29645 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPF.RMITPLUMBING-MECHANICAL.
BUILDING PROdRCI'IDENTIFICA'I']ON 29645
BUILDINGADDRESS: - SANITARY NO. - APPLICATIONSUBMITTALDATI.
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OWNER'S NAME: PHONE: COggTRAM OR'S NAME: LIC
tn MAl�l—L f_ U, W kT � `P(�S✓L 13NIC CON raol.#
ARCHITECUENGINEER: LIC NO: At) ES — fG� v D ❑
CONTACT: PHONE; lhJ .JF BUILDING PERMIT INFO
�N z 0, ❑ Consultant Fees Paid by Applicant(initial) SLUG ELECT PLUMB M[CH
7t ❑ ❑ /J ❑
LICENSED CONTRACTORS DECLARATION QTy ELECTRIC PERMIT FEE
I herehy afOrm that Earn licensed under provision mf Chapter 9(commencing JOB DESCRIPTION
CMZwih Section 7(X)Eof Division3 al he Businessand Professions Code,and mylicenseis RESIDENTIAL:
00 in full force send effect. PERMIT ISSUANCE
UV L,amw Class Lia# ❑SFDWL ❑KITCHEN REMODEL
fn QG Datc Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REPIPE
I„
NARCHITECTS DECLARATION ❑Sluim.UNIT ❑STRUCURAL
zO�Z4 l understand my plans shall he used as public records PANELS MODIFICATION
OZ-D UP102MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-IfIfIn AMPS IMPROVEMENT
y1�P7 W I hereby affrnm that am eFe�mpt from the DECLARATION
License Law for the OVER I WOAMPS ❑BATH REMOID.Ii11lREP�It�QDEb1fJLITIO _I
x 3 6 U following remnn.(Section 7031.5,Business send Professions Code:Any city or countySIGNS ELECTRICAL ❑OTHER
al LL LL0 which requires permit to permto construct,aper,improve,demolish,or repair any struemm
prior to issuance,al,so requires he applicant fimsuch permit toile a signed statement SPECIAL CIRCUIT/MISC,
a tlwt he is focused pursuant tm the provisions of the Commenor',Licence Late(Chapter 9
(commencing with Section 1000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. -
a o C that tae is eaempt themfmm and he basis bertha shared exemption.Any violation of V G/ADDITION ❑DEMOLITION
Y•
Section 7031.5 by any applicant for a permit subject he applicant m a civil Penalty of POWIiR DEVICES
m TENA [I FOOD SERVICE
�y not name than frva hundl'cA dollms($.500). }p1PRO
6 pr',as owner nl and Ne property,or my employees with wages us their sole compematiun, SWIMMING POOL ELECTRIC �r(il�
y will do the work, the slruew.is not imalsommnffered far.1,(Sea.'/044,Business T�7ER
W m sad Profession Cade:11,Ccularr nr's License Low docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES (�
E, .. property who builds nr in.pnrves thereon,and who doessuch work himself m through
his own employees,provided that such improvements are not intended or offered for NEW RESIDE.N'1'IAL ELECTS SQ FT.
