29721 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. n 1
BUILDING PROJECTIDE.NTIFICATION G 1
BUILDINGADDRESS: SANITARY NU. APPLICATION SUBMITTAL GATT
Ilio FSG 2 X96
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CONTACT PHONE: BUILDING PERMIT INFO
Y[�yrap�� '11 +.fj•y l�y� �}I�I�y11 CA)) Consultant Fees Paid by Applicant(Initiap �flD�, ELECT PLUMB �+ECx
�I��ll''IN✓�I���f
LICENSED CONTRACTOR'S DECLARATION
[J� J'•.V�J
I hereby affirm that I a o licensed under proQTY ELECTRIC PERMIT FEE visions of Chapter 9(commencing JOB DESCRIPTION
�OCZO�y
with Section 7(XXO of llivixinn3of the Business end Pyfesf'ons Code,and my license is PERMITISSUANCE RESIDENTIAL:
F+ly mfullforaundcff '�
❑SEOUL ❑KITCHHN REMODEL.
V I icense Class Lic.p
APPI-IANCFS-RESIDENTIA. ❑ADDITION ❑PLUMBING REPIPEyawD
CHUTECPSDEC-ARATION ❑MULTI-UNIT []STRUCTURALy
Z O n?� 1 understand my plans shall he used m pontic records PANELS MODIFICATION
OZ-, UPTO200AMPS �'(,{/ El INTERIOR ❑CHIMNEY REPAIR
P Licensed Prnfessinnal 201do01AMPS IMPROVEMENT
k$5 �a-J OWNER,overau limit
it Ce Counselor.,
ON OVER I000AMPS ❑BATH REMODEUREPAIR El DEMOLITION
y I herby.(fete ons 1 1. exempt limn the Contmamr'n License city
o fm the
x 3 d V following Taman.(Sermon]031.5,Rosiness send Professions Code:Any city or rmmY SIGNS IELIECTRICAL ❑OTHER
LLT LL which requires a permit to construct,alter,improve,demolish,or repair any structure
tobriarm it.tax annce,mso requires The applicant natant petmiun file a signed summea SPECIAL CTRCUIT/MISC.
y that he is licensed pursuant to the pnrvisinmofthe Cuntreeols License law(Chaper9
CSO (commencing with Section 700(daf Division3 office Businessman Pmfessimx Cede)or TEMP.MIDER OR POLE INST. COMMERCIAL.:
y o OL that he is exempt therefrom and the basis for the alleged exemption.Any violmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Y%1•m-'!L Section]031.3 by any applicant Toru pemtit subjects licenpplicemmacivilpenalt'vf POWER DEVICES
yy not mare than five hundred dullnrs(SSINp, - - .NANT 0I7001)SERVICE
GQ ❑I,as owner of the proper,or m m In eco with wages as their sole compensation, SWI M M I NO POOL ELECTRIC IMPROVEMENT
Y Yc P Y 6 pcmm
will do the work,and the he Contrivances
LicaeLownded or do Root apply to an Business []OTHER
w 3 and property
who bond,Cole:The Contreetcim License Law duo not apply to ten owner of O TL TS-SWITCHES-FIXTURES
property who oyees,or impmvea Narcan,and who nus such wok himself of fhrmgh
his own employees,provided that such improvements thin not intended m offereJ far NEW RESII3L+NTIAI.ELIECI'R SQ FT.
sale.If.howeveglI he vilthe budsng or or proint issold within lbruld or imprvetfis, Tire 01
SQ.FT.FLOORAREA EISA.FT.
