29017APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATTOWPERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PBRMITNo.
29017
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
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O gO VI 0ha-
OWNER'; NAME: �� ��I`NE:
�HeU /�1rMW151 Nt-� LIC NO:
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CON'IROLM
CONTACP -PHONE:
BUILDING PERMIT INFO
oW1J�'V�
'❑ Consultant Fees Paid by Applicant (Initial)
B ELECT P UMB
❑
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LICENSED CONTRACTOR'S DECLARATION -
I M1crehy affma that 1 am licensed under provisions of Chapter v (commencing
wiaM1 Sation]OW)of Division3o(the Business and Professions Code. and my license is
I. forte H.a 9
Do, las= CoalmflCr
Dat Canl
ARCHITECTS DECLARATION
I understand my plans shall be event as public rcconis
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
OSFDWL .KITCHEN REMODEL
❑
❑ADDITION C1 PLUMBING RE -PIPE
❑MULTI -UNIT 10sTRUCTURAL
MODIFICATION
❑INTERIOR 0CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMODEf PAIR ❑DEMOLITIO
X �
�1 OTHER
PERMITISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UPTO 200 AMPS
F�_cel
C W L)
E.
�bJ: t E.
Licensed Prafeasimnal,
OWNER -BUILDER DECLARATION
1 hereby .(firm that 1 nm exempt (tarn tPr Cssionslara Littme Law Rogue
following rtasom (Senior ]OJ 1.5, Business and Professions Cole: Any city or county
201-101IDAMPS
OVER IIlOUAMPS
SIGNS ELECTRICAL
Izl' O
�'
W;
WCO�
a o K
4•
nN
O
which requlrea a prrtdt to conxupn, alter, improve, deoudish, or repair any slmnurc
prior m its is ... tire, also requires the applicant fo owh pooka, file a.igocdsmtkmenl
that he is licensed pursuant to the provisions of the Conaenrt. Licence Few (Chapter 9
(comm<ncinS'uiN Smion 9(XX))e(Diviaion3nf Ne l{uxinesx unJ PmfexsionxCNe)or
that he is exempt intrusion and the basil for the alleged exemption. Any violation of
5 banapplicant for a permit sul octs the applicant m a ci vii penalty of
Section p
not more than rive hundred dollars l$SINO.
❑ Lo the work, the m n tut is anpin eos aithwred for ale (See, coo
p pe y y pensation,
will dothework, and the a, Business
SPECIAL CIRCUIT/MISC.
'BMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION -
[I TENANT ❑ FOOD SERVICE,
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OU'TLE'TS - SWITCHES - FIXTURES
l'
and Profcssimm Calc: The Canoumors Liccnsc law Jabs not apply m un owner of
he Conisnot, License Us.doforsale(Secto
prapeny, who builds ver improves thereon, mad who does such work himself or thmagh
�1
P
his own employee., provided that ouch imp ..vemems me not intended ver ofibred for
NEW RESIDENTIAL ELECTR SQ
sale. If, however, the building or improvement is sold within one ykarnlromplminn, the
SQ. PT. FLOORARIA
$/SQ. 14.
owner -builder will have the hooka of proving [flat he did mm ba lint nr improve lie per-
era J.
DEC OV
sus,
❑I, as �wnerof the propny,.meselusively ttmtnwting with licensed comrunnrs to
TOTAL:
1995
construct the ptq at (Sen. 9144, Bosinesa and Prnlbssions Cod....... C...... en's Li-
yhs
cense taw docs, not apply to anowncrofpropcny who foods or improves merema,and
QTY PLUMBING PERMIT FEE
Very Uf (a( HEy�'INO
who contracts su
forch pnive, witha eon morr(X) lidunsed IF vasut n, the Contractors
1117RMIT ISSUANCE.
License Low
❑ I .,it exempt muter See 11 & P C for this r..an
-
ALTER DRAIN & VENT -WATER (EA)
BACK FLOW PROTECT. DEVICE
Owner Data
VALUATION'
I
WORKBIi:S COMP17NSAI'ION DECLARATION
Ihereby militia under penalty of pefinry one of the following declare ns
J WO
DRAINS- FLOOR, ROOF, AREA, COND.STORIES
[have and will lnaimoin aCeniflate nl'Cnnxcnnn'xclGinsurcfur Wnrkcr's Cmnpen-
xation, an provided for by Section 3900 of the Labor Code, for the perfommna of the
'fYP[I CONST RUCTION
_
FIXTURES -PERT RAP
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance, as required by Section
3]WueffthTerrLaalmi-Cudg (milia darmance ofthe work fnrwhich this pfmlit is issued.
