29440 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. ^^ a QO
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL. LJV 44
BUILDING PROIF.LT IDEMrIFICATION
BUILDING ADDRESS:
L SANITARYNO. APPLICATION SUBMITTAL DATE
(% Siv —1
NER'S NAME: PHONE: CONT R:S ME: LIC O'
N/C CONTROLM
\RCHITECGEN I�yI. LIC NO: ADDRE.
•
CONTACT. PHONE: BUILDING PERMIT INFO
vP Consultant Fees Paid by Applicant(Initial)- BLI_>('j ELECT PLUMB NIECE
LICENSEDCON'TRACTOR'SDECLARAT10N QTY. ELEC'1'RICPERMIT FEE IrXJ� tYL'P` Ib
Thereby affirm that I am license under pravisiom of Chapter 9(commencing JOB DESCRIPTION
1Oya2 with Section70d0)ofDivisi n 3ofthe Businessan poressinnsCde, RFSJDF.NTIAI�
1 0p full force a ad effect �J cease PERMIT ISSUANCE eli�
S'wF to „7 ❑SFDWL CITCHEN REMODEL
aV License Class Lic.N APPLIANCES—RESIDENTIAL
�. Date Contractor ! ❑ADDITION ❑PLUMBING RE-PIPE
1F..Dm CHITECT'S DECLA PANELS r ❑MULTI-UNIT ❑STRUCTURAL
Zo JZ fund :an my plans shall the used as public records MODIFICATION
OZ O UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
ul Licensed Professional 201-1000AMPS IMPROVEMENT
ff J'I OWNER-BUILDER
at I am eU rapt from
m DECLARATION OVER 1000AMPS, ❑BATH REMODEI/REPAIR ❑DEMOLITION
q Q 1 herehy affirm that 1 am exempt from the RATI'mrx License Low for
x 3 V following reason.(Section 7031.5,Business and Professions Cade:Any city orcoumy SIGNS ELECTRICAL ❑OTHER
al O[^ which requires a Permit to conslsuct,slier,improve,demolish,or repair any xtmclure
.J7 prior to its issuance.also requires the applicant for such permit in rile a signed statement SPECIAL CIRCUIT/MISC.
ytont he is licensed pursuant o the provisions of the Conuacmrs License Low(Chapter 9
CC (commencing with Section 70[1 Division 3 of the Rosiness and Professions Com)or TEMP.MET ER OR PiINST. OMM .R IA
6 Ty M oL that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
it
P� 1i• Section 703 L5 by any applicant for a perm .euhjects the applicantto a civil penalty of POWER DEVICES ❑TFNANT ❑FOOD SERVICE
ZN not mom than five hundred doBau(S50I). IMPROVEMENT
❑ Lasownerof the pruport or my employees with wages astoeir sole compensation, SWIMMING POOL ELECTRIC
�Or will da the work.and Neswetum is oatimrnW poffer
dred sale e(Sec.7D4,Business ❑OTHER
dr and Profession,Cee:The Cantranors License Law does not apply m snooper of OUTLETS—SWITCHES—FIXTURES Z
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended mattered for NEW RE. DENIAL HLECI'It SQ FI'.
We.IL howeverthe building or improvement is sold within one year of completion.the My FT.FLOORAREA k/SQ.per.
