29675 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING I]ELECTRICAL PERMITNO.
BUILDING DIVISIO15 ICATION/PERMIT PLUMBING.MECHANICAL 29675 C C
BUILDING PROJF.C'1'IDEN'I'IFICAI'ION L o J
• RUILDINGADDRF.SS: SANITARY NO. APPLICATION SUBMITTAL DATF
OWNER'S NAME: �f - ]'HONE: Q.OET CONTRACTORS NAME: LIC NO. -
-/ K(fTS ZS B B L.F AliKI rI- Z. 40 NIC CONTROL N
• JIITEC VENC NEER: LIC NO: ADDRESS: El •^/ qG6
Atissli c- S o Luo 6 SANE LE aria `
CONTAC7P PHONE: BUILDING PERMIT INFO
Jrr1 S-rAk I)S•C- C�}O�)TLO—ssSg Consultant Fees Paid by Applicant _ yLDO ELF,CI� PLUMB M� '
GIA/M 4.44 AIQ.abWI-131.VO*03 I✓Arsely," �
LICENSED CONTRACTOR'S DECLARATION QTy. ELECTRIC PERMIT FEE -
1 hereby affirm Ihm I nm licensed uoJer provisions of Chupmr 9(commm�cing „JOI DESCRIPTION
�0Oral th Sectinn]OIXO of Divisinn3afihe Business and Professions Cole,and my license is RESIDENTIALir
0 in fall to.wI I113HMITISSUANC17 /. -
CWP License
effect. ❑SIVWL fan ❑KITCHEN REMODEL
aV�] Data Class Lick APPLIANCES-RESIDENTIAL 1
H'z LLl Uatc Cnnmam ❑ADDITII"�pppp��xx 2PLGMBING HGPIPE
< ARCHITECTS DECLARATION ❑MULTLUNI'I•+� ❑STRU RAI.
'- t,6 PANELS +�
z O'/+z 1 understand my plans shall be used as public records ODIFICATION
024- UP TO 31X1 AMPS
❑INTERIOR MNEY REPAIR
1-.0 c-LL] Licensed Professional 201-1000AMPS IMPROVEMENT
eij� OWNER-BUILDER DECLARATION OVER IIIINIA S ❑BATHREIZ)AUREPAIR ❑DEMOLITION
O W 1 hereby affirm that 1 am exempt from the Cootracterw License Law for the sal
iry5, dV followingace,on.(Section 7031.5,Businessmed Professions Code:Any city or reantySIGNS IILCCT L ❑OTHER
t++
eco I"' which a mar,u pcmut to cnnswct,Mon.improve,demolish,or repair any structure
�n priorwits issuance,also rtquircsthe applicant(nr such permit to fileosignW naemem SPECIAL CIRCU ISC.
y
that heI,IlecnaedPursuanno the pmvisiamoDhe Contmam's License[..a Chuptu9
W GAO (commencing with Senion]INNI)of Division3 of the Business end Professions CMe)or '1'F.MP.METES ORIN) SMMERCIAL
6 y m Y that he is exempt therefrom and the basis for the alleged exemption.Any violation of EW BLDG/ADDITION ❑DEMOLITION
iLLl1 Y•
Section 7031.5 by any applicant for n permit snhjucts theapplicatn to ncivil penalty of POWER DHYICES Ile,
sn .. TENANT ❑FOOD SERVICE
zQSQ not more than five buvdral dollars l8500),
Cl I;as owner of the progeny,or my employees with wages es their sole compensation, SWIMMING POOL IMPROV
�DrT,-('yP—�
tt� will do the work,and the structure is nal intended manned for sale(Sec.]Wq Business ❑OTHER
mad Professions Code The Contractor's License Law docs not apply to an owner or OU'i'LE9'S-SW FIXTURES
property who builds or improves themon,and who does such work huyntrsj�If or through
his own employees,Provided that such improvemems arc not ipppp!!!!ad .9
Rat for NEW RESIDE LRE SQ Ff. Will
sale.ILhowevm,the have dingmien,:;' mens issuldwithi tie ,the SQ.[op.FLOOR AREA 5/SQ.FT.
ncIf.Inede...file avian"murp proving thw he did n dnrimpr -to ur
give tef sale.). aau���.xx
I,as ow rot the prapenY,am exclwivdY cnntractin with li dcontroctnrsto TAL: �� Ow LQ
e mstpon the project(Sec.7044.Business and Profession,Code:)1 t rot's Li.
cense Lt.does not apply to an owneruf progeny woo buil) Improv mremn.eJ QJ•y. PLUMBING PE PEE
who commcts for such projeas with a contractnr(a)licensed p u troth t ",
Lireme Low. PERMIT ISSUANCE
❑I am exempt under Sec, f ]his mason 5
Owner Date ALTER-DRAIN&VENT-WATER(HA) VALUATION '
WORKERS COMPIINSArioitpv .ARATIO BACK FLOW PROTECT.DEVICE
Ihendyuffirmumter Kre.1yof perj.,..e o ]lowing Jedarati s'
�]I have and will maintain a Certificate of Consent to set-i . for Workers Comptin- DRAINS-FLOOR,ROOF.AREA,COND.
