29854 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /1/1 /� r q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL L�9 V8 5 4
BUILDING PROJECT IDENTIFICATION
BUIIDINGADDRESS: . SANITARY NO. APS}P'LLIIICATION SUBMITTAL DATI
OWNEERR'S NAME: PHONE: CONTRACT'OR'S AMG!:
NIC CO
LIC NO:�
NTROL#
ARCHIT CUENGINL'ER: LIC NO: ADDRESS: ❑
CONTACT. PHONE: I BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EST - P M MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION qpY ELECTRIC PERMIT PEE
1 hereby amrm that 1 am licensed under provisions of Chapter 9(commencing LOB DESCRIPTIO
a2 with Section 7")of Division 3 of the Business and Professions Cale,and my license is - RESIDENTIAL;
OO PERMIT ISSUANCE.
in full force and effect
4 - ❑SFDWL ❑PLUMBIN RE-PIP I.
UU license Class Lic.# pPP1.lANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
a Dutc ✓j1�2My pi Canttanar
Fly ARCHITECTS DECLARATION PANELS [I MULTI-UNIT ❑STRUCTURAL
y 011 s2. I understand my plans shall he used as public record MODIFICATION
02::110 UP TO 200 AMPS [3 INTERIOR [I CHIMNEY REPAIR
Ir to(:W Limmand Professional - 201-IIXNIAMPS
OWNER-BUILDER DECLARATION IMPROVEMENT
K Q 1 hereby affirm that 1 me exempt hurt Concourses License Law burns OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
ip5,0 F U following maxon.(Section 70315.Business and Prafiveinns Code:Any city or county SIGNS ELECTRICAL ITOTHER A/ s�G(JCjP
FO F' which requires a pennil to construct,alar.improve,demolish,or repair any or lure
prior to its issuance,also requires the applicant for such penin m file u signed statement SPECIAL CIRCUITIMISC.
6� What he is licensed pursuant o the provisions ofthe Convenor's License Law(Chapter 9
DO (commencing with Section 701101 of'Division 3 ofthe Business and Professions Coda)or TEMR METER OR POLL INST. COMMERCIAL:
6 0 dist he is exempt therefrom and lire basis for the allegW exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant fore somdt subjects the applicant m a civil penalty of POWER DEVICES ern ❑TENANT ❑FOOD SERVICE
nut more than e five hundredperry,or my employees
IMPROVEMENT
C Q ❑Lothe us work.and
the pestrac,mmyemployees wofferefrac(See.compensation. SWIMMING POOL ELECTRIC
CLd' will dove wok,and e: he Ci ,is tar's kendndede ow do forsac
apply to an Business OTHER
W � and Profnsiom Code The Contractors License law das not apply to an owner of OUTLETS-SWITCHES-PoXTGRCS
6 a.- propcny who builds or improves themon,and who does such work himself or through
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL ELECTR SQ
saleJf,however.the building or improvement issold within one yearnfcomplctiom the SQ.FT.FLOOR AREA $/SQ.IR.
owner-builder will have the burden of proving that he did not build or improve for put- `1 q
pose of selene / a
1,as owner of me Sm.704,stn exclusively contracting with Cade:)
Contractor's i- TOTAL; // a'
nnshuathees lett(Sec.7614,Businessend Professionds ora The s themes, Li- IfY1 JJ
acme Law dunot es such plymts with
aofpmpocs who
sedporiopmves Comgand QTY. PLUMBING PERMIT FEE /P'E'I /VJ3 ,
who contracts for such prnjecu wive nennwemna)licensed pursuantmthe Commemrs Q //gyp
License Luw. PERMIT ISSUANCE / vw
I amexempt under Sec. ,B&PCfarlhisreamn V7_ U
ALTER-DRAIN&VENT-WATER(FA)
Owner VALUATIONJ
Dam
WORKER'SCOMPENSAITONDECLARATION BACK FLOWPROTECTDEVICE 3�� 1%7-
1hereby affirm under penalty of perjury one of we following declarations:
I have and will maintain a Certificate of Consent taself-insure for Workers Camper- DRAINS-FLOOR.ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
anion,to provided far by Section 37M of the Labor Cala,for we performance of the
work for which this permit is issued, FIX'T'URES-PER TRAP
� I have and will maintain Workers Compensation Insurance,n acquired by Section
J7tl(mof the Lum,Code,for the pcdo...of the work for which this permit is issued. GAS-EA.Sys TEM-I INC.4 OUTLETS pCC.GROUP APN
My Worker's{f'pmpensatyan IZ5p er and Policy num n'_ GAS-IiA.SYSTHM-OVF.N4(EA)
Innier:�.&4LVRn iA !/I nt Policy No.:LL� ♦�.L( .
