29445 •APPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL_.POINT PEN ONLY 4
CITY OF CUPEBTINO BUILDING'.ELECTRICAL • PERMIT NO.
BUIL DING DIVISION APPLICATION/PERMIT• PLUMBING.MECHANICAL. - 29445/I C
BUILDING PROJECT IDENTIFICATION f•f�} J
R DINGADDRESS�,w . 1 SANITARY NO. APPLICATION SUBMITTAL DATE
41177
aRWNE NAME:- 'PHONE.
s - C�JTRACTO ' NAME: I.ICNO: � �
CONTROL If
RCHITECT/ G R: � NO: DRESS:
„ CONTACT.' PHONE. BUILDING PERMIT INFO
a /g ��V- n5uI caret Fees Paid by Applicant(Initial) � BI ELECT' PLUMB � MUCH' 4
a+c./ v y
..
LICENSED CO RACTORS DFCI ARAf10N' _n -
1 batch F m that 1 m I en ed under p f Chapter A(commencing ,QTY. ELECTRIC PERMIT -FF,B
P JOB DESCRIPTION
A a'Z. ithS t 9W0 Di ,
. n3 of the Bus dP teseion Code,and my lice a SRF ID NT
Er00 PERMIT ISSUANCE :+ IA -
n Poli[ ct and effec
�UU License Class 'Lic.# s - ❑SFDWL ❑KITCHEN REMODEL'
yZa Dam Conlowl APPLIANCES-RESIDENTIAL DADDITION El PLUMBING RE-PIPE
Fs Dizj; AR ITECTS DECLARATION PANELS OMULTI-UNIT OSTRUCTURAL
Z O f2'b I undesmnd my glens sM1a used as public reooNs MODIFICATION "
O Z UP TO 200 AMPS
�', O Licca ed P f 'anal _ D INTERIOR ❑CHIMNEY REPAIR,
:$5 OWNER BUILD OCCLARATION 20LI000AMPS IMPROVEMENT"
¢G LV I her by calf that 1 pt fr. the C I I L Law f the
," OVER IWO AMPS t ❑BATH REMODEL/RFPAIR El DEMOLITION
aOyU folio g a. (Section 70315 Business.. f. Code Any 'ry ry SIGNS f.1.FATNICAL ❑OTHER
U F' which req p nn't l c t r ¢ mpm ra h p ystructure
�y gran I I.uane I:o q tit ppl ca If 'u fl d d tin In SPECIAL CIRCUIT/MISE. .
p; tM1eth I Ic nsWp rsue n tit p flit C t reL Le (Chapte 9 _
p0 (commencing with Seed 90%1) fD 3ofthe Rusin dPrfe:' nsCd) r TEMP METER OR POLEINST. COMMERCIi-
d ea that he s exempt thercfmm and theb for the Nleged axe r .A y tion of
�N Section 903 P5 by any applicantf ° , El NEW BLDG/ADDITION, ❑DEMOLITION
p usuhlects the nppli t civil POWER DEVICES ❑TENANT FOOD SERVICE
y not more than five hundred dollars($50))
F� ❑ 1 as o voci o'the prop rty my employees with wages as the
pe n, 1 P .I FCTRIC ' 'IMPROVEMENT
willdr the work and that t t I.
nniffereJ ford (S 4Businesc E3 OTHER
tiand Professions Cale Th Contractor's License Law ones mat apply to owner of OUTLETS-. HES FIXTURES
progeny who brdds nr improves thereon,and who Jtxs such work himsel thnmgh -
his awn mnplcyeea,provided that such improvements ore not Intended or a red for NEW RESIDENTIAL.ELP.CTR SQ PC "
aide.If,Im eveelhemoldiogor improvement is sold within oneyearofenmple ,the SQ.Ff.FLOOR AREA ,l$/SQ,FT.
owner-builder will have the burden of,ening that he did not build or improve to - ✓�nL
pus tial J. or ..
