Professions Codes)The Contractor's Li- AID
nm law dos not apply to an owner of properly who builds or improves thereon.and QTY. PLUMBING PERMIT FEE ii
who contracts forsuch projects with a connaclons)licensed panuaat to the Contractor's
License Law. PERMIT ISSUANCE JAN
JI pp
O l ran exempt under Seo. .N&P C litnhis rein JA N
ALTER-DRAIN&VENT-WATER(EA) LUATIO
(IND
Owner ')at= C11y
Jr writ t
WORKER'S rml,of COMPENSATION DECLAMATION BACK FLOW PROTECT.DEVICE
lhand offnan under perfidwnf ofCon,oneofihcfollawfor inclination,
orker'i Ca �yy y��ts
haveamoide mainbyection 37W of he Labor Code,
e erfiam'so,Camper. DRAINS-FLOOR,ROOF,ARBA GONI).LY STORIES 'I'YVECONSTRUCTION
walkd.!as provided for panic
Section J]W of the htMa CWe,for the Pcrfomena of the
work for which this aintiiis issued. FIXTURES-PEH TRAP
❑I have add will maintain Workers Compensationce ofthw Insolence,h required by Sssued
J]ghdtbe Labor Cale,for the perfnrmmnce ol'the work for which this permit is issued GAS-F,A.SYSTEM-FIX KIYD.El J (KC.GROUT' APN
My Worker s Cn/�tpcnr/�inn Incur ncc carrier unJ Policy nuntbcr e
Carrier:!_"iibyp:•µq._—Polioy GAS-EA.SYS'1'1? ;OVER4(EA)
C:2 PI ATE COMPENSATION
NFRO W(s CERS' '•
COMVIiNSATION INSURANCE GREASF/INDUSTRL WAS'IL INTERCEPTOR
(This ucfon need not he completed ifthe permit is for one hundred dollars($100) BUILDING DIMS NFLFS
ar
les") GREASETRAP PLANCIIIiCK FEE (31L e
Icenify that in the performance ofthe work for which this permit is issued.)shall SIiWER SANITARY-STORbf EA.200 FT.
not employ any pawn in any manner so as to become subject to the Workers'Camper- ENERGY FEE `
0 ,Z within Laws of California.Date WATER HEATER W/VENTIELECTTMTAL:
GRADING FEE
Z Q Applicant
NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSI ENL TREATINGSOILS FLM
become subject m the Worker's Compensation provisions of the latbm Cual,you must
D7 forthwith comply with such pro, or this Penni,shall be deemed revoked. WATER SERVICE
0
a' CONSTRUCTION LENDING AGENCY NEW RE$ID13N'I'[Ali PCMB. Cr. PAID
V Thereby ulBrm that there isaconstndion lending agency for the performance of Regciptp
Ne work for which this permit is issued(Set.3097.Civ.C.)
0 U Lenders Nunn TOTAL:
L) Lender's Address
I certify than 1 have read this application and sin than the above information is HUIL t F'
rte correct.l ague to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
Z building redemption.end hembyamhoriae n,ravoatiasofthis city to cnmrap .the SEISMIC FEE
chomp-mentioned poised for inspection Purposes. PERMIT ISSUANCE
(We)agree us cne,indramily and keep harmless the City of Cupertino agaiasl ELECTRIC FEE
Iiabilitia,judgmems,costs and expenses which may in anyway acerae against said City ALTERORADDTOMECH.
PLUMBING Ff.
inconsequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0g0CFM)
SOURC . MECIIANICA FEE
GLATIONS
AIR HANDLING UNIT(OVER 10,00(1 CPM) CONSTRUCT NTAX
t A tract r ate EXHAUSTHOODOVIDUC1)
HOUSING MI GATION FEE
uiAZARDO TERIAIS DISCLOS RE
Will applicant or!more building occupant stoic or handle hazoNous materiel HEATING UNIT(TO 1110,(KK)BTU)
as defined by the Culawino Municipal Cade.Chapter 9.12,and the Health and Safety
Code.Section 25532(x)? HrATING UNIT(OVER IIXLINXI BTU)
IJ Yes ❑Nn VENTILATION FAN(SINGLE RESID) PAID
Will the a licont or future building t use equipment or devices which Date Receip
pp dbytheB yoipr Qu BOILER-COMP(JHP OR I h,000 B]'UJ
'mit haeatJis air ttmtuminanls as JeEneJ by the Bay Arca AU Quality Management
District? BOILER-COMP(OVER 1(p,0110 BTU)❑Yes ❑No
1 have real the htaardaus mmeriak n quire arm,under Chapter 695 of me Cali- AIR CONDITIONER ISSUANCE DATE
fomiu Health&Safety Cade.Seddon 25505,25533 and 25534.1 understand that if the NEW W RESIDENTIAL SUCH. SQ.FT
Wilding Jas not currently have a tenant,that it is my responsibility to notify the occupant
of die ar,immenB which nun be met prior m isma«e of a Certificate of(kpapaocy.
Owncf or mthmimd agent Date 'TOTAL: ISSUED BY:
OFFICE