owner-builder will have the burden of proving that he did not build or improve for pur- tn
poseofale.). f J
❑ Lascaner of Ne pmpertRa xcla,wrly contracting with licensed comments 1. T
constructtheprojec,(Sec.7046.Business and Prafessians Cade:)The Contractors Li- MAR
reuse Law does not apply to in owner of properly who builds or improves thereon, ad QTY. PL BIN PERMIT FEE 1996
who contracts for such pmice s with a contractorts)licensed pursuant the Contractor's 14
License law. tPERMIT IS. /�
❑l mnexcmpt audit ser. 11 A P C foils reason CSI I Ur �aUl-Lrsi w s
ALTER—DR VONT ATER(EA)
Owner Unto VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW P;0 D LCB I /_ Aywa
Ih...byaffirm under penalty of perjury ane of the following deaiurmionv
] Ihavcandwillmainmina CenificamofConwntio elf-insum(nr Workers Compcn- DRAINS—FLOOR.RODE OND, STORIES TYPE CONSTRUCTION
sailor,os provided(nr by Section 77fg1 of the Lubar Code,tar the performance of the
work for which this permit is issued. FIXTURES—PER TRAP12
❑ ave and will maintain Workers Compensation Insuruncq us required by$cation
I of the fa or aJc,fonhe performance of the work for which this permit est, GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
M War on rl 1 mote caner and Policy �'}�t
Currie. %rs o Policy Na +.7.�� GAS—FA.SYSTP.M-GYER6(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
i COMPENSATION INSURANCE GREASIDINDUS'I'RL WASTE INTERCEPTOR
(This scaionnecd nm he rympletW ifthe pemsit isforonehondracdollaralgl(gl) BUILDING DIVISIA FEES
or less.) GREASE TRAP PLANCHECK FEE
1 certify that m the performance of the work for which this permit is issued,l shall
p y nannuxa as to Nee r ,suhectao the Workers' SEWER—SANITARY—STORM EA.200 IT.
nrI mn toy any person in an a n j Cnntpem 13NEROY FF.E
� Z saoon laws of Calif..!..Dom WATER HEATER W/VCNT/ELCCfR
Q ,Applicant GRADING
rj NOTICE TO APPLICANT.IL ager making This Ceniticate of Exemption,you should WATER SYSTEM/1'REATING
hecome s diesel m the Worker's Compensation provision.,of the Lahm Gaue you most
p forthwith comply with such provisions or this permit shell be teamed revoked. WATER SERVICENJ V
n
u Q
CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SO FIE. PAID
U 2I herebyaffna,hntbore isoconsouctinn lendingageney Emilie,perfirmonceof Do Receiptp
L4 Hthe work lot which this Permit is isvued(Nee.3097,Cr,C.)
Lenders Name
TOTAL:
BUILDING
Lenders AdJrcxx
0. Icmi(y thmlhnve real Nis application and ante lhanhe above in(ormatinn is XMITIGAT
EE /LU a-
h cored.l agree to comply with all city and county ordinances and state laws relining In QTY. M17CHANICAL PERMIT FEET
G Z
building conswction,and berebyautoodamrepessmntivesofthis city toenter upon the l.J(We)agree to save,indemnify and keep harmless the City of C.Parinoagairet 1 PERMIT ISSUANCE .P.liabilities,judgments,costs and expenses which ay inrmya""oemeagxlnstsuldCityALTER OR ADD TO MECH.in consequence of the granting of toil perm APPLICANT UNDERSTANDS I CO W ALL NON-POINT AIR HANDLING UNITTO 10,000CPM) L ESOURCE REGUT/14 1171, AIR HANDLING UNIT(OVER ID000CPM) ION XSignalureof licant/Canrrncam c ❑XHAUs'T HtH)p(W/DUC'1) IT" NFEE
HAZARDOUS MATERIALS DISCLOSUR.
Will theapplicam or future building occupant storeor handle hmanlous mmetial as HEATING UNIT(ED 100,0001 ITU)
as defined by the Calmar,Municipal Coca,Chapter 9.12,and the Heahh and Safety
Cock,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
❑Ycx , Ell No
VFNILATION FAN(SINGLE RCSID) PAID
Will the applicant or fbame building occupant use t or devices which Data eccipt H
pp got p ea Air n BOILER—COMP(311P OR 100,000 BTU)
1 haaaNnus air contaminants as define by the Bey Area Air Quality Management TOT L:
via?
Lbuilding
Yes ❑No BOILBR—COMP(OVER Ifq,IXp BTU) ,uel ine read thebemoans naadels requirements tinder Chapter 6.95 of the Cali- AIRCONDITIONERISSUANCE: AJTE�Jy/�s�n Su@e Gde,e B t nax 25505,25537 and 25536.I uWctsynd that ifthe NE W RESIDENTIAL.MECf{. SQ.FT'.not cumnnly have a tenant,Nut it is my resµmsibiliry m notify the occupantments which must he men pfono issuance of a Ceificale of Occpancy.hori age Date \ ISSUED BY:
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