1,s. wner Orth prperry,am exclu.lvelY t t g 'd licensed contractors ok, lY� •
cons t the Project(Sec,]044 Business and Pr passions C J )fit C t act r, Li- n to Ian cheek
n ♦�
censeL d t apply to un owner fp party hobuilds o imp tit and kT'Y. ia1rT p eek co pletlon
who contracts for such projects with a comracou(s) tensed mrsuant to the Contractole
License Lnw. PERMIT ISSaor r Owner ace pt complete
❑l am exempt u ,B&P C for this reason /� /�
LO TER-DR - or C rrec Ing
D Di to Ian revs Ions on i ,.r VALUATION
W 'S C[ A'ItON DECLARATIO - BA FLO
thereby affrm oder penally p jury one of the following declerntians: ,
❑ I have and will maintain aC rtidcate ofCamara, :elf-insure for Workers CompemDRAIN FT ri STORIES TYPE CONSTRUCTION
,tion provides]forbySec( 3700 of tit Lekr.Cid,for the performance ofthe nrk g� or thirty da S
f h h@ s perm I t d. FIXTURES
(1 1 have and will maintain Worker's Compensation Insurance,as required by Section' e
37W ofthe Lah'rr Crirle,far the performance ofthe work forwhich this permil is issued. GAS-EAS M-1 INC. LF,TS '
My Workers Compensation Insurance carrier and Policy number are:
.00C.GROUP APN
Carrie: - •POI1eY No.: _ �GA3-EA.SEA 0.9 N.011 '
I CERTIFICATE OF EXEMPTION FROM WORKER S' Zf
COMPENSATION INSURANCE ' GREAPYIN TE INTERCEPT " UILD DIVISION FEES
(This welinn need not be completed ifthe permit is forrne hundred dollars($HXH GREASE TRA
or less.) = " ''
Icenify lhnl nthe pert o[tbe kf bleb thl p rn1'I,
...ed'
[shall
SEWER-8 STORM
,Out employ any pm erson any manna no as I be m :object theW kers'Compen- � ENP.RGY PEE
.soon Laws of 01iremou Date
.��.0 Applicant - WATER HEATER WNfi7/ELEC'R GRADING FEE
eta cn NOTICE TO APPLICANT If,after making this Certificate of Exemption.you should WATERSYSTEM?REAT[NG
became subject to the Worker a Compensation p s ons of the Labor Code you must _ SOILS FEE* s
W Q forthwith complywith such provisions of this permit shall be deemed revoked. _ WATER SERVICE -
CONSTRUCTION LENDING AGENCY . NEW RESIDENTIAL PLMB. SQ.F PAID ..ry
U•z "l hereby affirm that them is a emisuucoon lending agency for thef f Dore Receipt#
per oimnnce n
'-U the work for which this permit Is issued(See.3097.Civ.C.)
O
Liandarx Name
,,,� '9 TOTAL:
{J) Lends Addres. TOTAL:
Cr 1 certify that I have read()its applicationd state that the above information is BUILDING IEC
ti com"t,I agown.emapty.with II canard county mimence,and a lam mw,adatIuntil QTY MECHANICAL PERMIT - Fi
U7. building construction,and hereby authorizerepresentatives ofthis city to ante.upon the SEISMIC PCC - -
abwe-mentioned property for inspection purposes ' PERMIT ISSUANCE
(We)agree m save,indemnify'mid keep harmless HasCity Of.Cupertino again, ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any woyacerue against said City ALTER OR ADD TO MECH.'
mper
nit.crequence of the coming of lhi.petil. 1. LUMBING FEE -
fAPPLICANTUNDERSTANDSANDWILLCOMPLYWITH.ALLNON-POINT AIR HANDLING UNIT(TO.10,000 CPM) - ,
SOURCE REGULATIONS. - CHANICAL FEE -
AIR HANDLING UNIT(OVER 10,001CPM) CONSTRUCTION TAX'
1�
d'ignnture of ApplicanVCnntmunr Date . EXHAUST HOOD(W/DUCl7 I
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEB
Will the applicant or future building occupant store or handle hanardous material HEATING UNIT Of)I W,Oq BTU)
' as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
r Cade,Send..25532m)? HEATING UNIT(OVER 100,000 BTU).
❑y5 E]No
PAID
- 0 d VENTILATION PAN(SINGLE RESID)' - Dale Receipt#.,
Will the applicant or future building Occupant use equipment Or devices which
emit Immortals air,cnnwminent,as defined by the Buy Art.Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
hi
Diact7 '? ' . TOTAL:
❑Yes F1 No BOILER-COMP(OVER 100,000 BTU)
r _ I have read the musicians materials requirements under Chapter 6.95 of the Cali-, AIR CONDITIONER ISSUANCE DATE _
f .ia Hwlth&Safety Code Scebona 25505 25533 and 25534.I Jerstu d tit t if the NEW RESIDENTIAL MUCH. SQ.Ff. f
build,.,c tcu tly bay eI tthauti my ,p ibil,lyl ratify the occupant "
of The lealmoment,which m0 16eumialimr 1.iswinwe of a CanifficitteOf
Occupancy, 5 ,
Owmeroramhnrzedmgem - t Date 'TOTAL: ISSUED BY:
OFFICE,