29859 APRLICANTTO FILL IN INFORMATION WITHIN RED LINES-'USE BALL,POINT PEN ONLY' J.
CITY OF.CUPERTINO BUILDING ELECTRICAL. - - PERMIT NO.�
BUILDING DIVISION APPLICATION/PERMIT . PLUMBING.MECHANICAL. 29859
BUILDING PROJECT IDENTIFICATIONBUIIAI]NO ADDRESS: SANITARY NO: APPLICATION SUBMITTAL DA'I,I
"V ✓ L/V riF ., l r /r/ -1('" mac/y
OWNS ,.w/� PHONE: ✓V C 'T'RACTOR'S s�MsliE LIC NO rr ��
fr1S��^ l N.^ � INC. N/C * CON9'ROLM
�A tIR ENGINEER (Nl• LICNO. ADDRESS: �///��'I] V OS -
CONTACT: "PHONE: t. BIIILDINGPERMITINFO
�Or L p I,� 75-1,5-1516
� ❑ Consultant Fees Paid by Applicant(Initial) BLDG i1.ECf. PLUMu M�CH
V F�i�G. Llt l A
LICENSED CONTRAC'IYIR'S DECLARATION " QTY. ELECTRIC PERMIT 'FEE
I hereby anion that 1 am licensed under previsions of Chapter 9(commencing ,- - JOB DESCRIPTION
QaZ with S«tion OIXgpd Divisinn3of the Basions and Professions Cole,and mylicensc is RESIDENTIAL:
I W—r- in fullforeeandefffet. PERMIT ISSUANCE
WF ❑SFDWL- ❑KITCHEN REMODEL
NZd Dou License Connecter Class Lic.N
ti Q APPLIANCES-RESIUIiNT1AL []ADDITION ❑PLUMBING RE-PIPE
m .
ARCHITECT'S DECLARATION ❑MULTLUNIT 0STRUM URAL
E.,"JN PANELS' � '
Z O �y - I unJerswnd my plana>hall M uses)uv public recomn - CHIMNEY
CATION
O Z�+ - -0I"In 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
hi,C� Licensed Professional 201-1"AMPS IMPROVEMENT
OWNER BUILDER DECLARATION OVER 1000AMPSl ❑RA C REMODE'1/REPAIR El DEMOLITION Q I hereby firm that l pt t the Commences t L La f the
k 3 4 V
following most(Section 7031 5 Business nJ Pr fees Cole Any sit, r county SIGNS ELECTRICAL ER
ul which y pe,.if in w t h p d 1 h p ,notions,
�� poort 't ' I. y thapple tl hpe if fl g J hm est SPECIAL CIRCUI"1'7MISC" t
e4 thot he is I dp t to 11 p r le,c i t I (Chriev,9
00y (.on encnb with Scu' 700()ofD 3 of d Business IP f: Cde)or TMETER ETER OR POLE INST. COMMERCIAL r "
d e LL that he is exempt Iheref nm and the basis for the alleged exe punto Any violation of - ❑ W BLDG/ADDITION ❑DEMOLITION
It Section 0031.5 by any applicant for a permit subjects the applicant a civil penalty of. POWER DEVICES�m NANTROV El FOOD SERVICE
F Z} ern mote than fiscoft hundred grope ty,or y employees
- IMPROVEMENT
SG dast.thc work,
the property,or isnotmnydednitwages eseleirsole compensation, SWIMMING POOL ELECTRIC
will do the work,and the vnnure is not intended er offered s no,a(Sec.7(H4.Business OTHER
3 and Professions nds... mp Cenlracmrs License Luo does not apply m a.owner of IITLE I'S-SWITCHES-FIXTURES
�' .. his
Korea,who hulls,or impmveat inch,,and who fines redo conte himself or Enough ,
his own employees,'provided' thl inch c t, I' I 11offeredf NEW RESIDF.NI'[AL LLhCIR; ' 'SQ IT.' "t '
Tunic.if,lowever,do,bdlmahgm,improvement is sold withir7ore yeer of completion,the' SQ;FL FLOORAREA VSQ.FT
con l ld will have me burden fp gthat hdid u.' b IJ p ve f0 p
pose f 1 ) ... "C V� i,
coneror lbe propety,am exclusively enmramdng with licensed ciaihaenm in L^, I
coal as the project(Sec.II44,Business And Rofessinna Cole,The Ctalmelnr6 m
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE MAY � O (]nc -
who emnmeu for such projects wl0 a of n morl:q,)licensed puwuanuo the Contractor's �I
License Law. - !' PERMIT ISSUANCE I
of.. empt ' rSce. B.S rcwinis .son - ("1'ie
ve Dae ALTER-DRAIN Jt VENT-WATER(EA) ' yr UUVA_LUATIONI -
13 0
ORKF.R'SCOMPEFL
NSATIONDECLARATION HACK OW PROTECT.DEVICE
1 teby ef0rm under penally of perjury one of the following declarations:: a