MyW/ Ca eeyltprr. Gompeni s ace cu, mJ y Nioy nplWcr ver GOi1
-I V
aLi/'1G.CEliTIFICATE
GAS -FA. SYSTEM-] INC. 4 OUTLETS
DEC. GROUT'
AI'N
GAS -EA. SYSTEM -OVER 4 EA)
OF EX[MPTI NPROM WORKERS'
COMPENSATION INSURANCEGREASp/INDUSTRL
(This section need not he completed if the permit is for one hundred dollars ($ 100)
or less.) (This
WASTE INTERCEPTOR
BUILDIN DI SI Il!ES
PLANCf1ECK PL•L'
TRAP
SEWER -SANITARY -STORM EA. 200 FT.
z,Z
O
Icenify that rominn the performance oftheberenfor which tho the ut is Workers Co.,.- I shall
not employ any person in any manners as mM1aome.uhjecnnthe Workcn'Compen-
serum. Laws of California. Date
APpliront
ENERGY FEF.
WATER HEATER W/VENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: ..Ret making ahi Croificaln of lixempion, yore should
become subjano the Wu r. Cnmperomic. pr visions fifth. Labor Cade, you must
fonhwiN comply with ch provisions o,,his pen I shall he decimal revoked.
WATER SYSTEMG`RBATING
WATER SERVICE
a'
{ki
SOILS FEE
0.a
1].10
Fthework(o
CONSTRU O 1: N(.p.p.rr��!!lBsCY
Ihereb (Tion thathereiOle at boot idg.,unryfortlar,armarrancenf
hich Nis,waii is. f ex.3( ,Cie C.)
PAID
Dom Raripap
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
C)
Lenders ante
Lenders ddrexs
1 nify Ih t I his app cation and state that the above information is
TOTAL:
BUILDING FEE
V)
U ,2$
correct la ree roc 'hall cit nd county ordinancesand sore laws rdmingm
building co wcal.a... terbya Drize reprevenmlives ofthix cirymemerupnn the
QTY MECHANICAL PERMIT FEE
SEISMICFFLI
above-Ineait cd property arm aionpurpaus.
(We) a me to save, in nify and keep harndess the City of CincinnatiPF.RMITISSUANCF, against
ELECIi1C FEE
Iifl ilities,judg autf.enstsJcxpenvesw ieh may in any way afore again. mid City
incotivequcnc[ fm gm mgr his it.
ALTERORADDTOMECH.
PLUMBING PEE
APPLICANT U. E fA " AN ILL COMPLY WITH ALL NON -POINT
SOURC. -G ONS
AIR HANDLING UNIT TO 10,000 CFM)
MECHANICAL FE
AIR HANDLING UNIT(OVER IROBRCFM)
I
CONSTRUCTIONI'AX
EXHAUST HOOD(WMUCF)
Sign ofApplicant for Date
HAZARDOUS MAT ERIAIS DISCLOSURE
HOUSING MITIGATION FF,
HENfING UNIT (10 100,000 BTU)
Will theapplicantor future building acupato store or handle Neutrons unteri.I
as defined by the Cupeninn Municipal Code. Chapter 9,12, and the Health and Safety
Cuda, Section 25532(a)P -
HEA'L'ING ON[ -[(OVER 100,010 BTU)
❑Yes E] No
Willthe applicantomorfaturc building by the l use nAir nan Quordeviceswhich
emit hazeNous air comamin.mx s defined by the Buy Arcu Air Quality Management
Disaia7
❑Yes C] No
PAID
Uaie Le w.
T(3TA
VENTILATION PAN (SINGLE RESID)
BOILER- COMP(3HP OR 100,000 BTU)
BOILER-COMP(OVER 100,00) BTU)
AIRCONDITIONER'
I have rend IM1e hazuomo more, fit, rcuia, ant, under Chatter 6,95 ofthe Coli-
4 p
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PI'.
fomin,doHealth &es t Imic Coag Sections 2551t5, 25533and2.5.534. anlcrstantl Ihnlifthk
building cuucnlh atcnantticthat is fify the
jimar t I vet
of the mqulretnenN which mux[Mmel piooixmtnn[ti of 11 Cfniliano nl'(laalpuncy.
vanno ie"
ISSUED BY:
Owner or authorized agent Dom,
TOTAL:
OFFICE