29162 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERhHr NO.
BUILDING DIVISION APPEICATIONIPERMIT PLUMBING-MECHANICAL 29162
BUILDING PRO.IRC'P IDEN'TIF'ICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL UNIT
/Dano P�1,✓_-Q/J-4 BL ✓D. ��iNo (�A• l—`f-OIS
OWNER'S NAMHE PHONE: CONTRACTOR-S NAME: ./� LIC NO�:
V11,140^17- L✓u 992-d20 Z N/C CON'rR01,p
.A RCHITECTMNGINEER: LIC NO: ADDRESS: EDTw Z t _2 %4r f /65 D D•
CONTACT. PHONE: �p BUILDING PERMIT INTO
Consultant Fars Paid by Applicant(Initial) J_=n:2� BLDG ELECT PLUMB MECH
LICENSED CON'FRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEC
I hereby M.Net I am licensed under provision of Chapter 4(commencing JOB DESCRIPTION
Z wa Scv,kw7000f.f Divi,mn3of the Bminnan
sd Pronsde,an
fessioCadmy license is RESIDENTIAL:
F1_ in full force and effect. PERMIT ISSUANCE
W- FDWL ❑KITCHEN REMODEL
E
�UU License Class Cma milm APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
HF-�ul Dom 7OS DECLARATION
D y ARCfI1TEC1-S DECLARATION PANELS - [I MULTI-UNIT ❑STRUCTURAL
Z p rte Z 1 understand my plan shall fe used as public records MODIFICATION
OZ-C UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�_I_M FiTnod Profcsinnal 201-HXMAMPS IMPROVEMENT
�YE; OWNER-BUILDER DECLARATION OVER IWIIAMPS [:IBATH REMODEUREPAIR ❑DEMOLITION
Y Q I hereby affirm that 1 am exempt from the Contractor's License Law for the _
U following reason.(Section 7031.5.Business and Pmfcoion Cale:Any city or county SIGNS ELFCI'FICAL ❑OTHER
3 W y poor to
requires n permit re cores the alien improve,h permit to
or repair ,d Iwrwrre
OQ pdnnnslicened..........
alsorequires Nu applicant for such permit rnicense ynedsmtemem $PECIAI.CIRWI'PIMIgC. �j✓
sE 25}J Nm he is licensed punuam to Nc provision of the Contrunnr's License I�w(Chapter 4
W p;p0 (commencing with Section?000)of Division J of Ne Business and Profession Code)or TEMP.METER OR POLE INS'C COMMERCIAL:
6 n, C Nm he is exempt therefrom and the bmis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL%1 o,, Section 703L.1 byany applicant for.Pen(,.hjrsI1 the un
pplicanna civil pea,liy of POWER D17VICES ❑9 ❑
'ENANT FOODSERVICE
>. net mune Nan five hundred dollars($5(X).
F Z>. IMPROVEMIiN'1'
SSG ❑I,u owner of(he property,or my employees wird wages az Neirmle compensation, SWIMMING POOL ELECTRIC
p., will do the work.and the s0ucture is not intended!or offend for sale(Six. Business ❑OTHER
3 and Professions Code:The Contracmrx License Law does not apply to an owner of OUTLETS-SW'ITCN6S-FIXTURES
,o,ry,who Ind lds m improves Ilius.,and who does such work himself or through
his own employees,provided that such improvements an not intended or offered for NEW RESIDENTIAL ELECT SQ PT.
sale.If,however,the building in mpnvettmm is.cold within one year ofcnmpletinq the SQ.FT.FLOOR AREA VSQ.Fn
caner-builder will have the burden of proving that he did not build or improve for pur-
port of sale.).
