29243RED LINES • USE BALL POINT PEN ONLY
BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATIONFPERMIT
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29243
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OFFICE
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CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
B�1LLDpDrfG ELECT PLUMB MECH
� ❑
LICENSEDCONTRACTOR'S
mod"SDI?CLAHATION
I min? affirm this I um licensed unJer provisions of Chapter 9 mylicense is
with Seuion7000)ect, sionlnflhe Rosiness and RvfexxinnaGde, and my license is
In full but and effect,
License Claes Lin. p
Dam Contractor
QTY ELECTRIC PERMIT FEE
TOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. ❑KITCHEN REMODEL
❑ADDITION F1 PLUMBING REPIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
HATH REMODEVREPAIR ❑ DEMOLITION
❑ OTHER
0"I"AJAI Al
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITEiCPS DF,CIARATION
den
1 unWnd my plans shall be ueJ as public records
PANELS
UPT0200AMPS
Licensed Patessionvl
OWNER•BUILDER DECLARATION
1 herchy upon thin l am exempt from the Contort License Law for the
following rev.on. (Section 703 1.5, BmImess and Pmfessions Gyle: Any city or county
which requires a permit w cunnrvm, ober. improve, demolish, nr repair any structure
prisnoim issuance, also rcyuirex the vpplieam fnr.cuch pertninn file asigned smmmem
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter9
(commencing with Section 7IXXp of Division 3 ofthe Husinessmad Prnfeaslnns Gale)or
that he is exempt therefrom and the basis for the alleged ascription. Any violation of
Section 7031.5 by any applicant for it permit subjects the applicant to a civil penalty of
not mare then five hundred dollars ($501)),
I, as owner of the m norm compensation,
❑ P pe Y my or offered
will ds the work, and theI he Co a iv not imm�dul m orfc dol for sds (Sao.7014, Business
for set, (Sec.
and imy who
Case: imp Connacmrs L and v, Law Aces nm apply m if owner ht
prnpeny who hn11As or improves suchn, and who Jou .vunh work dee or ma Waugh
his own employees, po ldi nl Bim .such improvcmcmx arc not intended or infero:, for
sole. 111 hnwev will Imniltie loom ofprosint .v.vn a, iibinnneyeurofcnmpletior the
ownerhuilJcr will have the M1unlen of proving obit he did nut build or improve far par-
pnxe of sole.)'
1, as owner of the property, am exclusively eon r cling with licensed cantrauors to
e ostmn the project Sec. 7044, Business and Profession., Code,) The Contractor's Li-
i-
u
.cenulawJoesnateplymanownernlprolnnywhobuildsorimpmvesthereon,and
whoeontrects Pesach pntjectx with a continuants) licensed pamuam to the Commusaies
License law.
❑ 1 am exempt under Sec. , B & P C for this reason
2111-11Xp AMPS
OVER ]"AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MDC.
TEMP. METER OR POLE:NST',
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTI TER
POWER DEVICES
SWIMMING POOL ELECTRIC
OITfLP.TS- SWITCHES - PIX'fURCS OO
NEW RESIDENTIAL CLEC SQ FT.
-
-
SQ. FI'. FLOOR AREA
pP p p
- T'7 g
/n r„ •�
4/ N s� 1996
3,
�I'f Ur-
Lor
$/SQ. Pf.
TOTAL:
QT'Y. PLUMBING PERMIT FEE
-
I PERMIT ISSUANCE s'
ALTER - DRAIN&VENT-WATER IEA)
Owner Dale
VAL Ar N,
DO (/`�
WORKHRS COMPHNSA'ITON DECLARATION
1 herchy salamander penalty of perjury one of he folm
twing Jeclemtis:
on
I� I havevnd will alumina Cenificmem'Coment to,ch.insum for Worker's Canape..
cation, u providel for by Section 37M of the Lbor Code, for the pefommne, of the
work for which this permit is issued,
❑ 1 hove and will Imsinmia Workcra Compenati Insuoce, as captured by Section
son m
37011ofshe laMrCede,fordo, pedurmenceofthe work for which this permit is issued.
