29651 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO. ' BUILIIING-ELECTRICAL PERMITNO. .29651 9 6 51
BUILDING DIVISION APPI,ICATION/PF.RMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUH DINGADDRLSS: - SANITARY NO, APPLICATION SUBMITTAL DA'Z'E
2l 'L S� 6
O 'NER'S NAMP: +•' ILLiONi'o ON'IRACTOR:S NAME: LICNO:.
kM Cv •9�l •5331NlC CONTROL#
4RCHITECfIENCINI!UR: LIC NO: ADDNBSS: ❑
CON IAC 1'. PHONE: - BUILDING PERMIT INFO
�.' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEL;
I hereby affirm,that l am licensed n der p st s of chapter 9(commencing JOB DESCRIPTION
oaz with tied t7atn)ofui at 3 nheeei s dP f Dios Code,and my Tecate is
OO PERMIT ISSUANCE RESIDENTIAL:
F in fall f ced cffat. El SFDWL' ❑KITCHEN REMODE
U sa
L.
� U hmence CWss Lic.# APPLIANCES-RESIDENTIAL "
-Zed Date Corral ❑ADDITION El PLUMBING R17 PIPE
ANCHU'CCTS DECLARATION ❑MULTI-UNIT El STRUCTURAL
FONPANELS.
Z O m Z , i understand my Elam shall be uud es public recent, - - MODIFICATION
OZ4O _ , - UP10200AMPS ❑INTERIOR [:)CHIMNEY REPAIR
F.. Licenud Professional - 201-IOWAMPS - IMPROVIiMHN'r'
�y OWNER-BUILDER DECLARATION OVER IOTOAMPS - ❑BATH REMODEUREPAIR [I DEMOLITION
aaCC I hereby o(fmt that 1 am exempts an the Professions
is License Law for the
ip5,OyU which following (Section 702L5,BusinessandPmfeemmi Cale:Any city Or county SIGNS ELF.CTRICAI. ❑OTIiP.R '
which requires a al.ith m enrelmn,ohne inipmve,de .air t or repair any statement
,r p
pnonnhscensece,xlsant to th pre isionso for itith Coranmtiaofile se Low(mhapter t' SPECIAL CIRCUIT/MISC.
�Q� that he islingwJt Secti iBNepmvisions 3.ficImsin,o Licenselaw(Chaprcr9
�gp0 (commencing with Benton]11f1(1)of Division 30nhe Business anJ Pm(essions Cadcl of TEMP.METER OR POLF.INST, •� qq((]](](Q�
6o c that he is exempt therefrom and the basis for tine alleged o,cmpOan.Any vlolutian d, _ „[I Ni f p'101985 DEMOLITION
oxx,,o Section 7031.5 by any applicant for a permit subject&the applicant to a civil penalty of POWER DHVICLS vY
F. >. CITE ❑FOODSERVICE
F. >. not Dune thus five Dolor yempl, - - oIMPROVEMHNT u '
040 ❑Lo (work,the propricame emranded-ohenwages ostheir sole co4.B.,ineva SWIMMING POOL ELECTRIC A+ Ill, ♦✓Ur�ka��NV
will dmhe wons add 11he;The cma a tors LiceUl nr a do fnr of apply 7o44,owner
of ❑ 11�ETf
a 3
and Professions Cade:The Contractors License law docs not apply to an nwncr n OUTLETS-SWITCHES-FI%TURES n' _ •�_
pnspnty who bullJs or improves thereon,unJ who Jnea'u¢h work himself nr through
his own however
the
building that such imprns sold w am not ice to ofc or offered for
NEW RESIDENT 1.ELECTR SQ I'll
own(e. buildevevthhave the burden
en of Movant ithat he ithinoneild or
improve
the SQ.FC FLOOR AREA ESQ.FT.
owner builder will have rhe buNrn o(pmving that he gid not build or improve for Eur-
fault.). s
L as of the pmpcny,v exclusively contracting with licensed commcmrs to
nnxlmet the pmjcet(Sec.]IFM,❑ualnesx and PrOlexsona Cafep The Contrnctora U.
