29508 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-IrLECTRICAL PERMIT NO. 29508
1^ r
BUILDING DIVISION APPLICATION/PERMIT PLUM0/1
BING-MECIIANICAL s - L V4 5 �8
BUILDING PROJF.CP HIE hITIF'ICATION
BUILDING ADDRESS: ���� OW{_ D►2a SANITARYNO. APPLICATION SUBMITTAL DAO
. ,.
OWNERS NAME
__ME
CON 'L�IC NO:
N/C CONTROL Nf
il 404'
1RCHITECT/ENGINEER:. LICNO:
❑ -
CONTACII PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that l am licensed under pnrvision of Challef 9(Commercing JOE DESCRIPTION
-QQ'Z with Sectinn]afla)of Divieinn3 of the Business and prrfessi,,nv Calc,and my license is RESIDENTIAL:
WW 0 O PIIRMTI'ISSUANCE
F� ht full brcu and effort ,,LLtl
�OzU Liccnse Class G�ao le,
1cba ;&o.U7 -` - ❑SFDWL [I KITCHEN RfIMODIE.
HVW Data Crmnctur API'LIANCFS-RESIDEM'IAI. ❑ADDITION - ❑PLUMBING RE-PIPIT
FQH ARCIUTIiCTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
I undc.=it my plans shall he used as public records MODIFICATION
UPT0200AMPS
o°z�Q ,
Licensed Professional ❑INTERIOR ❑CHIMNL•Y REPAIR
OWNER-BUILDER DECLARATION OVER
U AMPS IMPROVEMENT ATEREODE
{y 01 1 hereby affirm that I um exempt farm the Conwcmrs License Law far the OVER ul(IB AMPS ATE REMOUEI/IiFPAIR DEMOLITION
pea 6 U fallowing reason.(Section 7031.5,Restarts wd Professions Cede:Any city or county SIGNS ELECTRICAL ❑OTHER
4l�O whicM1 rniuircs a permit m conawet.ober,improve,Jcmalish,tiro rcpuir any swcmrc {�-•��•�T'�(I����S%�
prion,,it,issuance,also--regniresthcapphem,for such permifto,Me aligned statement SPHCIALCIRCUIT/MISC.
} phut he is licensed purstastothepro,kionsofthe Convectors License Law(Chapter9
GG morruncingwith Seclion700Bof Dividrr3 ofthe Bminesand Pudessiml Ctde)nr TEMP.METER OR POLE INST. 'COMMERCIAL:
4 c e• that he is exempt therefrom and the basis for the alleged exemption,Any violation of • [I NEW BLDG/ADDITION ❑DEMOLITION
4, Salion703L56yanyup,licanlf,,rupermillubjulstheapplicannaacivil penally o! POWIiR DEVICES _
r W mop more than five hundred dolls.(1500). ❑TENANT El FOOD SERVICE
F�QI,os nwneof the IMPROVEMENT
Q ❑ propeny,or my employers with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the swcmre is not intended Droners]fnrsnle(Sec.7044,Business ER-
end Professions Cole:The Contractors license Law it.out apply to an owner of OITUXIS-SWITCHES-FIXTURES
a 3 property who builds or improves thereon,and who does such work himself or through
Nitrite employees,provided that such inmprovemems me nol intended or uttered farNEW RESIDENTIAL ELECI'R SQ FT.
sale.If,however,the building or inmpmveauem is sold within one ycurolcnapletian,tbe � SQ.I . 'LOOR AREA - VSQ,Er..
m-hullder will have the huNenof provin6 that he did nntbuilJ nrimprrve fqr per- �' - it n
Pox ofsaleJ.; m '
❑1,as owner of the progeny,am exclusively contracting with licensed amore m.m TOTAL:
construct the project(Sec.764,1,Business and Professions Csdca The Commnur's Li-
expose Low doesnmapplymanmsusa, f property who builds or improves Hereon,and QTY, PLUMBING PERMIT PEEwho contracts lorsuch pmjmts with a co macho s)licensed pu.unnnorhe Contxcmes
License law. PERMIT ISSUANCE ,
_ ❑lam exempt under Sar. ,If&PCforthisrcvon
Owner Date AI•TER-GRAIN&VENT-WATER(EA) SEPf.A ATION
s s WORKERSCOMP'IINSATIONDECIARATION HACK PLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following dudumtions: O I UI-_W W''Ll a 111411
•E] I have and will maintain a Cenificale of Consent to self-in.sum lin Worker's Camper DRAINS-FLOOR,ROOF.ARE A,'COND..
s hien,as provided for by Section 371(1 of.the labor Cede,for the perfomaince of the STORIES 'TYPE CONSTRUCTION
for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Workers Compensation Insa ince,as no umal by Section 11.
