29879 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING�MI9 IANICAI.
�� BUILDING PROJEC,19LA TIFICATION 29879
BUILDINGADURESS: `� ; / T `- SANITARY NO. APPLICATION SUBMITTAL DATE
2x41 l VIA PR-V O D V
OWNPJI��AMF.: I..ION SeRACTOR'S NAMFi: . - LIC NO:
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YY 1IVV// O N/C CO 'NOLM
SCHITECl/ENGINCE : LIC NO: Atm�D / �C ❑
CON'T'ACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) �_ BLDG ELECT PLUMB I MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that el I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
O�z with Sectimoll")ofDivision 3 ofthe Business and Professions Code.end mylicenseis - RESIDENTIAL
OO in - PERMIT ISSUANCE
fulu Class effect. ❑SFDWL - [I KITCHEN REMODEL
F' License Class LiaM APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RE-PIM
N 6 6 Date Co ntmcmr
IF..Sco ARCHITECTS DECLARATION PANELS r[NTERIOR
I-UNIT AL
Z85Z 1understand m lanshhall b,.scour public recmda MODIFICAT )N
oz—, yp - Fu UPT0200AMP5 OCHIMNEYRE]i
Licensed Professional - - 201-11HAlAMPg OVEMgS4 .�JOWN[R-BUILDER DECLARATION OVEN IIIW AMPS REMO EPAIR iMOLITION\ldQ 1 hereby affimtthat I am exempt fromthe Commcmes License Low for the VO following reason.( ection 9631.5,Business and Professi.na Code:Any city or county SIGNS IiLEC'1'RICAU R
t++31i F' which require,a permit to construct,alter,improve,demolish,or repair any threarrc
I:�:oprionoits issuencq alsorryuims the applicant for such Permit file aligned statement SPECIAL CIRCUIT/MISC.
} that he is licensed pursuant to the provisions ofthe Commuters License Law(Chapter Y
p1.
0 (commencing with Section 900X)of Division 3 ofthe Business and Pmfcasinnx Code)or TEMP.METER OR POLEINST. .
G 6 0&4 that he is exempt m mment and the basis forme alleged exemption.Any violation of ❑NE BLDG/ADDITION ❑DEMOLITION
Section]O31.S by any applicant for a permit subjects as,applicant to a civil penalty of POWER DEVICES ❑TENA ❑FOOD SERVICE
not more than live hundred dollars 15500).
F.Z} IMPRO ENT
Q ❑ Co are work.the propertture is empinyces with wages rmei(rale compensation, SWIMMING POOL 6LEC'1'RIC -
S�
will dothewod,and
s;The Cannon er,tended Licame Law dose,
not apply to an Business R
W�� and Professions Code;The Comrucmr's Liwnse Low dour na apply to an owns of OUTLCTS—SWITCHES—FIXTURES —
�' progeny who builds or improves thereon,and who does such work himself c r through
his own employees,provided that such improvements arc not hoarded or offered for NEW RESIDENTIAL ELECTR
sale.If,however,the building or improvement is sold within one year of completion,the SQ. .FLOOR AREA $zSQ,PT.
ter-builder will have the burden of proving that he did nm build or improve for pun-
pose of sale.).
