29373 w,
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CITY OF CUPERTINO IIUILDING-ELECTRICAL PERMIT NO. 29373
BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICA'T'ION
BUILDING ADDRESS: / 1 SANITARY NO, APPLICATION SUBMITTAL DAT'
aC939P V'mS'an/ "ry�Q.ta%no picitrr 3-Q `d (
OW ER' NAyE: PHONE: CONTRACTI)R'S NAME: LIC NO:
�' alien He.af Ps 4r�ts 9f1S 6coo 6WAV P- S63 OC sr � N/c coNTRfn.»
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONGWCP PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�.P e Coo era yo k 9E<S-- 0 6 1 CS
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
'1 hereby arra m In.,I i m licensed under provisions of Chapter 9(commcnaing JOB DESCRIPTION
�aZ with Section 7")of Division 3 ofthe Business and Prefiewhave Coade.road my license is
FOO full furceund effect. PERMIT ISSUANCE
�VZrT� License Class Lia» VL ❑KITCHEN REMODEL
vGi Dare Cimmcmr APPLIANCES-RESIDENTIAL ADDI fION [I PLUMBING RE-PIPE
ARCHITECT'S DECLARATION - ❑MULTI-UNIT El STRUCTURAL
6O�? 1 substandard my plans shall be used as public records PANELS MODIFICATION
Z 0 UP TO 200 AMPS ❑INTERIGR El CHIMNEY REPAIR
rr?f'u.4] Licensed Professional 201-I000AMPS IMPROVEMENT
9MOWNER-BUILDER DECLARATION OV17R J0MIAMI'S ❑BATH RE.MODELIREPAIR [I DEMOLITION
C' 1 hereby affirm that I am exempt from the Contractors License Low for The
{iiSO y V following reason.(Section 9031.5,Business and Professions Cale:Any city or county SIGNS[LECfRICAL ❑OTHER
sH�O f--' which requires a permit 1.cnnsnuc6 alter,improve,demolish,or repair any swcwre
prior o its issuance,also requires the applicant for such Permit o file a signed statement SPECIALCIRCUIT/MISC.
y that he is licensed pmsuau
no the prove
visions of Ne Contractor's License Law(Chapter 9
00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INSL COMMERCIAL:
d M C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Y•
Section 0031.5 by any applicant a permit subjects the applicromm.civil penalty of POWER DEVICES
..y (]TENANT ❑FOOD SERVICE
F=Qnot mare than five hundred dollars($511()' IMPROVEMENT
❑Lothe work,the pmpcvy,r is not
as The(Sea. 0,14.B ,inces SWIMMING POOL ELECTRIC ❑OTHE
f-, will do Na work,and the Th Con is tors License a w ad does
apply to an owner
of
and Professions Cede:The Connector's,and w taw docs vat apply to if owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who dues such work himself or through
his own employeese provided that such improvements are not intended or offered for NEW RESIDENTIAL I3LECTR SQ IT
sole.If.however wthe building burimprovement ithsold within one ildori improve
SQ.FT.I100R AREA ESQ.FT.
' ownerbuilderwillheveiheruNenofpmvingthalhedidootnuildorimproveforpur-
Earn of s
I,as owner of,he property,em exclusively connecting with licensed cnm
mctmars TOTAL:
Elowne
c0mauct the project(Sec.7OW,Business end Professions Code:)The Com—aa rs Li- f
cense Law does not apply to an owner of property who bulldsarlmprvestheream.and QTY. PLUMBING PERMIT FEE
who convects for such projects with a contractor(a)licensed pursuant o the Conlrumrs JJ
License Law. PERMIT ISSUANCE.
Cl I
am exempt under Sec. ,B&PC for is...