3701 ofthe labor Code,for the performance of the work
�for yw�hhiichthiss Permit is issued. GAS-G.SYSTEM. INC.4 OUTLEfS OCC.GROUP' APN -
MyWork.Er ropeJJ��$gtip la m1,51rnn`IcirtJeP i4Y No.yl4ft( ( / .gyp
Crooner.(, ZA ITV O ��018 CAS-EA.SYSTEM-OVER4(M)
CERTIFICATEOPP.XE TION MROMWORKERS'
COMPENSATION INSURANCE GRISSMNDUSTRL WASTE INTI?RC1?PfOR
Otis xutiun recd not M mmpletal ifthe pamnit In Tomos hundred dnllu.(EtlO) BUILDING DIVISION FEES
or kvsJ GREASETRAP 1 PLANCHECK PILE
I certify that in the performance of the work for which this portrait is issued,I shall SEWER-SANITARY-STORM P.A.200 Ff.
not employ any person in any manner so as to become subject m the Workers Compton- ENERGY FEE
Zsatin.lowsophrooma.Date WATER HEATER W/VII MLECR
00 Applicam fly- n• - GRADING ME NOTICE:T�P IC iIA Ix: fur making this J(mificate of Exempti�n'you shnd WATER SYSTEM)REATING
become subjecno the Workers Compensation provisions of the LaMar
code,you run SOILS FEF.
fon ovith comply with such previsions or this perm&ball he deemed revoked. WATER SERVICE -
Q
COtthem is I TONa const LENDING ding a NCY NEW RESIDENTIAL I'LMIi. SQ.PC PAID
.
" Ua he hYefimlhm them is ucnnswetion lending egcncy for the rfnnnmme of Receipt M
{gs F the work for'which this permit is issued(Sm.NPO.Civ.C.) - �'
.0 U Lenders Name ' TOTAL:
LEI Lenders Address TOTAL: e.
as I cenify that 1 have read this application and state that the aMme information is ' BUILDING FEE
0 counter.l agree to comply with all city and county ordinances and state laws relaing to QTY. MECHANICAL PIiRMIT FEE
U Z building conswction.and hemhyindamixampreandatives ofthiscity menterupon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE - '
(We)agate to save,indemnify and keep ha nde.the City of Cuperino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MF.CIL
in consequence of the granting of this permir. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT AIR HANDLING UNIT(TO 111,001 CPM) - -
SOURCE REGULATIONS., ' M HANICALIE .
s 'AIR HANDLING UNIT(OVER IgWOCFM) CO STRUCTIONTAX. -
SignamteofApplicanVComrector - Data s EXHAUST HOOD(W/DUCf)o HO SING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURP. -
Willtheapplicant orfumre hi iliingxeupantsroreor handle huzadous marten] HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health aed Safety
Coda.Sutton 25532(x)7 ..,/ HEATING UNIT(OVER 100.005 I1TU)
E3 Yea LYr mVENTILATION FAN(SINGLE RISID) PAID
' - Uate. Rucipt p
Lou Will Ratifil m utu f t hatmed occupant use m Air ardQu nr deuces Mwhich
anagement
t
M1 DooburN once mut. u. Idined'by the Bay AreaA Quality ❑UILf:R-GDMP(3HP ON IIM).M(1 B'I U] e s
xT01'AL:
DmsineT/ T- / HOD-ER-COMPIOVER IW,O(IBTU)L(TO
❑Yes Iklarr .
I have read the hmakar.nownalsrequirements under Chapter 6.95 of the Cali- AIk CONI3ITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 23534.1 undrnmad that if Um NEW RP_SIDF.NTIAL MUCH,
SQ.FE;
builds gd«s nm curtcntlY haves mnn(m),thet it is mY eamonibifity porosity the occupant
nl the iel::a•rma'd 'them�'fL"h missany m(n eni(cg�mf Occupy cy 1
�mm I A
Owner ornnzed agent Uom TOTAL: ISSUED BY;
,to . . . OFFICE, or