29403 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 29403_
] /I4 O
BUILDING PROJECT IDENTIFICATION J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
Z �f�fld C„eorJ/ �2 . C
OWNER'S NAME:. PHONE: [ ZRACTORS NAME: LIC NO, I V
APGf1 �uc>wi L55-XV67 f}diU.�.B/SSG-CL 556265 NIC C(BROL«
ARCHHECI'IENGINEER: LIC NO: ADDRESS: ❑
1019(7 Z_1AJC0c J Aur
/ CO.NTACC PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
'� X • ❑
LICENSED CONTRd..do,S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby h.fD and 1 am licensed neer ndPmean.of chapter 9(commenting JOB DESCRIPTION
HOZ with Sarre and
eQlivsinn3 drthe Baines>and Profcssmna code.ane myhartxe is RESIDENTIAL'
H1_ in full force vnJ eRecl. PERMIT ISSUANCE
F�F U() License Class Lic.M- 55!>2.65 [DSF[]ADDITION
]'CHENREMODEI,
tn6a Date Commctor APPLIANCES-RESIUEM'IAL ❑ADDITION ❑PLUMBING RE-PIPE
I,-p to ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p�Z I understand my plans shall he used as public records MODIFICATION
OZ—a UP TO 200 AMPS El INTERIOR C1 CHIMNEY REPAIR
F�2 F'.41 Licensed Prnfcy.innal 201-I000AMPS IMPROVEMENT
4OWNER-BUILDER DECLARATION
G C)W Q 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER IIXO AMPS El BATH REMODEIJREPAIR DEMOLITION
x3aF following....(Section 70315,Baas inand Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W LL Oro which requires a permit m cnnW
zd,alts,imp rmc,demolish,m repair any arrc
uca
miorin
mitsarme,nlcn requires the vpplicum far such prtmm
il to pica SPECIALCIRCUIT/MISC.
C� that he is licensed pux.ma,ome pnwiac.,cf the Comracmof,License law(Chapter9
x_00me
(comncing wim Section]000)of Nomad Sof the Businessend Profession,Care)or TEMP.METER OR POLE INST \ COMMERCIAL'
a L cK that he is exempt mercfrom and the basis for the alleged exemption.Any violation of
^,N
Section?031.5 by any applicant far a permit subjects the spplicanno a civil pe mill,of POWER DEVICES \\ ❑TENANT G/ADDITION ❑DEMOLITION
^Z6 t more than five hundred dollars($50(d. ❑TEANT ❑FOODSERVICE
D 1,us owner of the pnspmny.or my cntpinyecs with wxgen us Heir sole cnntpvnmdion. SWIMMING POOL ELECTRIC IMPROVEMENT
will Jo the work,and the structure is not intended or offered for sale(Sec.]ni4,Business \\ r ❑OTHER
W 3 m and Pmkss,was Cade:The Contractor's License law does not apply to an owner of /o OUTLETS-SWITCHES-FIXTURES
proprny who builds or improves former,and who deaes such work himself or through
his own employers,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SOFT. \ � n a e+
sale.If.however,the building or improvemncm is sold within one year of contpledogthe � , SQ.FT.FLOOR AREA $/SQ.ET.
r.haIder wi 11 have the hLai of pmvi its that he did ran build or improve for par- 'AI
r,�
,so ofxalc.) I(!�H 13 19
1,a..owner of the progeny,am exclusively contracting with hcensW contractors to I L 96
conshum the project(Sec.LH4.Business ant Professions Code:)The Condamine,U-
c se law does not apply to anowner(if propenywho builds orimproves thercon.and QTY. PLUMBING PERMIT FE Coy Ur Law.
