29102 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT,PEN ONLY
CITY OF CUPERTINO BUILDING-ELE4CTRCAL - PERITNO. 29102
BUILDING DI
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO, APPLICAI ION SUBMI'TT'AL DATE
- o398 W FazNANDc ill
OWNER'S NAME: ���Q 1 H: CONTRACTOR'SNAME: LIC NO:
sAII ,- ill chf�n 'eW s--'�Z v,t �.JIS-l.._ low - tl NIC CONTROLN
1RCHITLUTIENGIN 'R! LIC NO: ADDRESS: �• -
0 3 LAWreglee
CONTACT: PHONE: BUILDING PENMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DEC LARATION ❑ ElI hereby affirm that I man licensed under provisions of Chapter 9(commencing QTY ELECTRIC PERM IT FEE JOB DESCRIPTION
C X Z
with Section 7")of Division 3 ofthe Business and Professions Cadgand my license is
�0 0 PERMIT ISSUANCE RESIDENTIAL:
n full force and effect.
�UU� License Class LION ❑SFDWL ❑KITCHEN REMODEL,
F tsl Date Contractor APPLIANC1iS—RESIDENTIAL ❑ADDITION QPLUMBING RE-PIPE
Fp,oj ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT C3 STRUCTURAL
Z o! 4 1 understand my plans shall be used as public records MODIFICATION
O 2::110 UPTO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
rC4�� Licensed Professi...I 2nd-10MAMPS IMPROVEMENT
a that OWNER-BUILDER DECLARATION Contractors
OVERIWUAMPS ❑RATH REMODL'VRHPAIR j7SQEMOLITION
1 hdame affirm that 1 am exempt from the Comsat ors License Law for the `
°aa3iV following rcaua(Sution]U3 L5,Business end Professions Cole:Any city or crmnry SIGNS ELECTRICAL ❑OTHER
til lL which requires a permit to construct.alter,improve,demolish,or repair any stmcture
prior to its issuance,also requires the applicant for such prnot to rile a signed statement SPECIAL CIRCUIT/MISC. +
y Mat he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9 _
�X (commencing with Sectio.70(amof Division3rfthe Balis vw and Profession,Coup)or
TEMP.MET IiR OR PoLB,NST, COMMERCIAL:
that he is exempt therefrom and the basis I'or Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
w
Section TOL5 by any applicant fora permitsulrecurhe applicant toes civil penalty of POWER DEVICES
t mere than five hundred dollars(SSW).
[]TENANT ❑FOODSERVICE,
F'Z'<
IMPROVEMENT
111,as owner ofthe property,or my employees with wages as their sole csanponsation, SWIMMING POOL ELECTRIC _
y� O will Jo the work,and the structure is not intended m offered forselr(See.9144,Business El OTHER
aand Professions Code:The Contractors License Law]nes an apply to an owner of OUTLIGS—SWITCHES—FIXTURES
.. prnpeny who build,or improves thereon,and who does such work himself although
his own employees,provided Nat such improvements are not intended or normal for NEW RF_SIDIi IAL ELECFR SQ EL
sale.If,however the building or improvement is sold within one year ofcompletion,the SQ.EL FLOOR EA $/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for pur-
poo ol'xaleJ' 'TOTAL:
❑1,as owner of the property,am exclusively contracting with licensed contractors to -
perswet the project(Sec.7IW4,Business end Professions Code:)The Central Li- (�
Li-
cerise Law does not apply to on owner of pmprny who builds or improves moment,and QTY, PLUMBING PERMIT FEE v .4 s p�
whrcontoeu for such projects with a communist ist licensed pueuanno Ne Contractor's WY
License Low. PERMIT ISSUANCE OCw
❑lam axe pt oder Sec ,B&P C for
caner this reason e`
Date ALTER—DRAIN&VENT—WATER LEA)
1 VILL
µTORER:S CO ENSATION DECLARATION BACK FLAW PROTECT,DEVICE
'1 by
aMrm under,pepultylifpe,j.,..c of the fallowing declaaa0ons: Thr I`
•�I have and will maintain a Certificate of Consent to self-inure for Wmkcrs Ciampi DRAINS—FLOOR,ROOF,AREA,COND, STORIESYI'ECONS'I'RUCTTON
salon,as provided for by Section 37OU of the Labor Code,for the pan m endow all the
work for which this penal to issued. FIXTURES—PER TRAP
❑ I have.ad will maintain Workers Compensation Insurance,as rcqulred by Section
37W of the LuMVCode.for the performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC GROUP N
My Workers Compensation Insurance carrier and Policy number arc:
Comer: Policy No.: GAS—EA.SYSTEM-OVER 4 WA)
CERTIFICATE OF EXEMI'l'ION FROM WORKERS'
COMPENSATION INSURANCE GREASElINDUSTRL WASTE INTERCEPTOR
or tem.)