I,as owner of the progenm
y,am exclusively contracting with licensed courtrooms to TOTAL:
E] 1, the project(Sea.,0�4.Emitters ad Profesaio.,Cc, air C.m....., f-create MAY 71996
Law does not apply to an owner of property who builds or improves theon,aml QTY, PLUMBING PERMIT
who contracts for such projects with a coutmclons)licensed pursuant to the Contractor's
License low. PERMITISSUANCE vI7Y Ur UUYCI'I I IIVU
I em exempt under Sec. ,B&P C(.,this mason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
acr Date
WORKER' COM SATION DECLARATION BACK FLOW PROTECT.DEVICE
IhereM1y affirm under penalty perjury one of the following declarations:
❑I hsvennd will maintuina Cenificatcol'Consent to self-Inure for Worker's Cominco. DRAINS—FLOOR.ROOF AREA,CONE. STORIES TYPE CONSTRUCFIOP
ration.as pmvided for by See ..37M of the Lahr Code,for the performance of the
work for which this permit is issued. FIXTURES—PER TRAP
❑ 1 have and will maintain Worker's Compensation hmarance,a,required by Section -
39Wofthe Labor Code,for the pedormanaof the work far which this permit is issued. GAS—IA.SYSTEM.I INC.4 OUTLETS - OCOGROUP APN
My Worker's Comparison..Inurance ceaier and Policy number are:
Cornea Policy No.: GAS—IIA.SYSTEM-OVER 4 LEA)
CERTIFICATE OF EXEMPTION FROM WORKERS' OREASUINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi,ettim need not he compload ifthe penal ia-forone hundred dollars(SI 00) GREASETRAP
or less) PLANCHECK FEE
I certify that in the performance ofthe work forwhich this permit is issued,l shall SEWER—SANITARY—STORM P.A.200 FT.
nor employ any person in any runner so as to became subject to the Workers'Compen. ENERGY FEE
O Z ration Laws of California.Date WATER HEATER WNENT/ELECTR GRADING FEE
O Applicant
y NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a � become subject to Ne Worker's Compensation provision of the Lahor Code,you most
_ SOILS FEE
forthwith comply with such provisions or this permit shall be domed revoked. WAIT SERVICE
0
CONSTRUCTION LBNDING AGENCY NEW NCSIUP.N'TIAL I'LMB. SQ,IM PAID
V z Daa Reeiptx
llllp hert
-yyss Iby afGnn that Nete iaacanarvdian lending agency for performance perfounce of
the work for which his permit is inured(Sec.3097,Civ.CJ
u" Lenders Name - TOTAL:
O V Lenders Address TOTAL:
6Wi 1 certify that T have read this application and state that the above information is BUILDING FEE
IO enact.l agree to comply with all city and county ordinances and.stme laws relating to QTY, MECHANICAL PERMIT FEE
V Z building coend nstroaran. hereby malmire repasenutiv,sof thirdly toen,c,.,n the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree m suM,indemnify std keep harmless the City of Cupertino.gains PERMIT ISSUANCE ELECTRIC FEE
liabilides,judgmenta.msksondexpenus which may in any way acmucagtdna said City ALTER OR ADD TO MECH.
PLUMBING FEE
in .asequence of the gransing.f this permit.
APPLICAM'UNDERS'FANDS AND WILL COMPLY WITH ALL NON-POINT AIR DANDLING ON[[LTD f000CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicam/Cmttmc5or Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FPL
HAZARDOUS MA'I£RIAIS DISCLOSURE
Will the applicnnl m future building.ecupunt atoreor handle hazardous material HEAI INC,UNIT TO W,tI(10 BTU)
n defined by the Cupertino Municipal Code,Chapter 9.V2,end me Health rend Safety
Code.Section 255326o? HEATING UNIT(OVER 100.000 BTU)
r7 Yes ❑N. PAID
VP.MI'ILATION PAN SINGLENESID) Dare Receipt N
Will the applicant or future building occupant use equipment m devices which BOILER—COMP(3HPOR IW.000 BTU)emit hazardous air ammminants as defined by the Bay Area Air Quality Management TOTAL:
Di.atricR BOILER—COMP(OVER 100,010 BTU)
El Yet MN.
I have read the hazardous materials requirements under Chapter 6.95.E the Cali AIR CONDITIONER ISSUANCE DATE
f.m li Heath rc Safety me Code,e.[count,
25505,is ray and 23534.I undearmi Out if the NEW RESIDENTIAL MECH. SQ.FT.
building data not currently have o tenant,that it is sea ce opal eni as notify the.arry.
of the requirements which must be met prior m issuance of u Cenilicate of[kcupancy.
Owner or authorized regent
Data TOTAL: ISSUED BY:
OFFICE