who amacw fm loch Peoaks with a emttrmur(s)licensed pursuant le the Conrtunm'n
License Law, PERMIT ISSUANCE
❑1 s m exempt under Sm. ,B&P C for Ihis reason
Owner Dade
ALTER-DRAIN&VENT-WATER(EA)
VALUATION
� WORKER'S COMPENSATION DECLARATIONlowing BACK FLOW PROTECT.DEVICE
r have
and yaffrzm under Certificate
of perof
yent o[the fnsureior-Werkee.i Co
El Ihave andwill for byneion37 of the Labor
ulft.for the Workersce of th- DRAINS-FLOOR.ROOF AREA.COND. STORIES �•W TYPE CONSTRUCTION
sande,as provided for by is isun 3]W of the labor CWe,for the Performance of the
work for which mil permit is iaorW. FIXTURES-PER TRAP
I have and will myotome Workers Compensation Insurance,as requited by Section
3]BB of the Labor Cale.fine mhe;rancenance o(IM work for witch thin permit is issued. GAS-HA.SYSTEM-1 INC,40UTLETS OCC GROUP ANN
My Worke' t f r laaance carrier and Policy mmt
Carrier: aN Policy No.: 0fto 2S 45 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFlCATE FL%EMPfION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE.INTERCEPTOR
(Ihis section need not be completed Ban,permit is feature hundred dollars($MIDI BUILDING DIVISION PERS
or less.) GREASE]RAP
1 cenify In.(in the performance of the work far which thispermit is mated.I shall PLANCHECK FEE
not employ any person in any manner so as do become subject do the Wolases Compcn- SEWER-SANITARY-STORM EA.2(O FT.
Z salon Laws of California.Dam ENERGY FEE
Z O Applicant WATER HEATER WIVENT(ELEC R
GRADING FEE
y
NOTICE conics subject
APPLICANT:If,atone making this Gismos of
Labor Cca,you should WATER SYSTEM/fRF.Aq'INC
a heawith comp a me Worker's Compe..this provisions of the Labor Cute,you must SOILS FEE
forthwith comply wim such provision nr this permit shell be JeemM revoked. WATER SERVICE
C1.
U Z CONSTRUCTION LENDING AGENCY =ADDTO
. SQ.FT. PAID
UO Iherchyamrmiha them i.aconsvection lending agencyfonbe performance of Date Be -iptp
IL t•m the work for which Ihix permit is isucd(Sm.9(19],Civ.C.)
I••� Lender's Name
Lenders Address L TOTAL:
y I crnify mat 1 have teal Nis application and stme that the above information is ^ `a
(•- N Oaarcl.I aBrec dd comply wish ell city and county ordinances and sate Iowa retain Io BUILDING FF, (—
U rZ buildingvection,and hereby B QTY. PERMIT FEE
eons yaumon purposes. of this city to enter me SEISMIC FF.
above-(Wei agrensede
to saveerly for Inspection locepha
(We)agree ro save,indemnify and kap harmless the City of Cupertino against ELECTRI
liabilities.judgments,costs and expenses which may in anyway areae against said City .
in consequence of me granting of this permit. PLDMBL' F
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO IO,OOp CFM)
Lk
SOURC81y?p ULATI // MECHANICAL Pili
311519 L AIR HANDLING UNIT(OVER Igtpp CFM) CONSTRUCTI( TAX
Signature of ApphcantlContacdor Dac EXHAUST HOOD(W/DUCT)
HA]ARDOUS MATERIALS DISCLOSURE HOUSING Mf IGATION FTLE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 101.00 BTU)
as defined by the Cdpenino Municipal Code,Chapter 9.12.and the Death mW Safety
Code.Section 25532(u)'I HEATING UNIT(OVER 100.00)BTU) '
Yea
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Receipt p
emit hazadom air incantational.as defined by the Boy Amu Air Quality Manaseinent BOILER-COMP AHP OR I00,0BI BTU)
DINntl?❑Ya EKBOILER-[DMP(QVER 100.000BTU) 'JO AL:
I have re.Mdile hauNous materials rcquiament.nndcr Chapter 6.95 of the Cali- AIR CONDITIONER
forma Health&Safety Cede,Saunas 8505,25533 and 25534.1 understand that if the ISSUAN
!building does not currcmly have.lennnd,thxl it is my responsibility to nudity mewcupanl NEWRESIDF.NTIALMECH. SQ.FI'.
of the reyyi��yrmems m m I!w�ttet prior to i.suance of a Cenihcamnf Oy!Lpany�
!/ Ll n/3f.-.KP ^/3/94 �/•���/�/^J)�//�
Owner or authonxq ager Dm TOTAL: ISSUED BY. Vim ■
OFFICE