29834 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 29834^ ^ ^ sl
BUILDING DIVISION APPLICATIONIFERMIT PLUMBING•MECHANICAL L�9 VM34
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRFSS: OiL 0—A SANITARY NO. APPPLLIICATIONSO MITTALDATE
Lot 1W 2 UJW
O iR'S AMC: P 0 C(]yTR T(I)R'S M LICN a✓
GGJ NIC CONTROLM
\ CHITE (ENGINEER: LIC NO: ADDRESS; r ❑
Arbayrin
C PHONE: 73
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLU MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FIiE
I hardly affirm that I am licensed under provisions of Chapter 9(commencing JOB DF?SCRIPTION
O fP'Z with Scdian]qkO of Division of Ne Bu>inexsv 1 f s' ndm liccnseis PERMIT ISSUANCE
_ RESIDENTIAL:
FO a lull force and e8 y
aF.UZ�j Lice
Contract
❑SFDWL ❑KITCHEN REMODEL
NQS Uete Cnmmcmr API'LIANCP.S-RI?SIU13NfIAL ❑ADDITION . ❑PLUMBING RE-PIPE
R ELTS DCCT' PANELS
#.yOrn ❑MULTIUNIT []STRUCTURAL
Z O J Z 1 undersand my plans shall be used as public record MODIFICATION
OZ C UPT020DAMPS ❑INTERIOR ❑CHIMNEY REPAIR
P4�_ Licensed Professi...I 201-1000AMPS IMPROVEMENT
"'JJJ"`CCC -a{ OWNER-BUILDER exempt from
m the DECLARATION OVER["AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
y 1 hereby aflitm that I vat exempt from title Cumacmr's License Law for the ❑OTHER
p(36FV. which inquiresa Permit
70JL5,Busitessand improve.
de iolih,or:Any city arcaunry SIGNS ELECTRICAL
F O yj which requires o permit re quire,he alder,improve,h Permish, file
mash any swnom
6J thior t he its cense puratorcyuires he previsions of
Cutthe Contractor
ned aw(Ch statement SPECIAL CIRCUITIMISC.
NatheislicensWpursuunnthe provisiomoftheComacmr'sLic<nuLew(Chapmr9
W�0
0 (commencing with Senion7")of Division J of the Business and Professions CWe)or TEM('.MEfEN OR POLE INST COMMERCIAL
d q o¢ that he is exempt Nereftom and the basis for the alleged exemption.Any Anirom of ❑NEW BLDG/ADDITION ❑DEMOLITION
Y� V. Section 7071.5 by any applicant fora permit subjects the upplimmtnn civil penultyol POWER DEVICES ❑TENANT ❑FOODSERVICE
y not more than five hundred doll.($5W).
< e property o,my employees with wages as their hole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
❑I,as owner oftb
G will do the work,and the shucmre isnot intended.,offend farwie(See J044,Business ❑OTHER
aand Professions Code:The Cnmrecuo's License Law Jens not apply turn owner of OUTLHTS-SWITCHES-pIX'I URES
property who builds or improves thereon,and who does such work himself or through his own employees,provided that well improvements one not intended or offered for NEW RESIDENTIAL ELECIR SQ fT.
vale.IL however,the building orimprovement is sold within one year ofxmpletion,the SQ.FT.FLOOR AREA $/SQ.FT.
ownerhadder will have the burden of proving that he did not build of improve for pan
cosi of sale.).
❑1,as owner of the property,am exclusively contracting with licensW contractors to TOTAL:
construct Ne project(Sec.70,0,Business and Professions Code;)The Committers L6
cense Law does not apply to an owner of property who builds or improves thereon,anti QTY. Pl-UM13ING PERMIT FEL?
who contracts!r such projects with s commctorld licensed pursuant to the Contraon.'s
License Law. PERMIT ISSUANCE
❑I on exempt anile,See B R P C for this reason
.737W
Owner E ALTER-DRAIN.@.VENT-WATER(13A) VALUAyOIy
WORKERS COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE �p'`
I hereby affirm under Penalty of Perjury one of the following declarations: VV
I have and will maintain o Certificate of Consent self-insure for Worker's Complain- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'TYPE CONS9'RUCf10N
tion,as provided for by Salon 370D of the"hut Cute,for the Performance of the
rk for which this permit is issue. FIXTURES-PER TRAP.