Owner Data ALTER-DRAINas VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �+ _/OU'J SF7
1 hereby officer under penalty of perjury one mine following declarations: Ok ` I,
❑Ihave and wilt maimninaCenificme of ConsenOuaelGinsure for Workers Common- DRAINS-FLOOR.ROOF AREA,COND. STORIES TYPE CONSTRUCTION
setion,as provided for by Section 370U of the labor Code,far the parfarnance of the
work for which this parmil is issued. FIXTURES-PER TRAP
D5� 1 have and will nmimain Wake,Compensation Insamnce,as required by Section
OC
37M ofthth
e labor Code,for e performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS G GROUP APN
My Worketh ptpensniJnn lnsum tt ca�Iand Policy nuq
Carier:C L- C[�S4 TYe Policy No.:-�L7(gJ�9iDY GAS-EA.SYS TEM"OVER 4(EA)
CERTIEICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
IIUILDING DIVISION IT.
(This section navel not 4rnmpletedifthe parent is(crone hundred dollars($IOo) GREASE TRAP
in lcssJ PLANCHECK PER •'Y O '`jy Q
Iceni(Y that in the erfnttruntt nfthe work forwhJ'c�yhi tis ismed.l snail SEWER-SANITARY-STORM EA.200 FT.
Onot employ tiny genonJ�ny 111unny�e �h,od i Oto workers G�mpcn- ENERGY FEE
z xaliun laws of C. Date /J_ / WATER HEATER WNENT/ELECTR
O Appliwm GRADING FEE f
y NOTICE CO PLICANP.If,after making this Cenifieate of Exemption,you should WATER SYSTEM?RGATING n
a become subject to the Worker's Compensation provisions of the Labor Ede,you must SOILS FEE r/f Up /t
aQforthwith comply with such provisions orthispemilshdl be deemed revoked. WATER SERVICE , ffp�•
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.n.. PAID Pei
z I hereby affirm that them is o commuction lending agency for the perfomarecaf Da )kJ Rccci »
IU242 the workfor which Nis permit is issued(Sec.3097,Civ,C.)
0 U 1<nders NameTOTAL.:
Lenders Address TOTAL: �1
1 1 certify that 1 have read this spidemim and stem that the above information is BUILDING Fl. eg a Q(
TA comet.l agree to comply with all city and county ordinances and sone laws relating to QTY. MECHANICAL PERMIT FEE /
U building conswction.and hereby au,horiae representatives of This city to enter upon the SEISMICF o[�Jct
aMve-mentioned propcny for inspection purposes, PERMIT ISSUANCE.
(We)agree to save,indemnify and keep harmless the City of Cupertino eF.bit ELECTRIC
liabilities judgments,costs and expenses which may in any way acerae against aid City ALTER ORADDTO MECI.
in asequence of the granting of this permit. PLUMBING FEE M2.3(
APPLICANT
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
MECHANICAL LLE UU
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTA% 36pa4�
Signature dApplica sCommca., Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hmardii material HEATING ON["r(TO 100,00 BTU)
as refined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cale,Section 25532(0)1 HI7AI'I NO ONE T(OVER I(UM)BTUl
❑Yes Fl No PAIL)
VENTILATION FAN(SINGLE RFSID) DataRece t»
Will Nro
e applicant or fure building occupant use equipment or devices which BOILER-COA1P(3TIP OR 100,(X10 BTU) W.I3
emit bawrdous air contaminants as defined by the Bay Area Air Quality Management TA
DiDistrict' OQ
❑Yes 0 N BOILER-COMP(OVER 103.000 BTU)
1 hove read the haramli ms materials mquin meats under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
home Health&Safety Cade.SeNons 25505.3533 and 25534.1 understand Not if the NEW RESIDENTIAL MECH. SQ.FT.
building thcsm fly hnvea¢nant,that it is my respnnsibilirymnotify the mcupanm
mini jp a tswh¢h nu trio rinr to iuuance nfeCeni cmc afo(kcu n
nearen
Owner—orauthoneed Agent / Data TOTAL: ISSUED BY:�
OFFICE