29425 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PERMIT NO,
BUII,DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECTIDENTIFICATION 29425
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI ITAL DATE
1c ut V-V-
OWNE 'S NAME ��� Tqc fPHONE: CONTRACTORS NAME: T L'13C NO: 1�
C`�(T NIC I�/QCO^N/TROLp
�HCHITECIYENGINHER: LIC NO: CSS: V ❑ /PERMIT l l7
PHONE ign
NFO
CONTACT L e �-Gr PAK-fpp M3.0707 [:1Consullanl Fees Paid by Applicant(Initial) BLDG BUI ELECT PLUMB
MECH
/�- �7D�,ori stop 943.0'7 00 1� ,� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 'Y
1 hereby aRicm that 1 um licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section?")of Division 3 ofthe Bra,mrssanl Professions Cole.and my lioenm is RESIDENTIAL'
ISSUANCE
F intc forceand effect.fl 4 ❑SFDWL ❑KITCHENRF.MODEL
WOO
aU cnsc sr�P Central(
APPLIANCM-RESIDEWIAL ❑ADDITION ❑PLUMBING RE-PIPE
N 0. Uate Contra
ACHITCl DECLARATION ❑MUL'I1-UNIT ❑STRUCTURAL.
Fly PANELS
z Oto Z 1 understand an,plans shall he used m Puhhe records MODIFICATION
Oz=q UP'10200 AMPS L1 INTERIOR [:I CHIMNEY REPAIR
F+y..j Licenced Prolesxlonul 201.10FOAMPS IMPROVEMENT
y
OWNER-BUILDER DECLARATION OVER HNN)AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
C Q 1 hereby affirm mal an exempt from the Conlmctory Licence Low forth,
X a Y U following reams.lSeclum]0315,Business and Profexsions Code Any cit,or county SIGNS ELECTRICAL ❑OTHER
IA LL O N which requires a permit to construct,alter,improve,demolish,or repair any structure
t��m; prinnoio icsuuncy nLn requires the upplicum fiu such perming Fileucigned smmmon' SPECIALCIRCUITIMISC.
Y that he is licensed punuunnn the provisions of the Contractors License Law(Chapter9
Wa00� (commencing with Section 9(N0)of Division 3 ofthe Business and Professions Cal or TEMP.ME9t?R OR POLR INST COMMERCIAL:
6 a pC 'het he is exempt 0ercbam and the hods lar the alleged exemption.Any violaion of ElNEW BLDGIADDEHON ❑DEMOLITION
^N Section 7031.5 by any applicant to u permit subjects the applicant to a civil penalty of POWER DEVICP_S ❑TENANT [1['001)SERVICE
Y
not more than Five hundred dollars(S500). IMPIMPROVEMENTF.
_R <
M Fl 1,as owner of thpcmy.e pmor my emre
Ploys with wages ac their role cote
mpes'ion, SWIMMING PWLELECTRIC
FG will do the work.and the structure is not intended or opened fonale(See.]M4,Business ❑OTHER _� �>,TJy�
(ate]3 m and Professions Cale:The Controversies License Law does not apply to an owner ad &OUTLETS-SWITCHES-FIXTURES /
_ pm,xi who builds or improves themon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ pp. I
sale.If.however.the building or improvement is sold within one year ofcomplerion.Ne SQ,.I7 FLOOR ARG SISQ.FL/
ovider-trailder will have the burden of Proving that he did not build or improve for for, ( s
pass,of sale.).
Fl 1,as owner of the p r,scri am exclusively contracting with licensed contractors to L'
construct the project(See.7044,Business and Professions Code:)The Committees Li- MAY 28 19p9(� \
cense Law do.not apply¢.anowneruf property who builds or improves thrdsom and QTY, PLUMBING PERMIT FEE Is78 s
who contracts for such p rrecr.s with a contusions)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE CITY Ur �Lra:ItllleU
❑ Iamexemptundcr Sec. .R&PCforthismamn
Owner Date ALTER-DRAIN&VENT-WA . (EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECR ' E /1000. 000
I herebyuffinn under pcnultyof perjor,ord of the following decluruticar, x
1 have and will maintain u Certificate of Conscre m.elf-insure for Worker's Counter- ONO.per- DRAINS- 'LOOR.ROOI7.A STORIES 'I'YE,CONST RUCTION
sation, a provided for by Section 3]1X1 of be L.1, Code,for the performance of the
work far which this pendia is issued '1 -1-PERTRAP
El 1 have and will mainmln Workers Compcn iourn Insurance,as required by Section
370rof the Labor Cads,Torahs lmrmnnunccof the wnrkfncwhich thispencit......votGAVFA.SYSTHM-I INC.4061'1. OCC GROUP AIN
WorkCompensallaarnw: �)ps rtec
p road P)ey'p�{p�It��(
LIV4 N.NDly ic Policy No.: NC% 37 GAS-E .. S'H7Md)VFR4I IA)\'
CERTIFIC 117 OFEXEMPI'[ON FROM WORKERS' GREASE/IN .WAS TE INTERCEPTOR
COMPENSATION INSURANCE BUIL 'IVISION FERS
(This.acnion need nor he completed if the permit is for..handled dollars 15100) GRE 5. RAP O
or Iccsg PLANCHCK I
El'
I certify that Turn,perfmm.anceof the work for which this permitis issued,lsbalf SEW EH 1'A S'Y- RM EA.200 FT.
