29558 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMU N029558
.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAL L JV 5 8
tlUILDINI:PROJECr IDENTIFICATION
tlU1LDINGADDRF.SS: \1 Ig SANITARY NO. APPLICATION SUBMITTAL DATE
20 35 C S rE �E►.zs �n�s� &VD-
` OWNER'SNAMP: PHONE: CONTRACTOR'S NAME: LIC NO:
ZT ' 40 ?S'L— �' C - O/ NIC ONTROLx
ARCHITECT/ENGINEER: LIC N0: ADDRESS: ❑
rJ fo mY�16 Ss
CONTACT: PHONE: BUILDING PERMIT IN170
❑ Consultant Fceg Paid by Applicant(Initial) ry p [L PLUMB MECH
"1-•a1S1
LICENSED CONT'RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{C{ya2 with Section7aa))n,H)ivi lon3nf the Business and l'rnlesaltw Cod rolamylianscis RESIDENTIAL•
F-O0 full force and dTcn. '� /-'Q�^C4 t I'I?I1MI1'ISSUANCE ❑SPDWL ❑KITCHEN REMODEL
UE License Class Li,.to
�<L Date Commdm APPLIANCES-RESIDENTIAL []ADDITION ElPLUMBUIEG RE-PIPE
ARCHITECTS DECLARATION 0NIUIZIUNIT ❑STRUCTURAL
Z O- m
Z 1 undersnd my plans shall M1e used as public records PANELS
CZ JJ UPTO 2W AMPS MODIFICATION
E4m Licensed Professional - 0INT'I?RIOR 0CHIMNEY REPAIR
a 201.1000AMPS
CC OetIano eU1LDERDECe Coai ON BATH EMODT
yy C C 1 hereby nliinn Btat I nm exempt front the Cunimetnr's License Law for the OVER 1(100 AMPS 0 BATH REMODEURI?PAIR 0 DEMOLITION
36 V following reason.(Sect.....7031.5,Business and Professions Cole:Any city or county SIGNS ELECHUCAL 0OTHER
LLLL7T
0 which requites n pc.it m constum,eller,improve,demolish,err repair any swdure
qFQ prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/M 1SC.
2, a� that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
WC C (commencing with Section 7")of Division 3 of Business and Professions C(nle)or TEMP METER OR POLE INST, COMMERCIAL'
F o that he is exempt therefrom and the basis for the ullcVd exemption.Any violution of
Seclion 1111,56 an lidtm fora 0 NEW BLDOADDITION CDEMOLITION
Y YaPp permit subjen.c the upplicam macivil Penalty of 1'O\VER DGVICIiS :NANT ❑FOOD SERVICE
y not more than five hundred dollars(S5 W).
0 Las owneraf the propeny,or my employees with wages as their role compensation, SWINIMINGPOOLELECTRIC I OVEMENT
C will do the work,and the aumum is not intended oroffered for sale(Sec.9014,Business OOTHER
and Professions Cade:The Cuntredm's License Law docs not apply ,,an owner of OUTLETS-SWI'roffis-FIXTURES
property who builds or improves thereon,and who does such work hineself or Ibrotgh
Uci
his awn employees,provided that such hoproveniew are nal intended or ofeacd far NEW REST s 'TAI.ELECTR SQ Pr.
sale.If.however the building or improvement is sold within one yemo(completion,the -SQ.PY FLOOR AREA S/SQ.per.
mvner-lvuikhar will have the burden of proving that he did not build or improve for par- °�:�'•,
you of sale.).
