29644 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
IiDILDING PROJECT IDENTIFICATION 29644
BUILDING AD E7S Rracwoe« SANITARY NO. APPLICATION SUBMITTAL DATE
OWN( NAME: 11//�TI ,Y HONE -n 'GN'I'RAC R:SNAMpE ys LIC NO:
4 /b
l8L V keursOA/ s) 2S7 z 5 re y ) /W -JkJ 8, NIC CONTROL#
RCHITECr/ENGINEER: LIC NO: TRESS: ID
CONTACT: - PHONE!: y ILDING�P/FVVI/2(M�IT I`/NFO
VConsultant Fees Paid by Applicant(Initial) __ 11I.DG, PLUN2 MEC14
LICENSED CONTRACTORS DECLARATIONQ'PY. ELECTRIC PERMIT E T�f
I hereby ruination I am licensed under pmvisinns of Chaffer 9(commencing JON DESCRIPTION
with Section 9000)nf Division 3 ofthe Buesonesons Cases and C
sinsd ProfsiCldy license is RESIDENTIAL:
i full force and effect. PERMIT ISSUANCE
�#.U2U�1 License Class Lick SILWL ❑KITCHEN REMODEL
NQq Date - Comment- APPLIANCES-RESIDENTIAL ]TION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION- MU I.TI-UNIT{ CSTRUCTURAL
O Z`yam' PANELS
p I undemanJ my plans shall be used as public records UPT'0 200 AMPS !� MODIFICATION
bio€ Licensed Pmfexsinnal LJ INTE121OR ' CHIMNEY REPAIR
201-D100AMPS IMPR V P Tj
eat that I a
OWNER-BUILDER fr m Ce Contractor's
ON x
I hereby uffirm that I um exempt from the Commctnr'n Llceree Law for the OVER 1111111AMPS - ❑BATH R IIIiUI6PA41 DEMOLITION
d U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAI. 00
/`
40 F which requires a permit to construct,aper.improve,demolish,or repair any stracmre T 2/f G
prior m its i.auence.also ruryircs the uppleaut for such permit m file a signed statentem
PSPECIAL CIR T �• �Rfuma
Nal he is licensedpnr..i tatheprnvisimtsmfthe Contractors Licen.e Law(Chupter9
DOS (commencing with Seen,,.70011 Division 3 of the Businessond Professions Code)., TEMP.MrlIELL'INST. COMMERCIAL,
Q.y^y Nat he is exempt Nercfmm soothe basis for the alleged exemption.Any sodium.of ❑NEW BLDGIADDITION C DEMOLITION
X417 Y• Section 7011.5 by any upplicam for u perms subjms the applicl m m u civil penalty of POWERdaLm
y nn
--,him five hundred do]]ar.($5a1). ❑TENANT ❑FOODSERVICE
a0 I Inns owner of the pmpony,onny employees with wngee vs mmolrnnlecut tpmmainn, SWINIf IN.P ELIiC'T IMPROVEMENT
will do the work,and the structure is not intended or rHered for.sale(Sec.9044,llusinesa ❑O'1'I I IiR
and Professions Cale:The Comructor's License Law rices not apply to an owner of OUTLETS -Irl
a' property who build.or improves themem.and who docs such ,,,it himulf or through
his own employees,provided Nal such improvements are not intended or offered for NEW RISIDENTIA ML'
sale.If,however.the building or improvement is sold within alloy-...ofcamP...Ions,the SQ.FT.19OO REA S/SQ.FP.
