29912 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO I BUILDING-ELECTRICAL PERMIT NO. 29912 9^1 2
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L`IJA VJ L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'
X011 �. ��s�la-�eS dr _�Cs6�G
OWZ[LR'SNA,\E. PHONE: C RA OR'SNAME: LIC NO: 1•
L1 �S (O ^� 2 �• 8 7k Y - e ,� c_/0 ZS�2 NIC CON'rROLM
�ARCHITECT/ENGINEER: LIC NO: ADDRESS: Aye
-
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CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fact,Paid by Applicant(Initial) BLDG ELECT PLUM
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE El
1 hereby alBnn that 1 am licensed under provisions of Clwpmr 9(commencing JOB DESCRIPTION
CMZ
FSB with Section 7000)oflAmom3.fthe Budnessided Profes,,ions C:de,nod any license is RESIDENTIAL
tell fomcandcffea. PERMIT ISSUANCE /
aUU License Class Lic.a ❑SFDWL ❑KITCHEN REMODEL
rFisZW Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
A CHI'ITCTS DECLARATION, PANELS ❑MULTI-UNIT []STRUCTURAL
OZy? lunderslafy plans h Il eiet ablierecords - UP T0200 AMPS MODIFICATION
-- Licensed Pmfessinnal �.. ❑INTERIOR ❑CHIMNEY REPAIR
j OWNER-BUILDER DECLARATION 201-If%%1AMP5 IMPROVEMENT
W Q I hereby of man that 1 am exempt from the Contractors License Law for the OVER IUOUAMPS ❑BATH REhIODF.UREPAIR D MOLITION
xLx a U following reason.(Section 70315,Business and Professions Code:Any arty or county SIGNS ELECTRICAL ❑OTHI
W 3 ps y which requires a payout to construct,alcor.improve.demolish.or repair any structure
moo prior m its issuance,also the applicant for such tto file a signed y requiree pp piens gneJsmmmem SPECIAL Cl RCU'/MISC.
Y thmhe erislivenW pursuantmtheprovisions of IM1e Contractor's Licenselaw(Clwpmr9
tcin he 11.am,ah SvOdirector
ad t f Divisinnr the s aged ss and Rofeuiovi Cole)or TEMP.ZDEVI '
INS'T COMMERCIAL
d a c
thin he is exempt tberelmm and the basis for the alleged exemption.Any violation of
oil o2 Section 70315b ❑NEW BLDG/ADDITION ❑DEMOLITION
E.Za' YanY applicant for ohJeas the applicant civil penalty of POWERt more thin rive hundred dollar l$5001, ❑TENANT ❑FOODSERVICE.= I,as owner of the property,or my employees with wages as their sole compensation, SWIMMTRIC IMPROVEMENT
will du the work,and the xwcmre is not intended or offered forsale(See.70,41.Business ❑OTHER
aac and Profession Code:The Comraclors License Law docs not apply to an owner of OUTLE -FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or Offered for NEW RESIDENTIAL EL!! R 5
sale.If,howcveq the building or improvement is old within one yearof completion. SQ.FT.FLOOR AREA $/SQ.FT
owner-builder will have the burden of proving that be did not build or improve for pur-
pe,coluray
1,am owner of the property,am exclusively contacting with licensed contmctocs to py Q
mown the projcn(Sec.7044,Business and Profeaslons Code:)She Cmdoomrs Li-
cons law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT PEE tD
who nmmeet,Ensuch projects with a cortracmr(s)licened nmvnaatto the Contractor's ss
License Law. PERMIT ISSUANCE y
[]I am exempt ander Sec. .B&P C for this reason rn I
ALTP,R—DRAIN&VENT—WATER(FA)
•Owner Date V/VALUATION
Wm code,
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE yt._
I hereby affirm under Certify oe ofCcY one of the following Wdmas,Co 4/T//f 4u
I] Ihave and will for bynaCion 3700 of ilia sent to Labor
liar Wdurnecs Comp the DRAINS—FLOOR,12001',AREA,GOND. w STORIES TYPECONSTRUCf101
weirs,as provided for by Section 371)of the Labor Cade,lin the parfnrmnnce of the
work for which this Amnio is Ismail. FIXTURES—PER TRAP
❑ Ihave and will maintain fee Worker's ante filvev rkfor which
re,peranhr Section
3700 of the Lahr Cafe.fur the performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-I INC.4OUTLETS (>CC.GROUP CPN
My Workers,,C ppensmionln.wrnce carearaal Policy numberq,re�A
Carrier:w5 Fe w.p� - Policy No.:ZT e---/ r GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ORE- SEIINDUSTRL WASTE INTERCEPTOR
or less.)
