29391 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPF,RMIT PIA)MBINO-MECHANICAL I 29391
BUILDING PRO.IECF IDENTIFICATION
BUILDING ADDRESS: �s _ SANITARY NO. APPLICATION SUBMITTAL DATE
J 'C/mJ/I1NrrpyC
ER'S N MBp 1 - PHONE: CONTR 'S NAM t f LIC NO:
L`�` \u`�L.`P"•}WA n^ I COM'ROLp
lei ITECT/ENGINEER; L 'NO, ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Feas Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby anion wt 1 ant licensed under prevision,of chapter 9 mommeneing LOB DESCRIPTION
WOZ wtNSeelion]000)o(Division 3ofthe Ru.inessand Prefessiom Cede,undmyliceme is RESIDENTIAL'
F.�O in full force and e I PERMIT ISSUANCI!
aUZU License au DSFDWL O KITCHEN REMODEL
n61 Dale ntmctor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
A 1 SDECLARATION ❑MULTI-UNIT ❑STRUCTURAL
OZyZ y Ibe used in Public rtcords PANELS
UPTO 200 AMPS MODIFICATION
C ❑INTERIOR ❑CHIMNEY REPAIR
ce v 201-u1WAMPS IMPROVEMENT
CY OWNER-BUILDER DECLARATION OVIiµIOolIAMPS
^K W Q : 1 sy affrnt(hal 1 nm exempt from the Contractor's License Law for the ❑BATH REMODEVRIiPAIR DEMOLITION
3 a U follow
rcamn.(Section]OJ I.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
LL which"slim permit to construct,alter,improve,demolish,or repair any nrucmre
prior mita issuance,also ,In ares the applicant for such permit to file a signal smmnent SPECIAL CIRCUITIMISC.
2 "y that he is licensed pursuant to the prnvisions little Contractors License Law(Chapter 9
(commencing with Section]olgdnf Division 3 efthe Business and Professions Code)ar TEMP.METER OR POLE INST COMMERCIAL:
ti q m that he is exempt Iherefrcm and the Exists for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
P� Semen]031.5 by any applicant for.permitsubjeas theapplicant t...ME penalty of POWER DEVICES OTENANT 0FOOD SERVICE
=�. not more than five hundred dollars(8500).
QQ1,as owner of Ne pmpeny.army. employes with wages as their sole compensation, SWIMMING POOL ELECTRICIMPROVEMENT
aHit the work.end theswemre is nm imended oroffercdfor sale(sec.]1/14,puniness GOTHER
and Professions Cndu The Contraewrs License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pnpeny who builds or improves tumon,and who dos mch work himself or Bullish
his own employees,provided(hot such inpmvemtro enanot amended or offered for NEW RESIDENTIAL ELECTR A.,/ r�u n
sale.If,however,the building or inpnwement is sold within one year ofcomplction,the SQ.PT,FLOOµAREA 8/SQ.FII
wnerbuilder will have the limen of Proving that he did not build or improve for pur-
❑M 1,a aowne LIAR 71996
1,sea owner of the Ser.
704,am.Business
contracting with licensed mmcates h, TOTAL:
construct the project(sec.]IN4,Business and Professinm Code:)The Cnmmemrs Li.
cense Law does not apply to an owner of properly who huilds ser improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed innuanl to the Contractor's CII Ur I;Uren IINC
License Law, PERMIT ISSUANCE ss
-Sc
l am exempt under Sec. ,R&P C for this reason
Owner
AMER-DRAIN&VENT-WATER(EA) VALUATION
Dan
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of perjury one of the fallowing declarations:
Ihavoard will maimainn Cenificmenf Conscmmself-insnrc for Workers Carlo. DRAINS-VLOOR,ROOF,AREA,COND.
