29771 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,ELECTRICAL PERMITNO,
BUR,DINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - 771
BUILDING PROJECT IDENTIFICA'I']ON 29
BUILDING ADDRESS; ` SANITARY NO. APPLICATION SUBMITTAL DATI
OWt4 NAME:� PHONE: CONTRA R'S NAME:1 LIC NO N/C CONTAOLp
kRC O Cf 'NGINEER: LIC NO: ADDRESS: Ll
CONTACT, PHONE: BUILDING PERMIT INFO
3 Q L 'b O O ❑ Consultant Fees Paid by Applicant(Initial) HIM ;*—X_
�PL t`MN- MECH
LICENSED CONTRACTOR'S DECLARATION U QTY ELECTRIC PERMIT FEE ;< X_
1 hereby ancon Rrat I am licensed under provisions of Chanter 9(commencing JOB DESCRIPTION
WOZ with Sation](kgO of Uivisinn3ofthe Business and Professions Code,and mylicense is - RESIDENTIAL: .
F Iy_ in full once and L, I q PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�UV Licens s 1 Lick 1` s••• APPLIANCES'-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
HZ oo Dam ContuaOr
E ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAh
Z O r4'Z 1 understand my plans shall he mad ns public retards PANELS MODIFICATION
OrZF`C UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
Licensed Professional 201-1000 AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
I hereby affirm than I am exempt from the Contro is License Law for the OVER IOW AMPS . ❑BATH REMODEUREPAIR U DEMOLITION
16'xz234Wa.F following mail(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
ya which requires a permit m construct,alter,improve,demolish,or repair any stmcmm
1"-y0
J pdtirmitsissoance,alsa mquirea theapplicant for such permit 9.file.dismdamement SPECIAL CIRCUIT/MISC. O
� Y at-
that he is licensed pursuant to the pmvisions of the Continuities License Law(Chapter 9
���� (commencing with Section]II(ypaf Division3ofNeBminess anJ Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
a a o that he is exempt therefrom and the basis for Be alleged exemption.Any violation of ❑N BLDG/ADDITION ❑DEMOLITION
�5e(
Section 70315 bapplicantfibi
on . y any or o Permit sujects the applicant too civil penaltyof POWER DEVICES
al—mL ANT - ❑FOODSERVICE.
not mom than five hundred dollars(SSW).
C]1,as owner of the propenOVEMENT
as
y.or my employees with wages their sole compensation, SWIMMING POOLELECTRIC []OTHERwill do the wurk,end tuinnicturc is not intended or offered foo"le(Sec.]044,Business
and Professions Cude;The Comms License Law does not apply m an owner of O TLETS-SWITCHES-FIXTURES st
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.IL haweven the building or improvement is sold within one yearnfcampletion,the SQ.FT:FLOOR AREA &SQ.FT.
owner-holder will have the burden of pmving that he did not build or improve for put
pose urmlc.).
Lm(thepof the t AUG 27 1996
❑ property,not exclusively contracting with licensed canmrcmrs or
time Lo rho project(Sec.]IW4,Business and Dy who bus Code:)The Conhadon, Li-
whocoawdmsmm�pplyuran with
a cofpnrpeny wcensedsmirnpmves thereon,unA Q}'y. PLU BING PERMIT FEE
who contracts for such pmjecrs with n amtrvcmrts)licensed pursmm to the Contractor's
License Law. PERMIT IS E '-A-
L l!i`CI t MSU
❑ I am exempt under Sec. ,B&P C of this rcaam
.Owner Date 77
ALTER- AIN EM-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTE EVICE ! b ��
1 hereby affairs under penalty of perjury one of she following dcclm-f-,s: ( _�
❑Ihaveand will maintain a CmificeteofComantmself-iasum for Worker's Compen- DRAINS-FL R,ROOK ,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the labor Cade,for the performance of the
r which this permit is issued. XTURFS-P
m have and will maintain Workers Compensation Insurance,in required by Section
3700 of the Labor Code,for the Personal of the work for which this porous is issued. GAS-EASY. 40 IG'S I OCC.GROUP ANN
My Work�g Co "lion In nee con'
Policy .
Carrier.I(Lf7L ,(, s(aaTs/II
icy No.:�,ar�LY�O S GAS-EA.SYSTEM-O (EA)
CERTIIICATI?OF E%F.MPTfON FROM WORKERS'
COMPENSATION INSURANCE _jQREASPJINDUSTRL WASTE Et
CEPTO Q
(This section need not he completed ifthe permit is forors hundnddollurs 5100) BUILVITT,D ISION FEES
m less.)eGRPASE TRAP
I'LANCHECK F
n
Imithm in the performance of Ne work for which this permit is issued,o shall SEWER-SANITARY-STORM EA.200 FT.
ut mployoyan,y person in nny mannecm as m hemme subject m the Workers'Gnnpen- ENERGY FEE
normo Lows of California.Date WA'1'IN HEATER WNENT/ELEC R
7 Q Applicant I GRADING FE
r7 NOTICE TO APPLICANT 11;after making this Cenifcate of Exemption,you should WATER SYSTEMOHEATING
abecome subject m the Wnrker'x Compensation provisions of the Labor CWe,you roust SOILS FEE
LV forthwith comply with such provisions or this permit shall bel deemed revoked.
WATER SIiRVICE
a Q
UO CONSTRUCTION
LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.PI'. PAID Dauit
tg
1herebyaffirm that theta issco(Sett.0lending agency for the performance of
ty F the .,it fit,which this permit is issued(Sec.lW],Co.C.)
O Lenders Name fir V_
TOTA
Landale AJJrcss
p� 1 certify that I hove rtad this application end state that Ne above infortrmion in BUIL( 'G FEE
I') conal l agree to comply with.11 city and county ordinances and sum laws miming to QTY. MECHANIC110�CPM)
MIT FEE
U ,z, building contraction,and hereby authorize representatives ofthis city to enter upon the SEISMIC -EE
r aMvementioned Paul for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way aocaue against mid City ALTER OR ADD TO MECPLUM RING Fill
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT TO CFM7 ` MECHANICA FEE
SOU 13 REQL'ATIONS.
( Yln e/ AIR HANDLING UNIT(O00 CFMI CONSTRU ON TAX
Data XHAUSTHOOD(W/DUHOUSING TIGATION FEP,HAZARDOUS MATERIALS DISCLOSUREWill thonpplicmt nrfrum building occupant scoreorhandle hazardous amenus I IEXIING UNIT(TO 100,as defined by the Cup(fluor Municipal Code,Chapter 9.12,and the Ilnrlth and Snlbty
Coda,Section2532al't FIRMING UNIT(OVER TU)❑YexNnVENTILATION FAN(SINID) PAID
am Rsue1pIM
Will the applicant or future building occupant use equipment ordevices which BOILER-COMPOHPORBTU)it hazardous air contaminants as defined by the Bay Area Air Quality Management OTAL:District? BOILER-COMP(OVER TU)
-
E]yes (]Nn
I have mad the hamadous materialsAIR CONDITIONER ISSUANCE DATE
requirements under Chapin 6.95 of Bc Cdi-
fomia Health&Safety Cade,Sections 25505.25533 and 25534.1 timlerstand Bat if the NEW RESIDENTIAL MECH, SQ.FT.
building does rot currently have a tenant,that it is my responsibility m notify Be circulator
of the requirements which most be met prim".iscumme of n Cenificam of Ocuupancy.
OM
Owner or authnnxed agent Date L ISSUEDBY:
OFFICE