�❑Ihave and will maintain a Cenificate ofConxtn to self-insure for Worker's Crunch. DRAINS-FLOOR,ROOF AREA,COND. STORIES , TYPECONSTRUCION
00
nation,as provided for by Section 37of the Labor Code,for the performance of the
warkfurwhich Niepemolisicwed. VIXTURHS-PER'IRAP "
❑I have and will n onson Warker'n C...are sudnn Insumnce,us reyui fd liy Section - - -
37WoflheLabor Cods,for Nerfoimanceol the workforwhichd6, nilieisoeci. GAS-EA.SYSTEM.I INC. 0UTLET
pe pen OCC.GROUP APN
My Workers Compensation Insurance carrier Policy number arc:
Currier. Policy No.: GAS-EA.SYSTEM OVER J(
CERTIFICATE OF EXEMIMON FROM WORKERS' -
COMPENSATION INSURANCE. GRF.ASEIINDUSTRL W INTERCEPTOR B� ,G (VISION FlEES
- ini tion need not he eomplendifth permit is game hundred)dollars GRHASE TRAP
orlc )- PLANCHECKF
.1 of lythe n pH n ofd kf whichni.p ,i4s,wd,(,hall
' not em an SEWER-SA 1'ARY-S'I"ORMEA.2(mplI
employ Y person t in y manner m as t Ixx sme,ubjceu II Workers s Coo pen IiNHRGY PH
OZ marls fChfiioimDom - WATER ATER W/VENT/ELECTR
Z O Applicant GRADING 1'E
y NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATE SYS9EMTREATING
a ^ hncomc subject to he Workers Campenmtion provisions of the Labor Crde,you must SOILS FEE -
� [ forthwith comply withsuch previsions or permit shall be demoted revoked. R SERVICE
Q
•I CONSTRUCT ION LINDING AGENCY' +WRESIDEMDA1,1'LMB. ,SQ IT. PAID
Ihercl nlhttherc ac .'ami nlnding agency for t le.l'orn0 Dna ReeaipiN
P the work for which this permnis issued(Sc :30)7.Civ.C,)
fL Lender's Name t' - TOTAL:
O L) Lemder,Addmss ' - TOTAL: )
I cmify that 1 have read this application and state that the AMwe infnmtation is BUILDING FE.
L14 tomer,1 agree 10 comply with allcity and county ordinances and van lows relating ,, QTY. MECHANICAL PERMIT FEE
V 7 form
construction,and hereby authorize representatives of this eitym enter upon the SEISMIC FF.F
above-mentioned property for inspection purposes. I
PORMIq'ISSIIANCEr VE
(We)agree ,,save,indemnify and keep toneless the City of Cupeni no ugainet ELEcfRic F E
liahilitice,judgmenia,noesis end expenses which may In eny cony a«ruc xgninsLwid Cily� LEER OR ADU TO MITCH, �^
t in consequence of the gaming of this person. PLUMBING EE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO IQ000 CPM)-
A
' SOURCE REGULATIONS. MECHANICITE
AIR HANDLING UNIT(OVER 10,000 CFM} CONSTRUC710N TA X' -
.. Signamreof ApplicanEContmcmrDale EXHAUST HOOD(W/DUC)
HAZARDOUS MATIBEJAIS DISCLOSURE. ( t 11 I IOUSINGMI'TIGATIONFEE
Wili Nenpplionm or future thudding ncamtmt store or handle 1pvamous material HEATING UNIT pl0 100,INp B'TU)
as defined by the Capetian Municipal Cole,Chapter 9.12,and the Hcahh and Safety
CoSection 25532(.)!' . , [EPA TING UNIT(OVER 100,000 BTU) „
C]Yes []Na - - t..
VEN'T'ILATION FAN(SINGLE BESIDE PAID
Date ReeeiplM
Will the airy morfurore building Pcedpart heBuse eywir Qu mdevices
nnewhich BOILER-COMP(311P OR[(In"H'I'HE
)tit hazardous air onnummams as defined by the Bay Area A' Quality Management TOTAL:
Heiden? BOILER-COMP(OVIIR Bdjk DBTU)
❑Yes [-]No • 5
Ihive read the transforms mu¢riels remade,der Chapter 6.95 of the Call- AIR CONDITIONISR ' ISSUANCE DATE -
fomia Hea1N&Safety Cede.Sctiom 25585,8533 and 25534.I understand Nal if the NEW RFSIDENTIAL MECH. SQ.Pr, • t
building deer nes cumntly hove a¢cont.Nm ii is my msponsibiliry u+nmily the occupant
of Nc requim=ntswhich mum Fa met p6(irtn insumice of a Cenificam of Occupancy.
Owner or aummizednent - Date , , � • '
g ISSUED BY: .
OFFICE,