not employ any person in any manner so as to become subject o the Workers ComMn- ENERGY FEE
Z sation Lit—of California.Dare WATER HEATER NF /ELECTR
O Applicant GRADING
z' ej) NOTICE TO APPLICANT.If.after making'his Certificate of Exemption,you should WATER SYSTEM/IRGT
become subject to the Workers ComMaxatiun Provisions of the Labor Code,you must SOILS FEE
forthwith comply wilt such Provisions.,,his permit shall be deemed revoked. WATER SERVICE
LLJ 0
0. CONSTRUCTION LENDINGAGENCY NEW RISIUENTIAL P11.1B. SQ.FT. PAID Data c t f
L)Q Ihcaby affimt that there isaconsrmsiion lending agencyfortheperfmmarace of t`0
the work for which this pcmtit is issued(Sec.300,Civ.C.)
(--' Lenders Name TOTAL:
C) [ULl lenders Address TOTAL: BUILDING FEE rx
I comity that I have sad this.,irridsm and nate ohol the above information is
.F.a V0.) correct.I agree to comply with all city and county ordinances and.cute laws relating or QTY. MECHANICAL PERMIT FEE 1
UZ buildindi
,e...tuon and bercby authorise repmenwm SEISMIC FEE
stives of this city to enter wpthe 1 so t
atarve-mentioned poolwnY far incltec' a urinsec. PERMIT ISSUANCE
(We)agree Io save,indent fy ma keep humorless the City of Cupertino against ELECTRIC FIiE
limiloux,jwb,watc,00stcand a ich may in any way accrue against said City ALTER OR ADD'IO MHCH.
nseyue Ibe gra in" Ih6 per It. PLUMBING FCG
APPLIC T U ')FRS'1'ANDAND MECHANICAL 171712
COMPLY WITH ALL NON-POINT AIR HANDLING ON if(To IB,,po CFM)
ti0URC1 Iola ,LAJ'IONS.
_Z1--9 AIR HANDLING ON I'1'(OVER 10,000 CFM) CONSTRUCTION TAX
Ignatur fAPPI r. uo
Date L'XHAUS'EHOOD(WIDUCD HOUSING MpI GAI ION FEE
HAZARI WS MAT17RIA SS DISCLOSURE
WI the applicant or fut a building acupant store or handle Wondrous material HEATING 11Nl'1'('1'O IN),gX)B'TU)
s as delined by the Cupertino Municipal Code.Chapter 9.12,and he Health and Safety
Cale,Section 25532Ny? _ HP.A1 INC,UNI'1'(OVER 100,000 BTU)
Yea ❑No PAID
VENTILATION FAN(SINGLE RESID) Date Roox r-
Will the iroapplicant o future building by the B use equipment itQu or devices which BOILER-COMP PHP OR 1(0.00)BTU)
•mi'hazardom air conwmin:ams as define)by the Bay Arca Air Quality Managemem A .
Disuio? BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No
I have the hssaes morwria,tuirtenlc under Chapter 6.95 of dao Cali- AIR CONDITIONER ISSUANC-
fomie rdrym
.IN&Safety GNe,Sections 25505.25533 it 8531.1 mtdawaaad that if the NEW RESIDENTIAL MIKE. SQ.FT.
s building loxia out currently have a mown.that it is my responsibility to notify the occupant
of the requirements which must be met Our to issuance of a Certificate of Occuparwy.
Owne,miumborned agent Date TOTAL' ISSUED BY:
1
OFFICE