29489 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICA'rION/PERMIT PLUSIRING-MECHANICAL 29489
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DAI'1:
OWNER'S NAME: PHONE: CONTRA OR'SN e— LIC�U:
/��YP"G N/C CONTROhp
RCHITECf/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG 'hF.Cf PLUMB MECH
LICENSED CONTRACT OR'S DECLARATION QTY. ELECTRIC PERMIT FEE I
1 hereby affirm that I in licensed undo provisions of Chapter 9(commencing JOB DESCRIPTION
CIO�CIZ with Section 9000)of 3 of the Businessand Professions Code.and my Bounce is RESIDENTIAL-
Ur
SIF-' DENTI
Ur wr I PERMIT ISSUANCE
in mil force and effect. El [I KITCHEN REMODEL
<UU License Class Lic.x APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
Date Contractor
b,Oy ARCHITECT':S DECI.ARADUN PANELS ❑MULTI-0NIT ❑STRUCI'URAI.
Z O w Z I understand my plans shall be used as Public records MODIFICATION
OZ�OUPTO 200 AMPS 0INTERIOR 11 CHIMNEY REPAIR
Licensed Pmfcsai.mal 201-1N0IAMPS IMPROVEMENT
CY�JOWNER-BUILDER DECLARATION OVER IWOAMPS [IBATH REMODEUREPAIR (]DEMOLITION
IY aW Q I hereby affirm that 1 am exempt farm me Contractor's License I�w for me
'a1x OCU following reason.(Section 7031.5,Business and P,m ,ions Code:Any city or county SIGNS ELECTRICAL ❑0TH
W 3 4 N whichitsissuance,
rezones canto to tuna the alter,improve,demolish Permit i tar repair cent tamer
Da, that he slesedpursuant
to
oihe tbovisio so for Contrartninoicensle e ncd Low
SPECIAL CIRCUIT/MISC.
999py+�y
that he is licensed puauanuothe provisions of the Qrmrac..h License Lxw lChap¢r9
aI�C0O (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMRMETERORPOLEINST.
1COMMERCIAL:
2 y mat he is exempt therfmm and he humm
s for e alleged exemption.Any violaion of El NEW NEW BLD [I DEMOLITION
rot Notion]031.5 by any applicant 1'ur a permit subjects the applicant to a civil penalty of POWIiR DEVICES ❑TENANT ❑FOOD SERVICE
FZ} not mom than five hundred dollars(SSW). IMPROVEMENT
❑ Las owner of the propety,or myemployccx with wages as their sole compensation, SWIMMING POOL ELECTRIC [:1 OTHER
F will do the work.and the smumurc is not intended oroffcred for sale(Sec. Business
I�il—m and Professions Cale:The Cmdracmr',License Law does not apply In an surer of OUTLETS-SWITCHES_FIXTURES
4i 3 propcny who builds nr improves thereon,and who Joea such work himself or through
his own employees,p.,,&it that such impnrvemem,arc nm intended nr uttered for NEW RESIDENT[A),ELECTR SQ FT.
sale.IL however the buildirri rimprovement ias.ld sidiinonc yearofeompletim.the SQ.FT.FLOOR AREA S/SQ,IT.
owner-builder will have the burden of proving that he did nm build or improve for par-
,as MAR 25
I,as owner of the property,
ec.709 am exclusively contracting with licenced contractors i- 1996
tense La d project(Sec.o nn.Baines and rty who bei QWr:)'Treves trent'.Li- fs
r
c,neeLmortsfnot apply manowner marruct (o whosedporimpmves meson.and Ql'Y. PLUMBING PERMIT EHE l•f(r
who nmtmcafor rah.micas aim,encorehm(s)IiccnsN pursuant the Comment's L/h LU
a Gi r111%aU
0
License tw Law. PLRMI'f ISSUANCE'
lam exerts under Sec. .B&PCfor this resat
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner UIO
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
1 heresy afftnn under penally of perjury one(if the fol lowing Workee,Cor
❑(have provide for
37U)of CometsmCode,for the WmkcraCompcm DRAINS-PLUOR,ROOFAREA,GOND. STORIES TYPE CONS I'RUC3']ON
cation,as provided fur wi Section,isu3]W of the labs Cede,for the performance.f the
work for which this permit is issued. FIXTURES-PER TRAP
I] 1 have and will maintain Worker's Compensation In.wmncc,as required by Section
J]Wofthe Lar Code.fordie perfomanceof the work for which this permit is issued. GAS-FA.SYSTEM-1 INCA OUTLETS .GROUP APN
Lahr
My Worker's Compensation hourance carrier and Pol'ay mother are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER n(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRCASFIINOUSTRLWASTE INTERCEPTOR
COMPENSATION INSURANCE 11 BUILDING DIVISION FEES
(This satin ncednot be completed if the permit is boron,hundred dollars SHM) GREASETRAP
or less.) PLANCHECK FEB
Icmfy throw the performance ofthe work for which this permit isvowil.Idoll SEWER-SANffARY-STORM EA.2001-1'.
