29857 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICA11ON 29857
BUILDING ADDRESS: SANI'T'ARY NO. APPLICATION SUBMITTAL DAT1
I I
0'7 a SHn1TA U, n crj=tQ.f
OWNE 'S NAME: PHONE: COMIHACfOR'S NAME: LIC NO:
R�1c (I.USTU�/O S - b'� SAc Scu.InllnlC S 323S�o$ "/c cory'raol.x
xRCHI'1'ECTIEN NEER: LIC NO: ADDRESS: `` II
qq w0` S aQDU(f
CONTACT. PHONE: - BUILDING PERMIT INFO
's-QNnI 1 r�1[s$ a S1.s- Z Co--WD nt Fees Paid by Applicant(Initial) _ HIAG ELECT PLUMB MECH Ac� T
Len thad ID CONTRACTOR
order S DECLARATION QTY FLECTRIC PBRMIT FEE
thereby d.f mat Iamuae Bmendarprovisinnaofchapmr9 onmmense is JOB DESCRIPTION
�OZ withll firen7(X0)ofDivisionJofthe Business and ProfessinnsCMe,and mylicense is RESIDENTIAL:
W ince.,force and L PERMIT ISSUANCE
WW , Gens%F9 x 3�5"g OS ❑SFDWI. EI KITCHEN REMODEL
r'1 Date Comramr--� APPLIANCES-ItESIDENT1Al. y�d��y(���I]DITION [I PLUMBING RE-PIPE,
ARCHITECTS DECLARATION � W IdULTIANIT ❑STRUCTURAL
N
PANELS r-Z IanJers,attd my plans shall he used as public records MODIFICATION
OZ- UYq'0200 AMPS
PW License)ProfessinwlC1INTERIOR El CHIMNEY REPAIR
fq� ]aj
OWNER-HUILDIiµDECLARATION 201-I(KKIAMPS IMPROVEMENT
1 hereby affirm that 1 am exempt front the Contractor's License Law for the OVER 1000 AMPS -1 BATH REMODEIIRLPAIR DL'MOLITION
3 a H following reason.(Section 7031.5.Business and Pmfessinns Care:Any city or county SIGNS ELECTRICAL ❑OTHER
a which requires a permit to construct,alter,improve,demolish,or made any suucmm
,F]sa-Osn
prior to its issuance,alm re,mactheapplicant broach permit to fileasigneJstmernm SPECIAL CIRCUIT/MIS
P G`s met he is licensed pursuant n)the provisions rime Contractor's License Law(Chapter 9
(communing with Secdnn]1X0)0(Divisinn9nf the Raciness nnA Pndessinns Cndc.or TEMP.MET BE OR POLE I COMMERCIAL
6i qo C that he is exempt therefrom and he basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4• Section 7031.5 by any applicant far a permit subjst5 me applicant to a civil penalty of POWER DEVICES
-tn TENANT FOOD SERVICE
net more man five hundred dollars(E500).
t^Q I,As owner oftheproperty.orm toees with woes as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
❑ YestP ) 6 Ps
�Sy will do the work,and the structure is not intended or offered hustle(Sec.]BW,Business OTHF
a m and Pinfexsimis Code.The Coamcmrs Lot,n.e Law docs not apply to an owner of OUTLETS-SWITCHES-FI X'TURES vs
^ property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvement am not intended or offered for NEW REMDENT1AL ELEC R SQ PT,
sale.IThowever.me hailiingurimpmvemcntissoldwithin meyca .fcmn,latio.,the SQ.IT.FLOOR AREA EISQ.FT,
macer-builder will have the burden of proving that he did not build or improve for per- Q _
pose of coley S
❑1,u owner of the(See:property,,B excess and contracting with license,]Ccontrnerx m
-'vsnsirun the project(Sec:]1004,Business nnJ 14nfeasinns GNcU The Contractor's Li-
ceaso Law docs not apply to an owner of property who builds or improves thereon.and QTY, PLUMBING 11I7RMIT FEE
who contracts for such projects with a commands)licensed pursuanne the Commemes
License Law.
