29163 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILTNG-ELEC`T'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUME NG-MFICIIANICAL 29163I
BUILDING PROJECT BEEN
BUILIIINGADDRESS: SANI'T'ARY NO. APPLICATION SUBMITTAL DAF?
G '
OWN RS NAM PHONE: CONTRACTORS NAME: LIC NO:
NIC CONTROhp
aces
CHRECI'/ENGNEHIL EECrsADDRESS: ❑
CO ACT _.fes ,. � PHONF� - BUI LDING PERMIT INFO
,(�i�,�SN-'��" •� ❑ Consultant Fces Paid by Applicant(Initial) BLDG ELLC'I' PLUME MECH
�O ❑ 1--] M E]LICENSEDCONTRACTOR'S DECLARA ION QTY ELECTRIC PERMIT FEE
1 hereby afOr t that 1 on licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O 0.'Z with Scdinn]fg0)nl Divisinnlnl the Businessant...Sessions Cold,andmy license i. RESIDENTIAL:
r+lOp n PERMIT ISSUANCE
F�FUS LicenlsfYic c`SnJd effecL� ���O ❑SFDWI, ❑KITCHEN REMODEL
F-ZU Dam! s wr`!O Contractor APPLIANCP_S-RESIOCNTTAL ❑ADDITION ❑PLUM1IRIYG RE-PIPE
Fah And-out ECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZOvnZ Iuaderstend or,plansshali lse moil as Public records MODIFICATION
UPT0 200 AMPS
CZ-0 ❑INTERIOR ❑CHIMNEY REPAIR
LLI Licensed Proressional 201-IINNIAMPS IMPROVIiMFiN'1'
OWNER-BUILDER DECLARATION
CY�J OVER I000AMPS ATH NEMODEIJREPAIR El DEMOLITION
Q T hereby affirm that I am exempt from the Comtoe
racs License Law for the
k ,U following prawn.(Section"103 L5,Business and Professions Code:Any city nr county SIGNS ELECTRICAL [I OTHER
u7Olaf3 4. which requires a permit in ennstimet,alter,improve.demolish.or repair any structure
prisma its issuance,also mqulrestm henpplicunt for such permit file u signed statement SPECIAL CIRCUIT/MISC.
y�
that he is licensed pumuanno the provisions of the Contrucmr's License Law(Chapter 9 COMMERCIAL:
Sal (commencing with Section7")of Division 3 ofthe Business and Professions Code)or TEMP.MITER OR POLE INST.
a E c C Shot he is exempt therefrom and the bmis for the alleged esemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]031.5 by any pfinratfor a permitsubjeds the applicant In.civil penalty of POWER DEVICES []TENANT [I FOOD S17RVICE
y not more than five hundred dollars($500). IMPROVEMENT
L as owner of the Pntryny,nr my entployccs with wage us Ocie sole mmpemativo SWIMMING POOL CLi[CfRIC
p. will do the work,and me.structure is not intended or offered bur sale(See, Business ❑OTHER
6 w ed and Professions Code:TM Commences License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves thacon,and who does such work himself or through
his own employees,Provided that such improvements arc not intended or offered for NEW RESIDENTIAL CLEC1t SQ FT
sale.It, the huilaingor improvenras scold within,reyemof completion,the SQ.Ff. - ORIyS1Ui ' S/SQ.FT.
or-holder will have the burden of proving that he did not build or inmrove 5srpun
u idside.).prom
T,m other of the Sec.7 ,am esd ss and contracting with Rcenses_1-111 1I m TOTAL: JAN 3 1996
construct the project(Sec,vow,Business and Professions Code:)The Convenors Li.
