29604 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO. 29604
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: LiN ADSANITARYNO. APPLICATION SUBMITTAL DATE
S. Sr
OWNEo R'S AM : PHONE: CO R ORS LIC NO'. 0lk
.
U&_KCL^6L_ U 6 / NIC C ROLN
\RCHITECT/ENGINEER: ,-LIC NO: ADD BSS: / V ❑
i d 0��Pk�a� S.�i,
CONTACT: PUONE: BUILDING PERMITINFO
❑ Consultant Faces Paid byApplicanl(Initial) BLDG ELECT P MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELIiCTRIC PERMIT FEC
I hereby affirm that l am licermil ti der provision.of Chapter 9 feint cnalnB JOB DrSCRIPliON
�0Z wbh Bectinn]11fXll of Division3of the lluslness and l'rnfessions Cale,rend myliwnsc ie RESIDENTIAL:
F U[O[ ;"fail force and effect. CS '3 O S O/ I'IiRMI'f ISSUANCI3 ❑SFDWL ❑K CHFiN REMODEL
�U[' License Cl s Lic.M APPLIANCES-RPSIDENTIAI.
Date Comracmr ❑ADDITION UM NO RE-PIPE
Z004 1 understand my plARCHITECTS DECLARATION PANELS ❑MULTI-UNIT TRUCTURAL
ans,hull b,useelus public recntds MODIFICATION
OZ O UP In 200 AMPS ❑INTERIOR , ❑CHIMN17Y REPAIR
Licensed Profcsniotil 2111-INGAMPS IMPROVEMENT
q bd •�.l that I. exam t from
m Ce ContrRATactors
ON OVER I1ryp AMPS ❑BATH REMODEL,REPAIR 0 DEMOLITION
W 0.' I hereby affirm that 1 am exempt firm the Csslons or's License t,o for the
O IL LU. wh1owingreua.Permit to comfort,
t,she sscod Pmfdairal Coda:Any city or county SIGNS ELECTRICAL ❑OTHER
LL O yj which requires n Permit to c res the alien impmve,demolish,or repair any rwnure
'hat heor itsissuance,
rolso nt1.the thovisio ant for softhesuchpermr a Lice se LawJemtemem SPECIAL CIRCUIT/MISC.
N thmhrveri ,o,I pursuant mthepmvisi0naof Ne Contractor License LawChapter C,idc) 9
CO (commeneingwith Sereimn]DXp of hmi,on30f tM1aeged aiseimd Prolbsxlonn Cnde)or 'TEMP.METER OR POLE INST. COMMERCIAL:
d�xy e e thathe is exempt therefrom and the husie far the allege)exemption.Any vinl,Jon of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^ not mom
than by hundred
liana hxa permit subjects the npplicam m a civil penalty of POWER DEVICES
y ❑TENANT ❑FOOD SERVICE
STDt more than rive hundred dollars($Sfp).
Oioso,work.thepe oductonnyemploy«swiNwred for theiwhe(Sec.c0mpensmion," SWIMMING POOL ELECTRIC IMPROVEMENT
will dote worn and the awcmre..tori Lica
aLow due, ota,ec.]Wn,Boniness ❑OTHER
and PnyPosho Codr.The eves diction,
License Law dna not apply s an owner of Olfl'LETS-SWITCItIIS-FIXTIIRF_S
�' .. progeny who builds or improves thereon,tna who)nes such tintk intended(it
ar thnngh
his own employees,provided that.proM1 improvements thin not iyeaofd or all"emd for NEW RESIDENTIAL EI-IICTR SQ Ff.