salt.If,however.he building or improvement is sold within one year ofcampletion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have time burden of proving that he did nm build or improve for our. r•,^
pose efame.). - ,r (c L I
I,as owner of the pmpeny,am exclusively contracting wih licensed contractors m TOTAL:
nawct the pmjmt(Sm.7W4,Business and Professions Cadet The Convector's Li-
cense Law dcanot apply loanowner(it'property who Im Ids or improves thereon,and Q'I'Y. PLUMBING PERMIT EEL
who APR 301996
mntmnn fm such projects whh o cnnvecnm(O lleenacJ pursuvm w the Contracmrs
License law. PERMIT'ISSUANCE
❑ I stn exempt under Sec. .R&P C for Nis mason
1'
Uam ALTER-DRAIN&VCN'T-WATER(IIA) It
Owner "ygLDAT'ION'
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under pera ty of perjury one of the following dailarations:
❑ I havemndw illmainwinnCenifcute of Conseun to self-insure for Worker's Cnm(cn- DRAINS-FLOOR,ROORARFA,COND' STORIES TYPE CONSTRUCTION
sodium,n provided for by Section 3700 of the Libor Cade,for the Performance of the
work far which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
31(x)mfhm Labor Code,for the perfm.mce oflhn work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40UTLH'I:S
OCC.GROUP
My Worker'Compensation Insurance carrier and Policy number art: APN
Cartier. Policy No: GAS-PA.SYSTEM-OVER 4(EA)
CERTIFICATE OP EXIfMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSI RL WASTE INTERCEPTOR
(TTis section neW not be completed ifthe permitis fmone hundred Jollma($Ilk) BUILDING DIVISION FE13S
or less.) GREASE TRAP PLANCHFICK FEE
I certify that in the perfonabor.ofhe work forwhlch his pardon is issued,Ishall SEWER-SANITARY-STORM P.A.200 FT.
not employ any perso in any raantur_wJry-hmntpgtubjmt to the Workers'Camlwn- FNERGYFEE -
zZ onion Laws Info a Date 9 fa+ l 1e WATER IILATF.R WNENT/ELIiCfR
0 Applicant a 0 GRADING FEE
(.. yn NOTICE TO PL NT.IL after making this Cernif nor of Exemption,you should WATER SYSTEMTItEATING
hmanm subject to the Worker's Compensation provisions of the Labor Code.you most SOILS FEE
forthwith comply with such provisions or this permit shall be claimed brooked. WATER SERVICE
Q
CONSTRUCcIONLENDING AGENCY NEW NESIDF.NTIAI.PLMB SQ.19'. PAID
V O 1 hereby which
ant that here isoed(Seconstruction lending agency I'm the Perfonnvwe of Data Rmeipt#
� r he work for which this pcmmit is issued(Sm.3W1,Civ.CJ
I--' Lender's Name TOTAL:
kUTI Lenders Address 'TOTAL:.
1 ccnily that 1 have read this application send suite that the room information is BUILDING FEE
V) correct.l agree to comply with an city and county ordinances and nam laws misting to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby amhonse representatives of this city.enter upon the SEISMIC FEE
ohovo-ntentim.ed pmpony for blemlion purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino a urawt ELECTRIC FEE
Iiabiluies,judgments,casts and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in sequence of he granting of his permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1(1,11(0 CPM) r
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0011 CPM) CONSTRUCTION TAX
Signature of Applican/Commctor Dole EXHAUST 13001)(W/DUC'11 HOUSING MpDGA'ITON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or future building complaint stow or handle Income.,..[a .] HEATING UNIT TO Ifk,0f111 BTU)
as defined by the Cupeni no Municipal Code,Chapter 9.12,and the Heal ill and Safety
Code,Section 25532m)t HEATING UNIT(OVER I 00p00 BTU)
C]yes r_1 No PAID
VENTILATION PAN(SINGLERESIO) Dem Rmeiptp
Will the spplieamorfrtme building occupant use equipment or devices which BOILER-CDMP(JlIP OR IW,E(10 BTU)
emit humorousuimo
s air cmnndiu as&food by the Bay Area Air Qu thty,Management TOTAL: 7
District?
Year No
BOILER-COMP(OVER 100.0")BTU)
❑ ❑
I have read he hmurrlous materials requirenants under Chapter 6.95 of he Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505.25533 and 25534.I undersand taut if the NEW RESIDENTIAL MECH. SQ.FT.
building does stn emmntly have a tectum,that it is my re,ponibi lily m notify he vertical
either ra,uncnanls which tel he met prior.isswmce of o Cenlfcale mf Lemma,
Owner ser auhnnzcd agent Dae TOTAL: ISSUED BY:
OFFICE