STORIES TYPE CONSTRUCTION
sution,as provided for by Section 3]110 of the Labor Code,R Iwrfo m owe of the
weak for whichlhiw Permit is issued. FIXTURPS-PER TRAP '
Cl 1 have esti will maintain Workers Compensation Inwmxe,as m y Section
3700nfthe Labor Code,for the performance of the work for which aper "slued, CAS-L>A.SYSTCMI INC.4OUTLETS pw OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number. s ♦q �T
Carrico Policy No, GAS-F.A.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS CREASIJINDUSTRI.WASTE INTERCF,fTOR
COMPEN$AfIDN INSURANCE - BUILDING DIVISION FEES
(Thisseaion need nm be complaediflbe permit is forme,hundred Jollmn(81 GBGSETRAP
or less) P CHECK FEE
Loy anyfihrointhe performance fer as
for which this the ail Wrker,'cd,lsh SEWER-SANITARY-STORMEA,2004' IY Ur L Ur
not employ any person in any manner so ns m become subject m the Workeri Cumpen- I P4s(Ii FCL'
O Z soundApplicant
laws of California.Date WATER HEATER WNENTMLECTR
0 Applicant GRADING F[E
r~�i NOTICH TO APPLICANT:II:after making this Cenilicme of Exemption,you should WATER SYSTEM)TREATING
a ' become subject to the Workers Compensation provisions of the Lahm Cade,you must SOILS FEE
L>a F-r forthwith comply with such provisions or this permitsM1all be domed revAid. WATER SERVICE.
Q
CONSTRUCTION LENDING
ending NCY - NEW RE.SIDP.NTIAL PLMN. SQ.P. PAID
UO weak
which
mNe thereits cxd(Sec.on lending agency fur the performance of Dot iptq
N thework fm which this pemsit is issued(Sec.71p7,Civ.C1 "
0Lender',Name TOTAL:
U Lenderi Address TOTAL:
F1 1 certify that I have mad this application and state that the above information is BUILDING PER
y emrem.l agree to comply with all any and ceuoty anch i,,, amdxmamwwrdatingm QTY. MECHANICAL PERMIT FEE
U Z boilJing conswctimn.end hereby authorize rcprcacmatives of Nis city mentor upon the ICFEIAT�l OL O `
r abrownwanumed property forum,ction proposes. PERMIT ISSUANCE
(We)agree I.save,indemnify oad'keep ami the City of Cupertino against 1 ELP.CI'RIC FEC
Iiabilities,judgments,riels andexpeme,woichmayinmly wuyaecruvagaad said City ALTER OR ADD TO MECH. PLUMBING
in canve,son ce of the granting of this permit.
APPLICANT UNDERSTANDS A 'D WILL COMPLY WITH ALL NON-POINT
SOAIR HANDLING UNIT(TO 10,000 CFM) MF:CHANICA F:F,
URCRR LA'f10N5.
AIR HANDLING UNIT(OVER 10,000 CFM) CONS'fRUCf10NTX
r �fA,heam/Cco sand Dmc EXHAUST HOOD(W/DUCT) HOUSING MI'I'IGA ON FEE
HAZARDOUS MATERIALS DISCLOSURB
Will theapplicant or future building a,.,sootcorhuadle hamdhxu,momriel HEATING UNIT(10 B00.000 BTU)
Sir/,fined, ,he C.,sr a Municipal Cole,Chapter 912,end the Health and Safety
Cade.Section 25532(a)? HI?ATING UNIT(OVER 101,1100 BTU)
❑Yes ❑Nn - PAID
VENTILATION FAN(SINGLE.RE.SID)
V Date Recdptp
1
Will the air licant contaminants
a building by the Bay
eea Air cin Quality
devices which BOILER-COMP(BHP OR 100,000 BTU
Dist District? us sir comaminams ss Defined by the Bay Area Air Quality Management ) AI
Div ct?
- ❑Yes FI No NOILER-COMPIOVER IOB,Up BTU)
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER
ISSUA CED E
forma Health&Safety Cole.Sections M505.25533 and 25534.I understand that if the NEW RESIDENTIAL.MECH. SQ.PE -
building does nm currently have a tenon,tom it k my responsibility to nmify the mcta,ma
of the tnaulrements which must be met prior to issuance of a Certificate of Occuponcy.
Ownenvumhorized.gem Ume TOTAL: ISSUED BY:
OFFICE