29036 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAI. PERMITNO. ��JJO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING,-MECHANICAL
BUILDING PROJECT IDENTIFIC-A'1'ION
36
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
/00%O I&At, 1A.6 /)r - _
W
ONE 'S NAME: PHONE': CONTRA � Mli: /']',n (1�,1 N
A) T OG N/C CONTROLg
'ARCHITP.CfB3NGINECR: LIC NO: Aa7SSf�rGGIId J/,�O ���� ❑
CO l PHONE: ~/ BUILDING PER
69,10
0
E] Consultant Fees Paid by Applicant(Initial) BLUc ELECT PLUMB
MECx
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm shut I am licensed under'provisions of Chapter 9(commencing JOB DESCRIPTION
HOZ with Scnion70001o(Division 3 of the Businessand erofessions Cock nd my limon is RESIDENTIAL:
F ly°�, is full forceonl effect. /T� OSA/ PERMIT ISSUANCE, ❑SFDWL ❑KITCHEN REMODEL
�U{E,�,11 License Cb. Lic.p DCIV ApPLIANCFS-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
FF Z 4 Dae Con
yam' cHITECCS ATI ❑MULTI-UNIT ❑STRUCTURAL
YOr�i 7.J- yCansa n p PANELS •.
lunJcnnndm I shall he used as public recuNs / MODIFICATION
0 Z—= UPTO IW AMPS 7�7lGRIOR ❑CHIMNEY REPAIR
P4L Licenud Professional 201-1000AMPS ( IMP VE ENT
9 hd Se OWNF:mexemUER DECLARATION
Com eno OVER]"AMPS ❑BATH REMODEL/REPAIR„[)DEMOLITION
yGGy C a all 1 hereby affirm Lha 1 um exempt from the Contmcmrs License Law for the
SX 34 U following reason.(Section 7031.5,Bmismel and Polfiessinns Calc Any city or county SIGNS ELECTRICAL ❑OTHER
flxxll IL which requires a permit m cnnslmm, her.improve,demolish,m repair any amcmrt
print m its issuarre,ulsu rcyuireslheupplicuminrsuch permit to file.6gnedmetement SPECIAL CIRCUIT7MISC.
a� that he is licensedpusuantto[liepnsvlslonsoftileContnetorsLicenseLaw(Chapter9
G� (commencing with Sectio 700(bor Division3of,he Businessland Professions Code)or TEMP.METER OR I'OLE INST. COMMERCIAL:
tL M e'
that he is exmnps lhcmtrmn and the basis list she alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W 'Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of POWER DEVICES
in []TENANT ❑FOODSERVICE
not more than live ft handled property,
or t y Ship.
p 6 wi Lasowner
vick,the propeny,structure i nnployceswith wagescredf r aei(Sce.compensation, SWIMMING POOL I?LECTRIC IMPROVEMENT
^g, will darhewonal ande:TeContisnonla kende Lawdoesnrot apply 9044.Boniness El OTHER
and Professions Code:ITB Contractor's License Lew s such
not apply s if owner of OUTLETS-SWITCHES-19XTURIiS
F'3.+ Property who builds or improves thereon,and who nts a such work himself or through for IQI p F
his own employees,e provided that such improvements sol w thin not intended of completion,
or offered for NEW RESIDENTIAL ELCCIR SQ PT. [i
sale.ILhowever.r will hav ilthe burng or en ofpement isut hedid none build or improve fonthe SQ.FT.FLOOR AREA SISQ.FT.
owner b.ilder will have the burden of proving that he did not build or improve for pot- ,YO� y ,
pox nf,ele^)e - TOTAL: 'q 1 1995
❑ su vs ow r of the propeny,,l exclusively enmnctlng with licensed comnum's w
consumer Ne project(Sm.70W,Buzincs and Profcuiens Code:)The Conmaclnr's Li.