KCtin.need nal be confined!molar pemdt is fonmGREASE TRAP
r hundred done. BUILDING DIVISIO VEES
'
PLANCH[CK FEE
Iay that in theper(nrmanceolmewmkfor which this permit is issuedlshell SP.WER—SANITARY—STOIIM EA.200 FI'.
'not employlly any person many manner so as a+hccotne subject m the Workei en-CmnppNHItQY PRP.
0 �.. satinn Laws of California True .WATER H13ATER W/VENT/ELECTR
Z Applicant GRADING FEE
NOTICE TO APPLICANT.If,atter making this Cenificom of F.xcmptinn,you should WATER SYSTEM/IREATING
F' become subject to the Worker's Compensation provision of the Labor Code,you most SOILS FEE
forthwith comply withsuch provisions or thus pemtit shall he deemed revoked, WATER SP.ItVICG
0
CONSTRUCTION LENDING AGE
NCY NEW RESIDL'NTIAL PUNCH. SQ.Er. PAID
U 0 l hereby affirm that there is a construction lending agency for the performance of Date Receiptp
1L E" the work for which this .it is issued(Sec.3097.Cie C.)
0 U Lenders Name TOTAL:
Lenders Address - TOTAL:
a1 certify that 1 have laud this application and Stam that the above infarmution is BUILDING FEE Ir lj�
V) comet.I agree to comply with all city and county ordinances and and,laws renting to QTY. MECHANICAL PERMIT FEE
U Z building innswction,and hereby authorial representatives of this city to enter upon me SEISMICF-EE
above-mentioned progeny for inspection purposes. I PERMIT ISSUANCE
(We)agree to save,indemnify and keep beardless the City of Cupertino against ELECTRIC FEE
Iiahilities,judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECI I.
in asequence of the granting mf this pentut. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO lg(go CFM) MECHANICAL FEE
SOURCE REGULATIONS. �^
\ AIR HANDLING UNIT(OVER Io."CFM, CONSTRUCTION TAX
Sign um ol'Applieo Cmmacmr I Date EXHAUSTHOLD(WIDUC'1) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building mcupantsmre or handle huzudnus melerial HEATING UNIT CTO 100.000 BTU)
as defiaed io the Cupertino Municipal Cale,Chapter 9.12,end the Health eaI Safety
Units,Section 25532(a)? HEATING UNIT(OVER ITA,lX10 BTU)
❑Yes El No VRNTII.AI'ION FAN(SINGLE RE.SID) PAID
Date Reccipt N
Will the applicant in fins aure building cytogam use ea Air Qu or Marta which BOILER—COMP(3HP OR 100.000 BTU)
emit District?
a air contaminants as define)by the Bay Arca Air Quality Management
Distrin? TOTAL:
❑Yee [I No BOILER—COMP(OVER IM."'BTU)
Ill,a read the humnlous materials requirements under Chapter 69.1 the Cali- AIR CONDITIONER ISSUANCE DATE
from.Health&Star,Colic,Stations 8505,25533 and 25534.1 understand that if me NEW RESIDENTIAL MECH. SQ,FT.
building does not current,have.tenant,than it is my responsibility mistily thi e<mpant
of me requ pernam s which most be met prior In issuance M.Certificate of Opal ams,
Owneromwhorimd agent - Dam LCSI1H)BY
:
OFFICE
;�,8l98
E.,J.,HA _
Civil Engineer
1211 Park Avenue #212
SAN JOSE, CALIFORNIA 95126 LETTER
(408) 279.2954 Date `/Q1�. /. 1 9�.
To . ,wi.GDini C. . .. Q. Fi</ L..... .. ... subject `T2.,.. / 9.8', .. .Lor. 3 .7
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' SIGNED
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