Law does not apply to an owner of property who builds or improves thereon,and QTY. I- M 2MIT FEE
who
co
who nn
for such projects with a coor(s)licensed pursuant the Commmr's
License Law. - - PENMIT l P
- T-1I nm exempt under Sec. ;II&P C immix mason
I —19 IfF- Date ALTER-DRAIN ENT.'WAI (EA - _ VALUATION
WOkI E fS C MPI! PION DECLARATION BACK FLOW PROTECT.I IC: 1 O O
Ihcrehy artium under pewhy ofj ury arta of rho[allowing dedamtierts: '
I NN
haveand will mainain a Ccdlicare Of Consenttootf-inwre for Worker's Compen- DRAINS-FLOON,It001y AREA,Cr D. STORIES 'TYPE CONSTRUCT ION
action,as provided for by Section 3700 of the Labor Code,for the Performance of the
' work far which this permit is i"'and. - FIX'TUR HS-I'FR TRAP -
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor CiAc.for the performance of the work liar which[[its permit is issued, GAS-I!A.SYSTF.M-IINC40UTI.E'1' - OCC.GROUT' AI'N
My Worker's Compensation Insurance carrier and Policy number arc:
Cantu: Policy NO.: GAS-EA.SYSTEMOVER 4 TEA) „
CERTIFICATEOF[TEMPT10N FROM WORKERS' -
'COMPENSATION INSURANCE GNEASH/INDUSTRI.WASTE INTERCEPTOR
phis section need not ce completed if lie pemdt is far hundred dollars U I00) LIANO DIVISION FI.
orlexaJ GREASH TRAP - _ PLAN
Icenify that in the peRormance of the work fnr which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT. t�
not employ any person In mlymannerso us to became smbjecL[n the W..kern''Compen- - ,ENE 'EF, f�
O z smian Laws of California.Date WATER HEATER WNENT/F.LEC R
z 2 Applienm i GR IN
1E
fA NOTICE TO APPLICANT.If,after making this Cenificaa of Exemption,ymo should" WATER SYSTEMOUthAI'ING.
a ' become subject to he Worker's Cmmpenutinn provisions of the Labor Cale,you must - SOILS FBE
forthwith comply with such Provisions or this permit shall M deemed revakW. WATER SERVICE ,
ow
Q
;D zCONSTRUCTION LENDING AGENCY NF:W RESIDIiNT1AL PLMB. SQ.PI'. PAH)LJ ; I hereby affirm That here is a communion lending agency for the performance of Dam keceiptp,
lti the work for which this pemtit is issued(Sec.3197.Civ.C.)
Leaders Name Name ,TOTAL:
WLenders AAdreas 'TOTAL:
kL I certify that I have read this application and state that the above information is BUILDI G FEE
i. fn conect.l egreemrnmply with all city and county ordinances and state laws relating to QTY, MECHANICALPERMIT 17EE
U Z building conswction,and hereby authorize representatives of this city to enter upon the SETS
MIC I!G
.kale-mentioned properly for inspection purposes. "i ,
,(We)u,.tosave.indemnify and keep harmless the City of Cupertino against PERMIH ISSUANCE Nt ELECTRIC
luddities,judgmerus,costs and expenses which may in any way accrue against.mid CityALTER OR'A DO TO MEC II. Q }'LUMBINO FE
a. onsequcncc Of the gram ing ofmis permit., "
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010.1100 CPM) r
SOURCE REGULATIONS. MECHANICAL FI:
AIRHANDLINGUND'(OVER lojif)CFM) CONS'TRUCfIONT
Signature of Applicant/Contractor Date EXHAUST HOOD DVJN CT) HOUSING MITIGATI( FRIT ,
HAZARDOUS MATERIALS DISCLOSURE
Will the uPplicant iv Tumtm building oecupnnt nmre nr bundle h:na l i.,maerial IIHATING UNIT(T0 Hint all R-ru)
V,&fired by the Cupeninn Municipal Code,Chapter 9.12,end rhe Health and Safety
Code,Suction 25532(a)P - HEATING UNIT(OVER 100,000 BTU)
C]Yes ' F1 No PAID
VENTILATION PAN(SINGLE RES ID) Doc ptrild#
Will theapplicant or future building oreupant usecquipmenl or devices which BOILERCOMP(JHP OR IDU,f100 BTU)
emit hunmlou.s fir annandomils ns defined by the Bay Area Air Quality Management - TOTAL:
LBOILER-COMP(OVER 100,0410 BTU)
❑No read the hmaWam materials ret uircrimas under Cha ter 6.95 ofthe Cali- AIN CONDITIONER.p ISSUANCEDATE&Safery Calc,Sa[ions25505,25533anJ25534.1undersandOutiftheNEWRI!SIDI!NTIALMECH. SQ.PEnot currtntly hcnts which mmizedagent Dam {/ _ , ISSUED BY.
OFFICE — V