1 have and will maintain Workers Compensation Insurance,as required by Section
of the LebnrCode,for the performance of the work for whichtha ,mit ie issued. GAS-EA.SYSTEM-I INC.4 OUTLETSUCC.GROUP AI'N
yeWr nd nevi ns ad ec ierandPolio dm'M! Policy No.; 'GAS-13A.SYSTCM OVF.R4(F.A)
C[R FICATF.OF E% MITION FROM WORKERS'
COMPENSATION INSURANCE GREASR/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This action need not he complete If the Permit Is forme modred dollars(SI W)
ar less.) GREASE TRAP PLANCHECK FEE
I trolly that in the performanro ldne work for whichdda pnmit is bound,l shall SEWER-SANITARY-57URM FA.20t1 FT.
not employ any person in any manner u os m become subject m the Worker'Co.pdn- ENERGY HE
O
utinn Laws of Cnlifnrnia.Dam
y Q WACR HEATER WNE / CfRAcPlicum GRADING HE
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATI3R SYSTEM/IREATING
I-+ become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply wish such provisions m this permit shill he Jeemttl revoked WATER SERVICE
Q
CONSTRUCTION LCNDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FL PAID
V l hereby which
thi lhanhere is sued(See.i 0 lending agency fnnhe performance of Date Receipt p
k" t+ the ais for which this permit is issued(Sec,l09],Clv.C.)
O L) Lender's Name ^ _ TOTAL:
I
Ixnder' Address TOTAL:y certify that 1 have read this application and store that the shove information is BUILDING Fl3E/ \ if
3h comet.lagree to comply with all city and countyn dinuncesanJstmelawsrelmingm QTY. MECHANICAL PERMIT FEE
,� building constructions and hereby authorize representatives ofthiscity memerupon the SEISM
above-mentioned property for inspection purposes.
(We)agree tons indemnify vad keep harmless the Ciryof Cuperinn ogainst PERMIT ISSUANCE ELECTRIC FEC
Iiabllitics,judgments,costs and expenses which may in any way accme against said City gL'113N OR ADO TO MECIL
in consequence of the gaming of this prodd. PI! MBING FCEVI '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Io,000 CFM)
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of ApplicunVConwcmr Date EXHAUST HOOD(W/DUCD HOUSING MITIGATION FZii
HAZARDOUS MATERIALS DISCLOSURE
Will theepplicam or fpmrc buildingneutioat mmemliandle hazardousma¢nd HEATING UNITT3100,OW BTU)
as defined by the Cuperino Municipal Cute,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)? 1 HEATING UNIT(OVER 100,000 HTU)
Q Yes ON. VENTILATION PAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or furore building occupant use s.Air eu Of devices Management
mit ict? s air cnnaWnvna ns defined by the Bay Area Air Quality Management HOILF.R-COMP(TIP OR Ifk1,IXq PTU)
District? TOTAL:
❑Yes 0 N POII:IIR-COMP(OVER 100,000 BTU) -
I have mad the hvzardouo materials rcyaircments under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCn
forma H hit Safety Code. 'lection 25503,857]onJ 25534.I undersand Ihm if @e NEW RCSIDENTIAI.MECH. SQ.FT.
buildin at do, cam. LI tit ory 'Pomihilit, natty etunmm
of me ants is ust hu m p o' Of u Oenair, - coupon
or or autb tangent C•,� Dae TOTAL: ISSUCD BY:
OFFICE