.wheLmilds,however,[havelding orhe bur improvement ithat sold hewithin one yemoRomplefor ithe SQ.FT.FLOOR AREA S/SQ.ET.
owner-builder will have Ne burden of proving that he did not build or improve for pins
pose of sale.). TOTAL
❑ 1,as owner of the pee 70,1 am exclusively contracting Cite licensed contractors m ��� O
cone La the pmjeat(Sec.o an Banin,.w and rty a)t mi Code:3 The Conuamor's 1996
censeroo resistor,hriapply tomm with
of,procr(s whr.,dil or improves IscraC,mlm,and QTY. PLUMBING PERMIT PEP, Is7
who commas fnreuch Projects with u cnnwctor(s)Ilannal purauam to the Cnnvucmr§
License law. PERMIT ISSUANCEsI� laUt"r
1 am exempt under Sec. ,B&P C fo this reason 11ItU
Owner
ALTER-DRAIN&VENT-WATER(RA) VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby of fon under penalty of perjury one of the following declarations:
❑ Ihave anJwillmainminaCenificnmufConsennoselGinsure for Worker'nConipen- DRAINS-FLOOR,ROOF,AREA.COND. 'STORIES TYPE C(INS'TRUCTION
ration,as provided for by Section 3](10 or the labor Code,for the performance of the
work for which this pertit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as"itif W by Section
37M of the Latin Code.for the petfmmance of the work far whichthis permit is issued. GAS-F.A.SYSTEM.I INC.4 OUTLETS OCC.GROUP AI'N
My Worker' mpenyy In ane,artier and Policy numher aro:
Carrier I(( Policy Na:6 x 54/ f_O{� GAS-EA.SYSTEM OVER 4(EA)
IIRI'IFICATE 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRI,WASTE INTERCEPTOR
(This section need nm be completed ifthe permit is forone hundred dollars(SILO) - BUILDING DIVISION FEL%
or less.) GREASE TRAP PLANCHECK FEE
I certify that in performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 p..
not employ any persno ie any manner m as to becomn
e iihjeco rhe Worker'Carmen- ENERGY FEE
OZ sadist Laws mf ' WATER GRATER W/VIIN'I'/ELECTR
O Applicant / GRADING FEE
NOTICE TO APPLICANT.If,atidmaking this Certilleme of Exemption,you should WATER SYSTEbh,T RRxTING
a ; became subject to the Worker's Compensation previsions of the Labor Gyle,you must SOILS FIIE
{L) forthwith comply with such previsions or this pchmil shall he deemed revmkeJ. WATER SERVICE
Q
UO CONSTRUCTION LENDING AGENCY NEW RESIUEN'I'IAL1'1X0. SQ.Ft.' PAID
.l hereby affirm that is t construction lending agency for the pefornianceof Dale RcceiptN
w (~•t the work for which this permit is issued(Sec.3097,Civ.C.) -
Q U Lcndelr Name TOTAL:
D.1Lender's Amin,,
y I acidly that I have read this application and state that the above information is BUILDING FEE
V) contact.l agree as comply with all city and county ordinances and state laws uluting to QTg MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-metnioned pmpemy,for inspection purpuras.
PERMIT ISSUANCE ELECTRIC FEB
(We)agfw us.wave,mdlIondy and keep handles,les,the Clry of Cap,aino against
Iiebilities,juJgments,cnns andexpenseswhich may m itnywiyacereagai s,,mm City ALTER OR ADO TO MECH.
in asequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TA
Signature M ApplicunVContracmr Duro EXHAUST HOOD(W/DUCT) HOUSING MITIGATIO PER
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building rccupam score or handle loomloun material HEATING UNIT(TO 100,00013TU)
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code,Section 25532(0)7 HEATING UNIT(OVER 100.000 BTU)
❑Yes ON. VENTILATION PAN(SINGLE RESEW PAID
Date R,—sip—I.—
emit
Will the applicant of bussu huddling cerby the n ash cv,Area
Air ant 0r Matas which BOILER-COMP OHP OR 100,01X1 BTM
emit hazardous air contaminants as JclineJ by the Nay Arca Air Quality Management TAL:
District?
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
�
I have reel the hazallous materials AIR CONDITIONER
r5,a 53 errs under Chapter rasa of the Call- ISSUA-CE DATE
Toric Health&Safety Cade,Seddon,25505,255JJ and 255)4.1 undersmnJ that If the NEW RESIDENTIAL.MECH. SQ.E T'.
most gamsnotcMm'y hdv9a ten ant,thm it ismy respmsi,mficam gfymmsvvpwn
n t nems wh' must M:mm prior m issuance of n Cenilicae Onn m
Owner or amhnriud ager )ate TOTAL: s
SSUED BY:
OFFICE