29289 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALCPOINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION �APPLICATION/PRRMIT 1'LUSIDIN0.MECHANICAL, 29289 O
• IIl111.1)ING I'RO,IEC'1'IDf;N'1'IFICA'UON O
HUILDINGADDRESS: - t SANI'TARYNO, APPLICATION SUBMITTAL DATE
toioo N L3oa6
OWN• 'S NAME: -' w^- EHONE: CONfRACI'UR5 M > ��� LIC NO
1_ , J V- -N/C CONTROL
C AR UECT/FNG EIL - LIC NO ADDRESS: - - ❑
C0M'nCf: PHONEr - BUILDING PERMIT INFO
^' �f �2�/� ❑ Consultant Fces Paid by APPlicant(IBlTial) f ; L)G :CECT PLUMB MIiCH'f
N .V yr ❑ ❑ y
- LICENSED CONTRACTORS DECLARATION JOB DESCRIPTION
I QTY ELECTRIC PERMITQMZ FSE
1 hereby allirm that I um licensed under provisions of Chapter 9(cnmmening
{w{�o, with Section7")of Division 3 of the Business and Professions Code.and my license is RESIDENTIAL'I �� full fortrandefrccu PHRMITISSUANCP. `
.ROJ in
Class Lic.p ❑RFDWL• _ ❑KITCHEN REMODBI.
F�W Dale Contemn APPLIANCES-RESIDENTIAL, ❑ADDITION ,❑PLUMBING RE-PIPE
�7H ARCHITECTS DECLARATION "' - ❑MULTLUNIT 0SRUCTURAL
Iz0 7j my ssu PANELS -
v� Iundermm�dm Ian Y11m.,rdvs Publicrac ds MODIFICATION
'OZ=f - UPTO2011AMI'S"
I-�I"'� Licemal Professional - ❑INTHRIOR p'� pp CHIMNEYREPAIR
301.10NEAMP$ ,. IMPROVEMENT Y- 9 X'f
NH OWNER-BUILDER DECLARAfIOyP OVER I000AMPS ❑BATH REMODEL(REPAIR 0D DEMOLITION '
ippiw55,� lhereby 0.affirm
nat I . exempt o for theAEU follw g .. (S tio70315 9ac J P ,a ,Code:A YtY El
OTI
Owhich q permit construct, II P d 1 h pa any 1 cure SIGNS IiLECTNICAL 19OV
-
prion t. ane H y .Ih ppl If hl rmet BI g J t n l O
rn SPdiC1Al.C1RCl11T/MISC
}
that he licensed p a Ib pro' t in fmcC t t .I L, (Cbw1a)mr
00 fwm y IhS i 7G(NII [p' m3 fth Businessland P f -.- C I) r TEMP. H.
OR POLE INET. OF ULGIrpiI11 (1 '
a a eN that h is exempt therefrom and the basic for the alleged exemption.Any violuonn of BLDGIADDITION DEMOLITION
as
Section 7031.5 treaty applicant for a permit suhjecty theapplicum In it civil pewhynf POWER DEVICES NANT FOOD SIiRVICG `
a mom than five hundred dollars(S50p. 1 VEMENT
F=C
E)1.as owner of the property,or my employees wish wages as their sole campcnatiov, SWIMMING POOL ELECTRIC
p.
will lma,wnrk;and the structure is not intended oroffcam for mle(Sec.7G44,Business ❑OTHER
asad Professions Cole:the Comment,',License Law does not apP1y to vI owner,0f 'S-SWITCHES-FIXTURES I—
property whir builds or improves thereon,ant]who does such xork hlmsell "an
a, •, -.n
his a employees;provided that such improvements am not intended or offered for NEW ROIDENUAL ELECTRSQ IT. '
sale.If,boweveq lire Immidingor improvrmenlls,.1d within one year of cnntpletian,the - - SQ.FT.FLOORR..AAREA .$/SQ.FI'.
er-builder will have the human of proving that he did not build or improve for par- J�
I saltner
ow). of the pmPeny,am exclusively enmmenng with licensed coneactir m 1' -
con net the lan eel(Sea.2014.Business and Professions Cock)Tho Cmaticmr's Li- t
came wdoes'ndi apply mf per .
