29915 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PHRMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAI.
BUILDING 1'RO.IRcf IDENTIFICATION 29915
BUILDING ADDRESS: SANITARY NO. AI'I'LICATION SUBMITTAL DATE
OWNE NAMF. PHO CO GT sR'. AME: LIC NO.s
6
NIC CON'ROLA
ARCHITECURbIGINEF.R: LIC NO: A2v
k o
CONTACT. PHONE: v BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLED ELECT PLUMP MECH
`� ❑ ❑ ❑
LICENSEDrrun
DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Natt 1 m licensed under provisions of Chapter"(commencing JOB DESCRIPTION
Is NSedinn7gM))ofDivision3ofthe Business and rofessions Cale, d ylicenu is RESIDENTIAL
1- O in full fomeanJc t. ` PERMIT ISSUANCE
-QZU 1.icenu Cla. Lie. 7 �/ ❑SFDWL ❑KITCHEN REMODEL
tie Dem Conrmm APPLIANCES-RESIULNTIAL []ADDITION ❑PLUMBING RE-PIPE
I.,DmCHITECTS DECLARATO - PANBhg ❑MULT6UNIT ❑STRUCTURAL.
Z064❑ IunJersmnd my plans shall he used as public rcasnls - MODIFICATION
OZ�O UP TO 200 AMPS ❑INTERIOR CHIMNEY REPAIR
P4Lm Licensed Professional 201.1000AMPS MPROVEMENT
gyf; OWNER-BUILDER DECLARATION
K W G 1 hereby affirm that I am exempt from the Contractor'.License Law for the OVER How AMPS C1 BATH RF.MODEUREPAIR ❑DEMOLITION
ap5t Old U following renwn.(Section 70)1.5,Business and Professions Calc:Any city or county SIGNS ELECTRICAL. ❑OTHER
t++W O^ which reyuires a permit to construct,alter•unp nve,demolish,or repair any soumum
}
I Lai prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9
Id1..00 lcommencing with Section 10001ofDivision J ofthe Business and Professions CodI , TEMP.METER OR PO LE IN IT. COMMERCIAL:
e pe
that he is exempt therefrom and the basis fur the alleged exemption,Any violation of
Section banf [I NEW BLDG/ADDITION ❑DEMOLITION
Y• y y applicant for a permit subjects the applicant to POWER DEVICES ❑TENANT ❑FOODSERVICE
e applicaa cPenalty of
m
�
s,.q> not mom than rise thpwpc Anl budyemp. IMPROVEMENT
2p ❑Las owork,the propenyor is am intended with cared for lhcir sole(Sec.c0 ,Busiessn. SWIMMING POOL[LGCI'RIC
f- andwildo do work,ands he Coreisnoes License
Law
apply to an Business ❑OTIIER
W anderty who b Cal e:The Cas theor's,and
Lawdoesnmapplytolf owner of OUTLETS-SWITCHES-FIXTDRFS
6 3 progeny who builds or improves thereon,and who Jens such work deed or or through
his own employees,provided that such meat is sold
are not intended or offend for NEW RESIDENTIAL ELELTR SQ
ownef,uildevecthevethngor iden(11 Poising
Pone yeorimpryof etfomthe SQ,fT.FLOOR AREA $ISQ.FT.