not employ any person in any manner m as to become subject'.the Workers'Contain-
ENERGY FEE
Z sation Laws of California.Dam WATER HEATER WNENT/HLECPR
z2 Applicant GRADING FEE
In NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATIiR SY STEMITREATING SOILS FEC
a^ became suhject m me Workera Compenmtim....men,of the Labor Cole.you most
mnhwim comply with such provision,or cols permit shall be dee afoc,.ked. WATER SERVICE
Q
asCONSI RU(THON LENDING AGENCY NEW RESIDENTIAL PLh1 R. SQ.Ff. PAID
U0 Ihcnbyaffirm that there is a construction lending agency for the performance of Date Recciptp
Lka F the work for which this permit is issued(Sec.3097.Civ.C.)
Q U Lender's Name TOTAL:
r W Lender's Address TOTAL:
a 1 cent fy that 1 have read this application and sate that the above information i, BUILDING ITE
I.
rre
coct m l agree comply with all c by and county ordinances anJ.am,laws relating or QTY. MECHANICAL PERM IT FEE
U Z building construction,and hereby authorise representatives of this city to enter upon the SEISMIC FEE
above-mentioned propcny for inspection purposes. PERMIT ISSUANCE
(We)agree to xeve,Indemnify and keep harmless the City of Cupcnino xgain,t ELECTRIC FEE
lishiliacs,judgmema,costs and expenses which may in any way accrue against said City AI.TF.RORADD'TOMECH.
in comequence or the granting of tri permit. PLUMBING FEE
APPLICANT UNDERS'PANDS D WILL COMPLY WITH ALL NON-PO NT AIR HANDLING UNIT(I'O 10,000CFM)
Y- LATIONS.t MSCI{pNICAL FEE
SOURCE RI;TLATIONS
VL AIR HANDLING UNIT(OVER IO,INp CPM) CONSTRUCTION TAX
Sigrawretor
plie.VC m Dam EXHAUST HUOD(W/DUCf) HOUSING MITIGATION FEE
H US MATERIALS DISCLOSURE
Will the applicant or future building occupant some or handle hazardous material HEATING UNIT CID IINI,INN)B U)
as defined by the Cupcnino Municipal Calc.Chapter Sy 12.and the Health and Safety
Code,Section 255320)7 HEATING UNIT(OVER I W.000 BTU)
❑Yet, 0 N VENTILATION FAN(SINGLE RESID) PAID
Data Receipt x
Will m.apnbram m metre Wadding acnpn.t use egmtlpmen .r device amen
mit haardous air contaminants as defined by the tiny Area Air Quality Management BOILGR-COMP(3HP OR IWIKKI BTU) TOTAL:
District] BOILER-COMP(OVER IINI,WO BTU)
E]Y., ❑No
I have read the hazardous materials.. a under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
trim p
cords Hrroldbdm.s&Safety Cagle,Swoons 25505.23533 and 25534.1 unJmwed Nm if the NEW RBSIULIJTIAI.MECH. SQ.Iaf.
building Jaa not is whicy have a mnank th9 o is ua ce of aaCeniy hrte o fy cc pancy.
of the requirements which mast be met.rinr to issuance of n CertiOcate of Occupancy.
Owner or authona,d agent Data TOTAL: ISSUED BY:
OFFICE