IIIII W Cf$ atinyysnrsoc�arrierand Policy number ve:
Cam /�/l'C�� Policy Nn:
CERTIFICATE.. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This.,ion need not beeompleted if the pemnil is frrolte hun to d dollars($1 W)
orlcs,.)
:certify ohms the per6mtmtaof Weworkfor which this perminisirx'(7 icapi
not employ any person in say mumter so us m become subjectm the workers' Compen-
of California. Dae
Applicant
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, RODE AREA, COND.
STORIES
TYPE CONSTRUCTION
-
FIXTURES -PER TRAP' �e`
-AL
' GAS - EA. SYSTEM -1 INCA OUTLETS
OCC. GROUP
APN
GAS -EA. SYSTEM -OVER SEVA)
GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
YLANCIIECK FEE
SEWER -SANITARY -STORM PA. 200 FT.
ENERGY FEC
WATER HEATER W/VENT/ELECfR
GRADING FEE
NOTICE TO APPLICANT If. after makingthis Cenifcateof Exemption, you should
become subject to the Workers Compensation provisions of the Labor Cole, you muss
fnnhwioh comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING ng agency
I for by affirrin that Fronat i isacnnawctinnlendingagency Rothe performance of
work for which this permit is isxued (Sec. 3W7, Ci, C.)
Lenders Name
WATER SYSTEM/1'REATING
SOILS FEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLMB. SQ. FT.
Date Reccip if
lander'a Address
TOTAL: S'G
1 certify that I have mud this application and state that the shove information is
correct. l agree to comply with all city and county ordinances and state laws relminga
building cnnstrvction, and hereby authorize mpresenmtivesof Wix city aenterapan the
anovo-Weanloned property for inspection purposes.
g y urn p y rs pe g
(We) , ice a sive, i id telp f which
hunnlexs they f Cu nino u City
inbicasectuar of thecoasandaxthis pe which may at.., wny uccnm againvt said City
APLICANT UNDERSTANDr,nfS
AND WILL
APPLICANT UNDERSTANDS ANU"WILL COMPLY WITH ALL NON -POINT
SOU :CUL N.
ignature(if ApplicanOContmetor Dote
HAZARDOUS MATERIALS DISCLOSURE
Willtwritc,eam or fame building occupant .are or handle hmnNnp.antmerial
as defined by the Cupertino Municipal Gdq Chapter 9.12, and the health and Safety
Code, Section 25532(a)1
Fl Yet 71 No
cordons applicant or future building by theBtuse yAea Air uor Maes nagement
.t hauNous air amwmiwnm as defined by one Rey Area Air Quality Munegemcnt
�stnct?
❑Yes FlNo
I have real the haircut nusnutcriers teyaimmcnm unJer Chapter 6.95 of the Cali-
fwnia Hcadtg does & Safely Code, Sadism 25505, 255JJ esp 25534.1 to neraath Nat if she
building dons not currently have a tions that it is 53 rtsit B5 lloy to dinnu the umtpam
of the requirements which mut Ne met prior m ixvoance of a Cenificem of Occupancy.
BUILDING FIR:
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
ELECTRIC PP:BPLO
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
PLUMBING FFE
AIR HANDLING UNIT(TO 10," CFM)
MECHANICAL PCE
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCDONTAX
EXHAUST HOOD(WNULT)
HOUSING MITIGATION F:E
HEALING UNIT OLD 1011," BTU)
HEATING UNIT (OVER Ihilc n BTU)
PAID
VENTILATION PAN (SINGLE RESID)
Dia Reuel
BOILER-COMP(INP OR 100,OW BTU)
TO L:
BOILER - COMP (OVER DR." BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY: 'qn'0Zj
NEW RESIDENTIAL MECH. SQ. FT.
Owner o igalon iud agent Data
TOTAL:
OFFICE