pERM1T ISSUANCE'
E]I am exempt under See. ,B&P C for this reason
Owner Uma
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'SCOMPENSATIONDECLARATION BACK FLOW PROTECT.DEVICE /^F�1 -.1 ' —
Ihereby affirmunder Penalty ofperjury one of the following decimations: Vl7 (/
❑I have and will maintain a Certificate of Consent to self-insure,for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYI'Ii CONSTRUCTION
salon,as provided for by Scramm 37W of the Labor Cole,for the performance of,he,
work for which this Penni,is issued IgXTURES-PI7R'TRAP
I have and will maintain Worker's Cnmpcvation Insurance,us rea uimd by Section
] of the LMmCode.far the pcifor ance ofthe work for which this permit is issued. GAS-EA.SYS1EM-IINC.4OUTLETS OCC.GROUP APN
My Workers Comyycc tit? lnsuma artier and Poli<ya mhc,
Carrier, hull OeC Policy No.: gS-�J�Z` GAS-EA.SYSTEM-OVER 4IG)
CERTIFICATE 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANC17 - OREASEJINDUS'I'RL WASTE INTERCEPTOR ❑UILI]I IV IGNITERS
(His section need not he completed i f the perm is for one hundred dollars(E100) GREASETRAP
or less) P NCHECKFEB O
loyany that in,he Performaany
of the becomork e subject
perthe W rkes'Camper-d.I shall SEWER-SANITARY-SgtIRM EA.200 FT.
not employ any person in any manner w as m become subject m the Workers'Camper- E ERGY PEE • rI't'
Zcation Lawn of California.Dem ��1J
Applicant WATER IIIiA'TIiR WNEN'T/IiLECI'R µADING P
f%l NOTICE'TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTFMiTREATING '
a F" beemne suhject to me Worker's Compensation provisions of the Lehr CMc,you mus, SOILS FEE
forthwith comply withsuch Provisions or this pannit,mili Be deemed revoked. WATER SERVICE
Q
UO CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ,I'T. PA
Ihomhy uff1muhat there is a cnnmmc,ion lending agency far the perlbnnance of Dme R iptx
W H the work for which this permit is issued(Sec.3097,Civ.C.)
0Lenders Name TOTAL:
IU Leaders Address
L1r 1 certify that 1 have read this application and smm that me above information is BUILDING FEE
fn comer.l agree to comply wlm all city and county oiinances and state laws relating to QTY MECHANICAL PERMIT FEE
V ' building comrouraon,and bcrchy authorize mpre.enmtives nfthls egn.enantpsm the SEISMIC PER Cth
above mentioned property for inspection prpams. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iia lities,judgme ,cOsu and asPenses which may inany wayaecru,ii,mrstsuid City ALTER OR ALM TO MECH. �^
in sequencer ,egranting ofmis permit, PLUMBING FEE
AI .ICANq'U 1 ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IIANDIANO UNIT(TO 111,01X1 CFM) '
L TIONS. MECHANICAL FEE
Z- / AIR HANDLING UNIT(ovE'R PUxxjcF.M) CONSTRUCTIONTAX
Si mre f mUS MATIiR1ALS DISCLOSUREonVCs Time EXHAUST HOOD(WMUCT) HOUSING MITIGATION PEP.
Will to pplicnm nr Euum buildln6 nccupamemrcorlic dle hocol material IIHATING ON[f(TO 100,01X1 RTII)
os defneJ a Caperton Municipal Code,,Chapter 9.12,and the Health and Solely
Code, ❑Y
Salo es 155721¢)? HEATING UNIT(OVER 11X1100 BTI.)
•a ♦ - I t
�Nn VENTILATIONI'AN(SINGLERESUn PAID
Data Receipt#
Will the app.ican, io future building occupant use ea Air Qu or devices which BOILER-COMP 13HP OR 100,01X1 BTU)
ani,hanrtJuus air amwminnn,e as refined by the Buy Arca Air Quality Management UN Q 7 19H
District? fx����tx��nnnnnn BOILER-COMPIOVER IW,(XO BTU) sl /J 1 1.7 AI'
❑Yes KN.
Ihave mal dm hateardous``maerials requirements under Chapter 6.95 of the Cali- : AIR CONDITIONER �)II I l!1 ISSUANCE DATF,
fomia Health&Safety Coal.Sections 255115,25537 and 25534,1 understand that if the NEW RESIDENTIAL MECII. SQ.FI'.
building does not currently have u tenant,that i,is my responsibility to notify the o ccupam
of the mqui en i which must M met .or to issuance of a CeniRcme of Occupancy.
Over r or authorized agent Data TO'A '1 ISSUED BY:
OFFICE