e sel.wa«a not apply to an owner of nrelMnr who nwms or improves marcor,and QTY. PLUMBING PERMIT FEE
,hoc oanal,fnrsunh prnjlus with a 11 tmmua(s)licensee Pursmm,,the Gmeamoes CITY UI- UUH:hIINU
License Law. PERMIT ISSUANCE V
❑ 1 are exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(PAO VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
1 hereby affirm rmacr Renally of penury one al She following declarations:
❑Those and will maintain aCenilice¢nf Consent ncsdl-insure fur Worker's ComPem DRAINS-FLOOR.RIX)I',AREA,WNO STORIES TYPE CONSTRUCT ION
cation,as provided for by Section 310)of the Labor Code,for the performance of the
wort for which this permit is issued. FIXTURES-YER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section ff
Cumerrke Labor Calc.linthe r nPolicy
yNo nuwhich this permit is issucA. GAS-EA.SYSTEM-1EOVER40UThISfS OCC.GROUP APN
r r Inwmnce mic d Polis
y s r s-- GAS-HA.SYSTEM OV ER4(P,A)
CERTI KATE OP E%BMITION FROMWRKERS'Do `r
COMPENSATION INSURANCE GRE\SMNDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION TEES
(1'hil,celon need net be completed it he permit isfor one hundred dollars($1013) GREASETRAP
or le¢) PLANCHECK PEE
I certify that in 0m perfummnce ofthe work for whichhis permit is issued.I shall SEWIR-SANITARY-STORM EA.2(1014.
not employ any person ir s m ec esuyjpctnedw Workers'Co.,.-- ENERGY FT9i
Z cation Iaw afif m' ¢ WATER HEATER WNENT/ELECTR
OO APPlica 1. � -
N GRADING FEH
G NOTICEOAPPLE AMI':IL after making this Certificate of Exerraii you should WATERSYS'fEMOREATTNG
7 became anbjcct a the Workers Como s,or
is provisions tithe deemed
evo1ke,you must SOILS FEB
� ti forthwith comply with such pruvis' nn or this permit shall be deemed revoked WATER SERVICE:
�DZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAI.PLMB. SQ.Ff. PAID
U O lnmebr arnrot mat mereiaaennmmeann lenamg agenny rnr me lnrrotmanee nr Date Reeeima
lL O (•'l the work for which this Secant is issued(See.3097,Civ.C.)U Lender's Name TOTAL:
Lender's Address TOTAL: q
�. V U BUILDING FEE
1 eenar that I have read this aPPBwann and nate mat me above inrnmdhnn i.
ma
F h emme'.l agree or comply with all city and county ordinances and state laws adding to QTY. MECHANICAL PERM IT FEE
U Z building construction,and hereby uuthorive representatives of this city to enter upset the SEISMIC PEE
aboveametioned property I'or inspection purposes. PERMIT'ISSUANCE
(We)agree m shin.indemnify and keep harmless the City of Cupertino against ELECTRIC THE
liabilities.judgmenm,costs and expenses which may in any way accoe againstsaid City ALTER OR ADD TO MECH.
in consequence of the graming of this Permit.in
PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
AIR HANDLING ON]F(OVER 10,000 CFM) CONSTRUCTION TAX
SOUI(CTi ELATION S. ¢
Sigwmm of Appli UCom DO Da--aT EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilJing occupnm store nr handle hueurdous mammal HEATING UNIT(TO II0.00)BTU)
ass defined by the Cula iso Mamrin l Code.Chapter 9.12,and the Ilcallh and Sal cry
Cock,Section 2 532Dy1 HEATING UNIT(OVER 11)(0,000 BTU)
❑Yes 0 N VENTILATION FAN(SINGLE RESIDE PAID Dam Reeeipta
IVES the applicant or future building occupant use equipment or devices which
emit hazardous air conmminunts as defined M1v the Bay Area Air Quality Management BOILI7R-COMP 011POR I(MRS)BTU) TOTAL: /
District'
❑Ycs [D No BOILER-COMP(OVER W.(NIO BTU)
I have read the hmdbow promo,,apporemcnu-Wer Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
famia Itralth&Safny Chide.Sections 25505,25533 and 25534.1 undemminJ roar if the NEW RESIDENTIAL MECH. SQ.y-L Q
building docs not shmhtly have o lm,ant.that it is no resp-nihiTny In notify lhcmxupdn
of the requiremenm which moa ba met prior-to essannce of a Cenificare of(xcupadr.
Owner or anthoriuJ agent Dam TOTAL: ISSUED BY:
OFFICE