(This section need not he completed ifthe permit is for one hundred dollars 1$Bq) GREASE TRAP BUIL GDIVISION FEES
I'LANCHECK FE
Boy anythm in they my
of be work far whter je this me
is issuedlshelf
on- SEWER—SANITARY—STORM EA.200 FT.
not employ any person in wy marum/.� y.t yecgy 5 bjecnr the Waken'Coupon-
ENERGY FF,E
sZ cation Laws of lifo Did .7 //S/Ybu
Applicant
Y WATER HEATER W/VENT/ELF.CIH
z r GRADING F[
I NOTICE•T APPLICANT:IL after corking his Ceni)wm of Exemption,you should AT ER SYSTEM/I'RHATING
P
; become subject to the Worker's Comp rwanion prov sinus of the Labor Code,you must
fonhwith comply with such provisions or it shall be deemedrevowd. SOILS FEE
� O perm: WATER SERVICE
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ FT. PAID
L) 0 l hereby affirm Nauherc is a conanction lending agency for the perfommrnx of t Receipt#
{Ir Fthe week far which this permit is i ssucd(See 3097.Civ.C)
f aadeea Name
0 W Lender's Address T t TOTAL:
d 1 certify that I have read this application and state that the above inforram on is
_
(n correct,l agree m comply with all city and county ordinances and stme lows relating to QTY. MECHANICAL PERMIT BUILDING FEE
V z building eonstrvetion,and hereby authorize rcprettmatives Of this city menmr upon the FF S[15St
PEG
move-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m wve,indemnify and keep harmless the City of Cupertino againxt ELECTRIC
lmlrlities,judgmems,cosi,mcl expense,which may in any woyaccmc against said City ALTER OR ADD TO MECH.asnseyucnce of the graining of this permit. PLUMBING
APP.1CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CFM)
SOI EREGULAT S. 1^ MGCHgNICAL TE
_ s�
I aa�-. f-/ AIR HANDLING UNIT(OVER IEOOBCFM)
[SIG__ CONSTRUCTED TAX
Signature of
.1 Not ° Dam EXHAUST HOOD(W/IIUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGs ION FEE
Will The applicantnr(Muni building occupant scoreor handle Health, material HEATING UNH'(TO IIlO,(NNIBTU)
as de.Sed by the Cupertino Municipal CoJc.Chapter 9.12,and the Health and Safety
Calc,Section 25532(,)7 HEATING UNIT(OVER IINI,0101 ILTU)
❑Yes F7 No
VENTILATION PAN(SINGLF,RISID) PAID
Will the air cont, or Patna building by the Bay
A equipment or devices which Receipt a
emit hazalloms air contaminants as defined by the Bay Aren Air Quality Management BOILER-COMP CHP OR 1 W.IXHI RTU)
Diaria7
E]yes E]No BOILER-COM P(OVER 100.00()BTU) TOTAL
I have read thc lissom us mammals requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
famia Health&Safety Calc,Sections 25505.25533 and 2 5J4.1 unJersmml that If the ISSUANCE DATE
building does--currently have a lenam,thin it is my respendbility to notifyth cacme,nt NEW RESIDENTIAL MECH. SQ.FT
of the rcquircarairs which must be met prior to issuance of o CeniOcam of Occupamy.
Owner ur uwhorized,gem Urs¢ AL: ISSUEDB :
OFFICE