smian,as provided far by Section 3700 of Ne Lahr Code,for the perormonce of the STORIES TYPE CONSTRUCTION
.,it for which this permit is issued. FIXTURES-PER TRAP
O I have and will maintain Worker's Composition Inxnranco,as required by Strait,
TIOOof the Labor Code,for the pedomtance of the work for which this permit is issued. 1 GAS-EA.SYSTEM-I INC.4 OUTLETS CA OCC,GROUP APN
My Walker's Cordsawr m.Insurance cunderlaid Policy numheram:
Curlier: Policy No OAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF 1I!MP IONFROMWORKERS'
COMPENSATION INSURANCE GREASEIENDUSTRI.WASTE INTERCEPTORor ital.) BUILDING DIVISION FI!ES
(This sationneeJ nil he mmplcted if the pe.all,Europe hundred dollars IS hold GREASETRAP
1'IANCIR!CK FEC
(cenify that in the anyperformanceof the work for whichthis detrains issued,rCoIshall
not employ any person in any mannermaxmbecome subject mile Werkerk Compen- SEWER-SANITARY-MRM EA.211018'' ENERGY HE
0Z smian Law of California.Date WATER HEATER WNENTIELF.CTR
77 O Applicant 2 GRADING FEE
Grp NOTICE TO APPLICANT.11 after making this Cenificme of Exemption.you should WATER SYSIEMOIH!ATING
become subject to the Workers Compensation pmvidam,of the labor Code,you most SOILS FEL!
fmhwitbeintply withmreh pnsvisimnorthis permitshull hedeemed revoked. WATER SERVICE
d
z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.FT. PAID
U I herfor by affirm which
is a agency for the performance of Date ReceiplN
the work for which this permit Is issued(Sec.3097,Civ.CJ _
U. V Lender's Name D TOTAL:
Leaders Address TOTAL:
0. I cenify Brat 1 have read this application and state that the aMve information is BUILDING IEE
rn correct.I agree m comply with all city and county ordinances and state haws relating m QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby mahatim repreuntativesofthis city memerupon the SEISMIC FEE
.a ahovo-mentioned properly for inspection purposes. PERMIT ISSUANCE
(We)agree to ane,indemnify trod keep hion les.the City of Cupertino against ELECTRIC IEE b
liabilities,judgments,costs and expenses which may in any way records,against mid City ALTER OR ADD TO MECH.
in conagaence of the g..t,ngnl'Ihis y�m' i PLUMBING PEE
APPLICANT U' S NDS toD ^ILI.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0301 CFM)
SOURCE � ,CS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00I CFM) CONSTRUCTION TAX
S I of Cnmmcmr qac EXHAUST HOOD(W/DUCT)
ACMDOUS MATERIALS DISCLOSURE / HOUSING MITIGATION FEE
Wm to plicanl or Rome building occupant store or handl heranlous materiel HEATING UNIT TO IW.oIN)BT117
m defined by t c Cup`ldam Municipal Code,Chapter 9.12,and the Health and Safety
Coda Scedon 25532(,)?, HEATING UNIT(OVER Ilgl.00)BTU)
El Yd, DNo VEM'ELATION FAN(SINGLE REMD) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt p
emir haaardous air commitments as defired by the Bay Area Air Quality Management BOILER-COMP QHP OR BIEN BTU)
District?
O Yes ON. BOILER-COMP(OVER 100,000100,000 BTU) TOTAL:
1575
1 have renin the harardou.s material., AIR CONDITIONER ISSUANCE DATE
r5,15533 ad under Chapter 6.95 of the if the
bunia Health&Safety Cada,have
25505,255JJ and 25534.1 a notify the
that if 0c upant — NEW RISIDEMTAL MECH. SQ.PT.
r buildingildrea et.whichrivailly have be it prior
ismyreapomibihitytlitem'OetuN ry.
• of the reyuiremhems which must he mel prinrmissuvnce nfe Cenificme of Occuryncy.
Owner or uuthmited agent Date TOTAL] ISSUED BY:
OFFICE