orwater-builder will have the burden of proving that he did not build or improve for par- ,.S
pose of noted. LS {TTS
❑1,as owner of the pmpeny,am exclusively cammming with licensed ewnmchore Ir L:
construct the pmjeci(Sm.9044,Business and Professions Code:)The Contractor's Li-
Luw Jrcsnmm npplymvn own-ndproperty who huilJa or improves thcrnm,and QTY. PLUMBING PERMIT FEE
whitener vets fo chp. r. the man nctorts)licensed pulmotto the Comrumors
License law. PERMIT ISSUANCE
❑Inns axe pl der ,B&PC far i a n '
e see
Owner Date ALTER-)RAIN&VENT-WATER(EAT VALUATI0
s `
W 1 .R'S COMPENSATION DECIARNUON KFLO% TEC]'.DEVICE /i/�`�� /I�
I hereby affirm under penalty of perjury moofthe following declarations: + _ 0
p]IMveandwillmointainnCmificme ofConsennn self-insure for Wnrkere Comber- D - ND. STORIES TYPE CONSTRUCTION
nation,at provided far by Section 3700 of Ne Luton Cod,,,Code,for te hperformance of the
work for which this Permit is issued. FI R
C 1 have and will maintain Worker Compensation Insurance:.1 required by Section
3900ofthe labor Cole,fnrthe perfommnce.fthe work brawn ch this permit is issued. G -E TP. I S OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number am:
Carver: Policy No.: GAS-FA.SYSTEM-OVER 4(EAT _
CHRI'I IICATE OF EXEMPTION PROM WOR KE RN '
COMPENSATION INSURANCE GREASF/INDUSTRL WAS TE INTERCEPTOR BI11LD1 r NFELS
(•Ibis section aecdnot he completed iflhe perm,is fiction,hudr
ned dollars(SI(I() GRGSE TRAP
or ic,".) PLANCHECK FEF.
I certify rival in The Performance of the work for which this Permit is issued,l shall
not employ any person i n any manner so as to become subject n the Workeri Conipem SEWER-SANITARY-STORM EA.200 FT. ENERGY TEEAjA ^�
Z union Lew,of California.Date WATER HEATER WNENTIELE(TfR
z Applicant GRADING IT
.N. NOUC13 TO APPLICANE 11 after,,taking this Ccrificate of 13aempfimi, mi,dusuld WATER SYSTEMO`RHATING
C•'! become subject m the Workers Compensation prnvininns of Ne Labor COJe,you muse SOILS I
> P.
WF1't forthwith comply with such provisions nr this permit shall be chmaed revoked WA'I'ERS17RVICE
Q
.a7. z CONSTRUCTION LENDING AGENCY NEW RCSIDENTIAL]'LMR. SQ.FT. PAID ,
V Iforwhich his
cHereissued Scetinn l7.Jung agency for thecerfommance of ate
Lkt H the work for which this permit is issued(Sec.3099,Civ.C)
0 U Lender's Name TOTAL
fender's Address L.
Fy 1 verify that I have mad this application and true that the above information is BUILDING M
fZ) cameo.I agree to comply with all city and county eminences and state laws relining to QTY. MECHANICAL PERMIT FEE
(.1 building construction,and hereby authorize representatives ofthi.s city to enter main file SEISMIC 4E
above-memin
inned property for spection purposes. PERMITISSUANCE
(We)agree to save,indemnify nnJ keep taintless the City of Cupertino against ELECTRIC .E
liabilifies,jud nr,ttm.codexpeaseswhichmayinanywaysecme...hest said City ALTER OR ADD TO MECH. PLUMB] OFEE
in conmqu th oft is peit. -
APPLIC .Tel A DS 1N] WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'F(TO 10.0110CFM) MECH ]CAL PEC
SOURCE EG AT ) S
AIR HANDLING UNIT(OVER 10,000 CFM)
'((ivl set 9 CONS UCf10N TAX
Sign mm ofApplic. nmmcmr Date EXHAUST HOOD(W/DUCT) HODS ITIGATION IEE
AZARDOUS MATERIALS'DISCLOSURE
Will the applicant or future building ocuparttore or handle huzamous materiel HEATING UNIT(TO 10),0Ik1 BTU)
az defined by the Cupertino Municipal Code,Chap¢.9.12,end the Health and Safcty
Code,Section 25532(:0? HEATING UNIT(OVER 100,1100 BTU)
❑Yes IdNo VENTILATION FAN(SINGLE RESID) PAI])
Will the applicant or future building Dar Re r pf#
pp g by die B use equipment or devices which BOILER-COMP 3HP OR 100,000 BTU)
emit hazardous au contaminants m Defined by the Buy Area Air Quality Manogcment (
District? BOILER-COMP(OVER 100,000 BTU) 'TOTAL:
❑Yes �&
Val=z
our mIs under Chfi95 of the C.li- AIR GDNDII'IGNERISSUAN(. ATE
fomiCM 5 lion 2 5,25537 wJ 25534.I understand fM1m if Ne NEW RESIDENTIAL MECH. SQ.IT.buildlyl r run thea if ismy mspunsibiliry enmity NcsecupantofNll Wor" pnceofaCenificof c
Ownerorinthoracm. I t[pV.'✓✓s" Eaate ISSUED BY:
OFFICE