❑Las owner of the pmPenn am eadusively contracting with licensed contractors to T l L
c,smornaet the project(Sec.7W4,Business and Professions Code:)The Camructor's Li-
cenuLawdoesnotapplymanownerof property who builds or improves thereon,and QTY. P M P 1�wiM IT 17EE
who commasl'nrsachprojat,ve1hncotnracmr(s)licensed pursuant to the Conlmet.e. lk 1�y� /( p raP
License Law. r PH MIT ISSUANCC v' - r /•i f' F/
❑I am exempt under Sec. ,B&P C far this rca..a
ALTER-DRAIN&VENT-WATER(EA)
Owner Date VALUATION -`
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE\ S
I•' Iherebynllirmunderpenultyafp jaryonetfthefallowingdeeluralians A'�l '" ��IIZFJ
❑ I have and will innintainaCenificalcnrConservinsetGinsurc for Worker's Co... DRAINS-FLOOR,ROOF,AREA,CONDvsi, STORIE yV TYPE CONSTRUCTION
aalion,as.... 00 fud for by Section 37of the labor Codrfommntt
.,for the peorthe LI
work for which this permit is issued. 17XTURES-PERTRAP
0 1 have and will maintain Workers Compensation Insurance,as required by Section
37M ofthe labor Code,fonhe perfomunce ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC. OUTLETS OCC.GROUP ANN
My WorkeesQQ pensation lasyyec��ncecartier and Policy numhr
Cartier: $T 1-W[l Policy Nn: �' OAS-EA.SYSTEMAVER 4(EA)
CHIEF IFICATE(ID EXEMPTION PROM WORKERS'
COMP13NSSFION INSU RANCI3 G REASEANDIISTRI.WASTE INTERCEPTOR
(This aene
ctinnednot be camplelow¢d ifthe ..it is folhundred dol I...(SIM) BUILDING DMS NRGS
tor less.) GRNASETRAP PLM,CIfECK PEE
toy anythatin she Performaanymannce ro the workas
for subject
bjech tto perthe Warkero'Co.penl SEWER-SANITARY-STORM EA.gal Fr.
not employ any pcnnn in any manna so as nt become suhjen to the Workers'Cnmpen- ENERGY FEE
,Z scion Laws arCalifornia.Date' ^
� � Applicant WATER HEATER W/VI?NT/F.LECTR GRNIINGFEE
Tj NOTICE TO APPLICANT:IL otter making this Cenilicme of Cxemption,you should WATER SYSTGM/1'RI3ATINGIf
a ? become subject 10 the Worker's Compensminn previsions of the Labor Code,yon must SOIfS HE
D.l forthwith comply with such provisions or this permit shall he deemed revoked, WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,Fr. PAID
V 0 kfareby vshidf rte permithat
isns.] i0n lending agency for perfommnca of Receipt#
(A U Lender's Name for which thin pemlil is i.vsnal(Sc,(Se3097,Civ.C.)
U Lender's Address Q TOTAL:
111 LenddI comity
Or I cenify thm I have read this application and nam that the aMve informational BUILD FEE a ��
V) correct.l agree to comply with all city and county ordinances and slate laws mlalingm QTY, MECHANICAL PERMIT FEE
L) building c0nswmion,and hereby authorize representanivesofthis city to emeruponds, SEISMI E Satz
above-mentioned propeny for inspection purposes, 11
t.(We)agnea to slive,mdumtirymtd keep hornless lire Cityvf C,,tmongahlst 1 PERMIT ISSUANCE ELECDt1C PEE
IieM1ililies,judgmenls,calls anJ expenses which mny inuny wuyacervengma,,said Ci,y ALTER OR ADp TO M13Ci1. '
in onsegoeace 0f the granting of l ' nail - PLUM BING FEE
APPLICANT UNDER A ' A ' 'ILL CON LY WIT ALL NON-POINT AIR HANDLING UNIT(TO 10,fKK)CFM)
SOURCERECULATION.' MECHANICAL E
AIR HANDLING UNIT(OVER 10,00!)CFM) CONST'RUCT1 TAX
Si,mmri fA,,Ii,.bt/C.uoE dole EXHAUST HOOD(W/DUCT) HOUSING MIT ATION THE
HAZARDOUS MATERIA ..OSUR _
Will the applicant or future building(we stere it,handle hazmdausaranrid HEATING UNIT(TO I MIME BTU)
as defined by the Cupenino Municipal Code,Chapter 9.12,end the Health and Safety
Code,Section 25532(.)? HEATING UNIT(OVER 10(1.000 BTU)
❑Yes r_1 Nor VENTILATION PAN(SINGLE RESID) �/ PAID
Nnd the air o,nmt or future hulloing by the i ase Area
Air Qu or Management BOILCR-COMP(JHP OR IOO,WOIITU) '
ismet? BOILER-COMP(OVER HgLown'ru) TOTA
O Yes ON.
AIR CONDITION17R
Health
o Safety
Code,
Setioris 255 requirements under Chaptm695ofth.Cali ISSUA EDATE
forma Health&Sarcty Cale,Sestinas 25505.is my end 25534.1 a)nolifand lout if 0e NEW RESIDENTIAL MECH. SQ.Fr. -�
building dax encs which have be met
o issuance omslMlitycate of Occupancy+
of the requirementx which must be ren prinnoissuance o(u Cmifcule of Occupan2y. '
Owner or authonzcd agent Dale A ISSUED BN_J�
OFFICE