Owneat s.h.cr will hovetheburden ol'prnving rhos ba did nal build or Improve far Aur-
pose of sole.). (/U
01,as owner of the popery,am.Business
contracting with:)The
drnmeal i. •�
construct Tice project(Sec.o an Business end T'refehe but ds or i The Cantrecros, Li + (✓
mouse Law Juor sus non ch pr oan ith a of copsperlyeembs whosedprrmmpmves thermContra,ord QTY. PLUMBING PERMIT FEE
who comma for such projects with n crnmeor(s)licensed pursuant In the Comrerols /j fw�
License Law. PERMIT ISSUANCE I'I1 12
Tete exempt under Sec. ,B&P C forlinkmu.mn '
Owner Date ALTIiR= &VENT-WATER(EAT a'11 r(j, VALU ON
WORKER'S COMPENSATION DECLARATION 1 U1'• l
I hereby affirm under penalty of perjury one of the following decLuafions: BA ROTELT.I3IEVICE (/{ ISI) '
❑l haveand will maintains Cerifcateof Cunsem oself-insure for Workeri Cooper. LL 777 a
a DRAINSz • ROOF,ARITA,COND. RIES TYPE CONSTRUCTION
sarion.ss pmviJN for by Section 7]1X1 of The Labor Cele,for the performance of the
4o for which this permit is issued. FIXTURES-PE
W4
1 haver and will bouillon Woo is Campensodou or.oncc,as required by Section
ofthe Lubar Code,for the performance ofthe work for which this permit is issued. GAS-IEA..YSTEM-1 C.4 'LEI'S
My Wo `Compenserm, suranre carrier ad Policy numb OCC.GROUP APN
Cubic eSy�n�. Policy Na: � C S-F.A.,YS OVER A)
_ CA O A 1'NINFROM WORKER"
COMPENSATION INSURANCE GRI\511ND L WASTE INT CE
(This section need not be completed Has,permit is for one hundred dollas($1101) BUILDING DIVISION '.
' CS
nr less.) GREASEAN,- PLANCHECK FEE U5 iaI—
Iready par inthe performance(ifthe work forwhich this permit is issued,I shall SEWER-SAN ' RY,=Sic- PA.21b FT.
not employ any person in any manner so as to became subject m the Workers'Compete ENERGY FEE sill
Z2 Applicantsof California.Dam WATER' TORW Ril.. GRADING FEE
V) NOTICE TO APPLICANE..If.after making this Certificate of Exemption,you should I�rq f$ �/fREATIN ,
abecome subjen to the Worker's Compensation provisions of the Lahr Coda you mope SOILS FEE
W forhwith comply wall such provisions or this Permit shall be deemed revoked. '1gA'IP.R SGH
aQ U 619
OZ CONSTRUCTION LENDING AGENCY NEW RI?LSI AL SQ.FC PAID
I hereby otEmrtha There iaanmamction lending agency Tonics performance of Date R,ceip p
The work far which this permit is issued(See 3111 Civ,C.)
0 Lender's No. TOTAL:
Lead ev AddreoavVI
0. 1 certify Net I have read this application and state that the above information is \ NI111.DING FE O .r
In c rrect.l agree to n+mbly with an city and ranty ominances unJ stere laws rcleting n' QTY. MECHANICA]-PCR,11T FEE
V 4 building construction,and hereby nuNorimm,erescnrdves lot this city 10 onternn The SBI: F
uhovcmenlioned property for inspection pugmus.
(We)agree oaave.indemnify and keep hominess be Ciry of Cupertino against PERMII'ISSUANCE ELE 1 E
liabilities,judgments,costs and expenses which may in any way aame againstaid Ciry ,TER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT AIR HANDLING UNIT(TO I(I,WOCIM)SOURCE REGULATIONS. 'µ / JMECHANICAL PC
45 b5)-/D AIR HANDLING UNIT(OVER I(1,1X)OCFM) CONSTRUCTION' 1X
Signore of ApplicanUConuacmr Date f EXHAUST GOOD(W/DUCT) HOUSING MfI'IGAT NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupam sore orhandle hurarders material HEATING UNIT(TO 113,01)0 BTU)
as dented by the Cupertino Municipal Cole.Chapter 9.12,and the Health and Safety
Code,Section 25532fe11. HEATING UNIT(OVER 100,0m,BTU)
❑Yes VENTH LA'I'ION FANS INGLIE R ESID) PAR)
Date R err M
will the applicant or future building occupant A equipment or Miee9 which BOILER-COMPOHPOR 100.000 BTU)
mit hazardous air conmminants os JefineJ by the Bay Area Air Quality Mvnogemem TOTA '
District?
❑Yn still BOILER-COMP(OVER 100,005 BTU)
I have acrd the hauNous natural.,requirements under Ceepter 6.95 of the Can. AIR CONDITIONER ISSUA DATE
ondir Health&Safery Code,Serionx 2550.5,25533 and 25534,1 understand shot if the NEW RES I DCNTIAL MECI I. SQ.Irl(
building dna nor centrally have a hand..that it is my responsihilin,to notify the recup:mt
of the rowPu menti which must be me prior to issuance of o Cenincate of Occupamy.
Owner or authodual agent Date ISSUED
OFFICE