29464 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUILDING-ELECTRICAL. PERMIT NO 29464
9 aJ 6 a�
BUILDING DIVISION APPLICATIONXERMIT PLUMBING�MECHANICAL L J4 4lhJ 4
BUILDING PROJF,CIp IDENTIFICATION
BUILDING ADDRESS, SANITARY NO, APPLICATION SUBMITTAL DATE
ve$o N . w �q-q
OWNER'S NAME PHONE: CO ItASTOH'S NAMI': LIC NO:./
1L9 NIC CONI ROLp
R TPCIIENGINF,iR: ,NO DHCSS.
S 75 UCSD uq V � ❑
COI�NTACT: ,1 PHONE: BUILDING PERMIT INF
1��"Y r' L�IIA�i'O �?/ 16A. 2 ❑ ConsulLam Fees Paid by Applicant(Initial) BLIx' GLe PLUMB MF
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hmebY affirm Thal 1 am licensed under pmvisime,of Chapter 9(commencing JOB ESCRIPTION .
�0QRZ with Sextbn Axtl))of Division 30 the Business and Profession.,Cree,und my l icense is RESIDENTIAL:
O ' PERMITISSUANCE
QW Uatenin luCaa force nJ cffcet aC3 Cnntrucs33?/ 3 pppL1ANCE5-RESIDENTIAL ❑ADD TION ❑PLUM LNG EPIPEL
FOy �ARCF�II I'1°.CI'S DIiCLARATION � � PANELS ❑MULTI-UNIT El STRUCTURAL
Z O y? I understand my plans shall be used m public records ...��i��'��,^^^"'III111✓✓✓ MODIFICATION
OZ—Q UPT02011AMPS ❑INTERIOR EI CHIMNEY REPAIR
F.1.-tat 1. enscJ Pmfessioo•l 2ol-IIx1)AMPS IMPROVEMENT
�yf� OWNERHUILUERDECLARATION OVER 1100 AMPS ❑BATHREMODEUREPAIR ❑DEMOLITION
5 W Q I hereby affirm that 1 am exempt from the Contmcmr's License law franc
°�g O G U following mission.(Section 7031 5,nosiness and Professions Code.Any city or county SIGNS ELECTRICAL ❑OTHER
a y which rtyuieas o permit to rnnstmcl,alcor,improve,demolish,or eapuir any almewre IN lI
1"40 pnarwilxlss..me,hu requires the applicant for such permit m file it SPECIAL CIRCUFOIJISC. p
pq5 }� thathei.herewidpureuant mthepruvi.osms ofthe Cnmmelor's License Law(Chapter 9
kc 0a Icommeacimi idiSectim,7000).T)....it.Jmfthe Business and Prnfeoli...Cala ter TEMP.METIER OR POLE INST. //kk
a%ca LL that he is exempt therefrom and the basis(or the alleged exemption.Any violation of ❑ GIEDDITI�1[�}n DEMOLITION
ir
��N
Section 7031.5 byany applicant for a pernot%objects the applicant to a evil penalty of POWER DEVICES T /JJ�I°0011 SERVICE
.mom In..five hundred dollars(851x1). 'IMPROVEMENT
FZQ ❑Lestwner.fare properly,or my employees with wages as their sole comprnsation. SWIMMING POOL ELECTRIC )
1,x,0 will dol Inc work,and the shectiom is not intended or offered for sale(See 7044,Business OTHER Vs" s,n.'
w and Professions Csdr:The Commears License Law does not apply m un owner of 1 OUTLETS-SWITCHES-FIXTURES sim,
�'3 properly who builds or improves threats,and who does such work himself or through
his own employees,provided did such improvements are not imported or offered far NEW RESIDENTIAL EL C7fR SQ FT.
sale.ILhowever,the building orimprovement is sold within one year ofromplction.the SQ,FE FLOOR AREA $ISQ 17,
sur-builder will have the burden of proving that he did not build or improve for put-
ofvale.). ,f (�( ��o 1
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sm.701 Business and Professions Cade:)The Contracmrt s U.