ase Law dssee nm ltP ly m an nwaor of propeny who builds ar improves thereon.and QTY PLUMBING PERMIT FEF, )) VY Let
whoconu cis forsuch projectswith a comncrogs)licca e p mua t to the Contnssoes tJII INQ
License Law, PERMIT ISSUANCE
Ej lamexemptunder Sec. ,B&PCfv,dnamomn
Owner DataALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following decLuati...:
I have and will maintain eCenificam ofConxm to self-insure for Workers Compen- DRAINS-FLOOR,ROOF AREA,COND. STORIES - TYPE CONSTRUCf10N
sation,as provided for by Section 37(X1 of the Labor Code.for the performance of the
work far which this pcmdt is issued. FIXTURES-PCR TRAP
vin and will maintain Worker's Compensation Insurance,as required by Section
3 ofthe Labor Cole,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worke ali Ins. cin enniermul Policy b I n f
Cartier, 7 I policy No.:0=1t- GAS-EA.SYSTEM-OVER 4(EA)
ERTI•CATE OF LXCM PTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INT17RCEKON BUILDING DIVISION IrCBS
(This section need not hecomplemJ if the perosis is fornne hundred dollars($100) GREASETRAP
or less.) PLANCHECK FEE
Icenifythain she ped'nrmne,all ,t become subject to permit isiss.ed,Iser. SEWER-SANITARY-STORM HA.200 FE notoniI.e any Canon In any mimncr so us 1n hannm auhJecnn the Wotken'Compcm ENERGY FEB
0z Applicant
Lawsnf California,Dam WATER HPATI?R W/VHN'I'/EI,ECPR
O AFPlieum GRADING PEE
y NOTICE.TO APPLICANT:If,Mier making this Certifirn,of Rxempti......should WATER SYSTBM/I'REA'HNO
abecame subject m the Worker's Conspcnxsinn provisions of the labor Cule,you most BOILS FEC
W forthwith comply with such provisions or this Permit shall be deemed revoked. ,WATER SERVICE
� z CONSTRUM[ON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID41 Dam Receipt as
V 0 Ihercby nflinn chat them ise mndmcsion lending agency for the performance of
L--�
the work for which this permit is issued(Sec.309],Civ.C.) -
as
0 Lenders Name TOTAL:
V Leaders Address IO
y1 certify that I have read this application and state that he above information is BUILDING FEE
(A correct,I agree to comply with all city and county ordinances and sant laws relatingm QTY, MECHANICALPERMIT FEF.
U z b.ildimgerms.ucsion,and herchyaashndm reprexnntivesofdtiscity to eaerupon the SEISMIC FEE
simm ar cationed properly for inspection Curry,.,.
(We)ag.a.save.indemnify and keep homeless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
lishilities.j.dgniumm consent]espsmxs which may in any wayaceneagaims said City ALTER OR ADD TO MCCIL
inconxqurnce of the Van mot. PLUMBING FEE
APPLIC D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM)
_ MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,0(1()CFM) CONSTRUCIIONTAX
Signature o(Ap am/Conlnctur Dae EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HA7ARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store or haWle hazadous material HEATING UNIT(TO 100.00 BTU)
as defined by the Cupertino Municipal Cash,Chapter 9.12.and the Health and Safety
Cede,Section 25532(v)? HEATING UNIT(OVER 101,000 BTU)
El Yea ❑No
VENTILATION FAN(SINGLE RFSID) PAID
Date Receipt#
Will the applicant of fame building deined occupantuse equipmentor devices which BOILER-COMP IMP OR IINIJNNI BTO)
emit hazardous air cnnmminants m defined by the Pay Area Air Quality Management TOTAL:
Disvict?
❑Yes 7 N BOILER-COMF(OVER 100.000 BTU)
I have read ihehannlous materials mfmrrmcna under Chapter 6.95 of We Cali- AIR CONDITIONER . ISSUANCE DATE
fomia Health&Sa'ety Cole,Sections 25505,25533 and 25534.1 understand that if she NEW RESIDENTIAL.MF.CH SQ.FI'.
building Jens not currently have a Icor,hat it is my responsibility to notify the occupant
of the re omments which and be met prior In issuance of a Cenificam of Occupanty.
Owner or amhntizcd agent - Date TOTAL: 'ISSUED BY:
OFFICE