an owneramperty who builds ar improves theon,and' QTy, PLUMBING PERMIT FEE I
wlm Contracts far,nah abiaab vvIlh a a.rroc m,(,,)HLensed parsaam In Im Cmancemr5 '
License Law. _ -
❑ Iam efa`I<"1B&I'C for this reason PERMIT ISSUANC12
Obvic + ALM R-DRAIN&VENT-WAI HR(HA) sevALUAD
WO ' -SOMPENSAI'ION DECLARATION BACK FLOW 111401 ECT DEVICE
1 hertby affirm under pcnahy of perjury one of the following declaration:
.� lat
I IoNcand will maintain a Cerificum al Consent to self-insure for Workers ComPem DRAINS-FLOOR,ROOF,AREA! OND. S'1'UIt1E5 ' TYPE CONSTItUCI'I0N
train,as provided for by Section 370(1 of the Latmr Cole,for the performance of me
work for which this pertnifis issued. - FIXTURES-E'ER TRAP ,tV
❑'I have end will maintain Worker's Compensation Insurance,as required by Section
3700 of the LlhorCode,forma perfommmoof the work for whichlhis panni,is issued. GAS-EA.SYSTEM-I INC.4 U • S OCCGROUP APN
My Worker's Compensation Insurance carrier and Policy mount,arc: -
• Camcr: Policy No.: GAS_EA.SYSTEM-OVER 4IRA) '
CPRTIFICATE OF EXLMITION FROM WORKERS' '
COMPENSATION INSURANCE GREASFANDUSTRL WASTE IN RC.
(This ao for need not be completed if'he permit is human,hundred dollars($I00) - IIUILDIN( IVISION ITES
or lass.) - GREASETRAP
PLANCII[CK FEE
7Icertifythus in the nrrlhcwork for which this iik�issua11
not employ any oriany number soas mbecomemhject et inIa Workers ComOvcn- SEWER-SANUARY--STORMEA.203
ENERGY FEE
,Oliver Laws nlCalkrrnel Data
C) WATERIIEATER W/VEN /ELiLTR
�a
GRADING FEE ,t
y a'~ NOTICE TO APPLICANT It,afmnouking this Ceni fchm of Exenlplio,.you.should '
- -
become subject In the Worker's Compensation provisions of the Labor Code, SYS,you must SPE"
W G forthwi th comply with such provisions or lh is permit shall be deemed revoked. WATER S17RVICE
0. Z s LENDINGAGENCY NEW RliS1DENTIAI,PCMB. SQ.FT. PAID
U O Ihercbyaffrm that them issuemwninn lending agency for the Performance of Dom u tpn#
4is f~' the work for which this permit is issued(Sec.71197,Civ,CJ T
,O Ulender's Name , Vi
lenders Address - TOTAL:
I rectify that I have real this upplicutlon and went that We eMrve uronan tion is BUILDING si
M correct.l agree to comply with all any and county mdjunbces and sone laws mlvtingm QTy, a MECHANICAL P17RNIIT FEE
U 7a building rortlrucliu I,and herchy awha ze rtprencntativcs ollhis city manner upon the SF,ISM IC .I
above-mentioned property for inspection amposes. PERMIT ISSUANCE ELECTRIC TEF.�
I C44
(We)agnea m save,indemnify and keep harmless the City of Cupertino against '
liabilities,judgmemx,costs and expenses which may in any way same against said City AIA ER ORA DD I'O MECH. PLUMBING FEE
accom coflhe g,art,ri this pernil. ,s
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO 10,00(1 CPM) MGCHANICALFEE
SOURCE REGULATIONS.. s s
AIR HANDLING UNIT(OVER Ig00GCFM) ICONSTRUCI'IONTX '
Signmurt afApplicahJCmocarm, Uvlc EXHAUST HOOD(W/DUCT) HOUSINGMITIG 'ION PER
HAZARDOUS MAMMALS DISCLOSURE
Will the applicant or future budding occupant some or handle hersmoas mraoned HHATING ON I'f(To 100,000 B'I'U)
as definal by the Culmina Municipal Cale,Chapter 9.12,and the Health and Safety
-� Code,Section 25532aml / - HHATINGUNH(OVER 100.010I -
❑ `
Yes r p}Nn VI?NTILAI'ION FAN RESID) PAID'
,,re IJat ,Recti t#
Will the applicant or Town building occupant use equipment ordevices which BOILER-COMP(iHP OR IOO,f100 BTU)
d
, Plan hueardnus air aternnmimnls vs definod by,oho Bay Anal Air Quality Mumgememo O
s District? BOILER-COME(OVER 100,000 BTU)
El Yes 's:.
AIR CONDIT)kONER
I have J the hat uduus materials requirements oder Chapter 6,95 of the Cali - ISSUANCE DAT
forms Health&Safety Cole Sections 25505 2511 and 255341 understand that if the NEW RESIDENTIAL.MECH. SQ.FT. : "
bmldngd .n Icmm rate ntJhottsmy repo 'bltym notify the oecuprt
of the eau which n tvuanw nfa CsnT�e mo[Os upuoy
Owner or Drize gent - Da 'PDTAL: ISSUED
OFFICE '