ase Law does not apply to an owner of pmlamy who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such prnjema with a commands)licensed pursuant sur the Commeme
License law. PERMIT ISSUANCE
❑ 1 an exempt under Sec. .B&P C for this reemn
Owner Date. ALTER-DRNN,F VENT-WATEH(G) '''� VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1
❑Ihuvecond mill poefrCjuornycidmteluthfef-imeare finogr Worker'siCo mpete- J✓
DRAINS AREA. Sl'ORIILti TYPE CONSTRUCf10N
tion,as provided for by Section 37W of the LaWth
r Code,for e performance of the
we for which this permit is...red. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insamna,as required by Section
3 of the LaWr Code.for the peraparmnce of Ne work for which this permit is issued GAS-CA.SYSTEM-)INC.4 OUTLETS OCC.GROUP APN
My Wm- Col; aalonl Irunce currier and Policy nu
Cvricck]tr�71ew7 Policy No.: r GAS-IiA.SYSTEM-OVER IRA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE)INDUSTRL WASTE INTERCEPTOR
BUILD G Slo EES
(Thissectitn need not be complaintif the proof is for one hundred dollars($1IMI) GREkSETRAP
or less.) JFEE
NCH[CK FE
Ianilytbmin.heped, amerarlhawork lis which Ibis palmi.is issued,is hall SEWER-SANITARY-S'T'ORM HA.2(1017.
not employ any person in any manner w as to became subject to the Workers'Compete- RGY 1E'ka
•
ZZ cation laws of California.Date WATER HEATER WoVENTIELEC R
Q Applicant DIN;M
NOTICE TO APPLICANT.If.after making this CeniGcate of Exemption,you.should WATER SYS'I EMOIREATINO LS FEE
(•-' become subject to the Workers Compensation provisions of the Tabor Cale,yma must
Wforthwith comply with.such provisions arms permit shallh deemed revoked. WATER SERVICE
a �
UZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. D � Reaciptn
LJ Q Thereby union hthisthat
ximit i is.couSite 0n Reading agency for performance of
the wok for which.his permit is iswW(Sec.JIMJ],Civ.CJ
U. I"' I<ndcrs Name TOTAL:
O a Lceder'.,Address TOTAL: hDI IPL$
IF^^' 1 early Nat 1 have read This application and late that the oMrve iofornmlinn is raI
h cancer.l agree m comply with all city and county uNinmees and state laws mla.ing to QTY MECHANICAL PERMIT
U building eonstmction anti hereby authorize reptesenndives of this city to enter upon the FEE
above-mentioned property fur mpecorm purposes. PERMIT ISSUANCE
(We)agaem...a.indemnify and keep harmless.he City of Cupertino againr RIC I'LE
WE
Iiabilitics,judgmers,ensu and expenses which may in any way acerueagainst said City ' ALTER OR ADD TO MECH.
in asequence of the graming of this pennil. GFLE
APPLICANT UNDERST WILL COMAPLY/f�ITHALL NON-PO T AIR DANDLING UNIT(TO UL000CFM) HANICA FEE t/a
SOURCE CULATI //J/ � �/, AIR I IANDLINGUNI'1'(OVER 10,M)CIT1) STItUCIION 'n%
SignummofApplicant,Comrucor - Via, EXHAUST HOOD IWNUC) SING MITIGAT NFEE
HAZARDOUS MATERIAL 4 DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.001 BTU)
as defined by the Culmrino Municipal Cole.Chapter 9.12,and the Health and Safety
Cade,Section 2553201! HEATING ON IT(OVER 100,000 BTU)
Yes No
C] VENTILATION FAN(SINGLE RESID) PAID Dan aipttl
Will.he applicant nr future building Occupant use aluipman ter dpvias wM1lub
mil hazardous air commitments as defined by the Bay Arca Air Quality Management DOILER-COMP(3HP OR 10x0,000 BTU)
Distda] TOTAL:
C]Yes Fl No BOILER-COMP(OVF,R Iq),IXXI BTU)
I have read the hstardem,mandate requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DAT
humin Health 5.Safety Code.Seelions 25505,25533 and 25534.1 madentamd Ibet if the NEW RESBIIiN'I'IAL MECH. SQ.FP.
Wilding does not currently have a tenant,that it is my responsibility,to notify the espirpaot
of the reyuiremenN which must W met prior to issuance of u Certificate of Occupancy.
Omma,o,auNonud age.. Data ALT ISSUED BY:
OFFICE