oar-builder will have the burden nl'pmving that he did not build or improve for par- 9� q
you of owner
wne
❑1,u wf the Sm.70, .Business s and contracting with licensed rontmcmrs m TOTAL: PJ
construct the project not apply
o an war and Professions bui Code improves or Tho Contractor's nd Q rs a
cenulawdtsnr suchplymts owner ouractcrty whoseddsnontthe thereon and try. PLUMBING PIiRMIT FEL? H K/
whence Law,for such projects withacontruc¢rt(s)litensad punuanuathe Cnmmnor's Qi,� Vf 1996
License exempt
PEIIMI'1'ISSUANCE s7i7®
❑lam exempt under Sec. ,B&PCfor this reason LUP '
Owner nate ALTER-DRAIN&VENT-WATER(EA) A6 ON
WORKER'S COMPENSAI ION DECLARATION BACK FLOW PROTECT.DEVICE
I harsh,old.under penalty of perjury one of the following dulamtians:
I]I have and will maintain a Certificate ofConscm to self-insure lou Worker's Compen- DRAINS-FLOOR,BOOR AREA,COND STORIES TYPE CONSTRUCT ION
i schen,as provided far by Section 3700 of the Lithns Code,for the peUkumance of the I
work for which this Permit is issued FIXTURES-PER TRAP
1 have and will maintain Worke'a Compe mien Insurance,ar required by Section
3700 of the Lobo Code,fon he ace fthewnrkfrrwhichthispermitisissucd. GAS-EA.SYSTEM-I INC.40UTLES OCC.GROUP APN
My Wur rope
at as In rencce n' rand Policy n
Cartier, olicy No.:'�LOPEJJ{{/ 'Q�`_ (�� GAS-FA.SYSTEh1-OVI;R 4(EA)
JGpEXEMPUONFB Tr''CCOMPENS'AT ON NSURANCIf /J �(/ GREASIMNDUSTRL WASTE INTERCEPTOR
(This uctionn the completed ifthe permit is for one hundred dullars(S 100) BUILDING DIVISION FEBS
or less) GRFASE'IRAP PLANCHECK FEE
I ccni(ytk in the rfnnnan a work for which this permit is issued,lobuli SEWER-SANITARY-STORM EA.200Ir1'.
not employ any rson in any ma as m become su 'ecuo the Workers'Compete ENERGY FEE
cation Lu Wifnmis.UP
O O Appli t9 44 0944124 WATI?Ii III:A'TER WNRNT/F:LELTR GRADING FF.B
!z+ J' NOT F. APF'LIC .If,after makingthis C tfic c of Bacm tion, should
I^ N beta uhjttt to the orker'v Cnmpcnsatbn p isin of the IaMUGde,you must WATER SYSfEM/IREATING SOILS TCF
WfnnhwiN comply wi such pmvisinnsmNis pc ell bedeemedrevoked. WATER SERVICE
az CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ.PT. PAID
UO " IherchyaflirmthanhereisaamswdionlcnJing egencylimhe perfommnn N' Date Receipt#
IA s- 'hework for which this permit is issued(Sec.3097,Civ.CJ
O Lender's None TOTAL:
LUkI Lender's Address TOTAL
1 e nify that I have real this application and state that the above information is BUILDING FEE
.F.t (0.4 correct.I agree to comply with all city and county ordinances and state laws relating u. QTY. MECHANICAI,PERMIT FEE
U 7, huildiro,colsloleion,and hanhyintloidso naln, city menernpon the SEISMICITE
above-mc ' rte ropeny for inspection purposes. PERMIT ISSUANCE
1 e)agr to save mnify and keep harmless the City of Cupertino against ELECTRIC FF.F.
fish s.juJ coni, expenses which may in anyway accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in Pe..ft songofthis permit.
AP n(CANT U ;RS DS AND W LL COMPLY WI'TII ALL NON-POINT AIR HANDLING UNIT(TO 10,(KKI CFM)
RCE REG TIONS. MECHANICAL PER
AIR HANDLING UNIT RIVER 10,000 CFM) CONSTRIICTIONTAX
Signature pl --own" EXHAUST FOOD(WMUC17
HAZARDOUS 1 TERIALS DISCLOSURE HOUSING MITIGATION FEE
will the rMlicantorfumrc h I ing occupant store orhandle hozarJous mate HEATING UNIT(TO 110,(x011 BTU)
us def W M1y the Cupertino Municip Cede,Chapter 9.12,and the Health and Safety
Code Section 25532(a)7 HEATING UNIT(OVER 10,000 BTU)
❑Yes C]No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment m devices which Date Retain,If
emit harnrdous air mourro pants as defined by the Bay Area Air Quality Msm,irem BOILER-COMP(314P OR 100,000 BTU)
Di,mu? TOTAL: semg
C3 Yes nNo BOILER-COMP(OVER 100,010 BTU)
I havered the has imsmatedalsrcquim=ntsuMrChapter6.95 ofda Cali- AIR CONDITIONER ISSUANCE DAT
femis Health&Safety Cede.Sections 25505:25533 and 25534.1 understand that if the NEW RESIDENTIAL MECIL SQ.Fr
building does no cunendy have o tenonl.Nm it is my resptmslbiho to molly the wcup of
of the requirements which must be ten prior to issuance of a Cer iGane of Occupancy.
0.Pat,,,and.... ad agent hate TOTAL: ISSUED BY:
OFFICE