CERTHICATE OF EXEMPTION FROM WOR ERS'
COMPENSATION INSURANCE GREASFIINDUSI RL WASTE INTERCEPTOR
or less)
(Thlsmction need not be completed Ifthe penot Is for one hundred dollars is I WGRHASETHAI'
) BUILDING DIVISION FEES
- -
I'IANCI{F,CK FEE
1 ccnify that in the pcRonnen<e ofthe work far which this permit i>issuW,Istria
not employ any person in an manner so as m become subject we Wnrkeri Com SEWER-SANIi'ANY-STORM EA.20o FT.
Y 1 Pen- .jtENERGY FEE
,� .ruins Lawsof California.Data
O Applicant WATER HEATER WIVENT/F.LECTR - GRADING FEE
In NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTI!M?REATING
abecome suhjen to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
{2Iforthwith comply with such pmvisinnsor this permit shall to deemed revoked WATER SERVICE
Cl
Dz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ FF. PAID
U 0 l hereby affirm that them is aconsauction lending agency fords performance of Date Receipt#
the work fur which this pammit is issued(See.3097,Civ.C.)
0 f" Lender's Nam 1 TOTAL:
Lender,Adams, L:
Ty I ccnify that 1 have read this application and state that the above information is BUILDING FEE
IAcorrect.l agora to comply with all city and county ordinances and setas laws telatiog to QTY MECHANICAL PERMIT FEE
U 4 building vivstmction,mad herehy cathodic represemamivesnfmhis city m en¢rupan the SEISMIC I'EE
above-mentioned Propcny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harries,the City of Captain.against ELECTRIC FEE
liabilities,jud,imms.c(summdexpens<s which mirymany way acrmc against xuid Cary ALTER OR ADD'1'0 MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTAYbS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT OY)I0,000 CFM)
SOURCE RF ,ULA N.' MECHANICAL FEE •
AIR HANDLING UNIT(OVER IO,OIHI CFM)16 CONSTRUCTIONTAX
Signal of Ap i n t mr me EXHAUSTHOODGNMUCO
HA7a/A2DOUS MATERIALS DISCLOSUR HOUSING MITIGATION FEE
Will the applicant to firma huilding(weapon smrear handle huznrdaus mamdvl HEATING!JNIT(TO 100.000 BTU)
a. defmnW by the Cupertino Municipal Cale,Chapter 9.12,and the liealth and Safety
Cade,Section 2553200)? HEATING UNIT(OVER 100,11010 BTU)
E]yes �No PAID -
VENTILATION PAN(SINGLE RESIp)
Date Receipt#
Will the applicant mventre building byoccuparm se equipment ordeviseswhich 'BOILER-COMP QHP OR 100,000 BTU)
'mitict' 'us air conmminams as defined by the Be,BArco Air Quality hlanagcmem
District? TOTAL:
❑Vas No Rol hER._COM I'(OVER 100,0011 BTU) „
I have mad the harardaw((s mamtialsAIR CONDITIONER
requimmenu unties Chapter 6.95 of the Cali- i$$UAN
foods Health&Safety Cie,Sections 25505,25533 and 25534.1 undersrad this if the NEW RESIDENTIAL MECH. SQ.PT. -
huilm it it Art y11 a term%Lt "mfmym,xrdhHhY to nndly theceaspant
oft,requi rnts is a m issuance oft Cerdficmc fOec 'n -
Owner .alltnrize age Z pate TOTAL: ISSUED BY:
OFFICE