scow red Nes"."y,son sims,i and crom,di it with licensedcmntracmism
onstrI,own project ISec.]014.Business and emfesions CWc:)ens domlu,lo Li-
mnee lawdeas not apply to an owner ofpmpcny who huildsm improves be..add QTY. PLUMBING PERMIT FEE
whoconvacts forsuch proire with acontraemr(s)licensed pursuant muse Commemr's
License Law. PERMIT ISSUANCE
O lamexemplunder Sec. ,B&PCfomhisneama
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dam
WORKER'S COS PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby idl mai under penalty rel'perjury one of Nu following declaraWInka'tlons:
onion,
as provide for byneCion 37 c ofConwrl Labor
Code.for for Worker's Co.,.- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCT ION
smiom,us provided for mi Section 3T30 of the Labor Code,for Ne performance of the
work have
this permit is issued. FlXTURFS-PER TRAP
❑ I huvc and will Code,
Workers anceo he w work
for which
h required by Section
J'!(Xl ofthe LOMu Ctde,for the Performance ofthe work far which Otis permit is issued GAS-FA.SYSTEM-I INCdOUTL1i9F OCC.CROUP APN
My Wmkch Compensation Insurance carrier and Policy number me:
Carrier. Policy No: GAS-FA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS GREASfIINDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not hecompldcd ifthepemtit is for one hundmd0ollars D 00) GREASETRAP
or less.) PLANCHECK FEE /
I certify that in the performance of Ne work forwhich this permit is issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to hecoma subject to the Worked Cempem- ENERGY HE
O,Z actin Lmws of California.Ilam WATER HEATER W/V IiN'1'/ELECTR GRADING FEE
Z o Applicant
NOTICE TO APPLICANT.If.after making his Certificate of Exemption.you should WATER SYSTENLTREATING
� ^ beaomebject m the Worker's Compensation provision%of NC Labor Code.you must SOILS TEE
su
G
forthwith
hcomply with
chat provisions nnhispermit shall hedeemcd revoked. WATER SERVICE I
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID/�39b
7 z hereby %a construction lending agency for de performance of Date RmeiptM
V. 0 the work for which this Penni(is issued(Sec.3041,Civ.C
0 Lendefs Name L'
Lembea Address Ta � BUILDING FEE Z
I certify Na(1 have read da,apdamion and sm a Nat the ahrve information is
h correct.l agree to comply with all city and county ordinances and sen laws relating, QTY. MECHANICAL PERMIT FEE
U ,7Z. buddingeonwuction,and hereby authorim representatives oftakeity to enterupon the SEISMIC FEE
aMwe mentioned properly for inspection purTnms' PERMIT ISSUANCEw
(We)agree to save,indemnify and keep hamnless the City of Cupcnino against 9 CLECI'RIC FF,E 2 ,Ll.r y
liabilities,judgments.costs and expenses which may in any way ammer against said City ALTER OR ADD TO MECH, s t
ouse,mme of the granting of Penni(. PLUMD GF.E o
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,NX)CFMIMSCI{gNICAI. EF,
, kLOms
SOURCE REGULATIONS. LA
' AIR HANDLING UNIT(OVER IB0IXICFM) CONSTRUCTION
S,,wweof A,,dc.wYCommcmr Date EXHAUSTHOOD(W/DUCT') HOUSING MITIGATIO, FEE
HAZARDOUS MAI ERIAL$DISCLOSURE
Will Ne applicant or future building occupant store or handle hamrdous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12.and he Health and Safety
Code,Section 25532oo? HEATING UNIT(OVER 100.000 BTU)
E-]ye, No VENTILATION FAN(SINGLE RISIU) yf A ' 7hm Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,01X)BTU) ,IIP s
t hwafdous air contaminants as defned by Ne Bay Ana Air Quality Management TOTAL:
1 i• ,
Di%trittR BOLLEN-COMP(OVER 100,B10 BTU) "rrIFV
❑Yes [:1 No
I have read dw hvallous materials (s under Chapter 6,95 of be Crib- AIR CONDITIONER ISSUANCE DATE
5,2re
fnmla g dons&Safety Code.Section 25505,255JJ and 25534.I understand that if on NEW RCSIDENTIAI.MECH. SQ.F7.
building does nut currently have u,meto,(hoe o is my....I aCraiy en notify the fe,r,m
of Ne raluirenmms which tuna be son prior m Iscuanm rel'a Cenillcwc of Occupancy.
Owner or auNmned agent Dae ISSUED BY:
OFFICE