29774 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO ° ,BUILDING-ELRCPRICAL PERMIT NO, w w
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29
NUILDING PR13,IISCT IIINNDPICATION
�. 774
BUILDING ADDRESS: y - SANII'ARYNO. APPLICA IDN SUBMITTAL DAD
C I Gt/
OWNEiRS NAME: PHONE: - ONMR: LIC NO:
\ - t-r N/C ONTROL#
h d -
S'- \RCHITE"I'/CNGINE R: IUM,: ADDRESS. ❑ "
CONTACT. THONG: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ' ELECT PLUMB MECH
• ❑ - Wk ❑ ❑
LICENSEDCON'TRACTOR'S
under previsions
QTY ELFCTRIC PERMIT FEE
1 hereby affirm that I an fthe BJ under provisions of Chapter 9(commencing JOB DESCRIPTION
�Owiih Section ndm)otDivisinn3 of Ne Business and ProfeuionsCWe,anJm license is
� y PERMIT ISSUANCE - � ^�� RESIDENTIAL: '
inrull fora and effect. Q - ❑SF'DWL ❑KITCHEN REMODEL
License Cx Lic.p APPLIANCES-RESIDENTIAL
InQ Dmc WCTS onor ❑ADDITION, El PLUMBING RIiPIPE
((--py C 'CTS DECfA ATIO fg� PANELS ❑MULTI-UNIT ❑STRucrURAI.
OpVi7J- IonJentvnd my plans shall be used as public ranras Flgfs'!> UI"I'021NIAMPs " MODIFICATION
Fy:^f I] - / El E)CHIMNEY REPAIR
Licensed Pmfessiomal 201-1000 AMPS IMPROVEMENT
y9aye OWNER-BUILDER DECLARATION i,
��� 1 hereby affirm that I am exempt from the Co"trectnr's License law for the OVER❑00AMPS ❑BATA REMODEL P IR DEMO ITION
x?T U following mason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER '
41 0. which reyuires a permit to conswcf vher,improve.dnnalish,nr repair any stn¢mre _ ��� �-
�.'�� prior ui its issuance,also imp its the applicant l'or such Permitto Me a signed statement SPECIAL CIRCUIT/Ml SC.
6 that he is licensed pursuantmthepmvisimeofthe Contracors License Law IChvpart9
00q (mmmmucing wfith Seainiau)(NryaDivision3 of Ne froonnsand Prnfesomm Gule)m IEMP,METER OR POLE INST. - COMMERCIAL:
Q. c LLthat he is exempt therefrom and the basis for the alleged exemption.Any violation of - ElNEW BLDG/ADDITION [IDEMOLITION
to
section 7031.5 by anyapplicamfor a pennitsubjccm,he applicamme civil pensltym POWER DEVICPS []TENANT ❑FOOD SERVICE
Spnot more than Love hundred dollars($500).,
❑Las owner of the prnpeny,or my empinyecs wird wegw as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the macro re is nut intended oroRered for sale(Sec.7014,Raciness ❑OTHER
THER
and Professions Code:The Contractor's License Law docs not apply to an owner ofOUTLETS-SWITCHES-FIXTURES
property who bonds or improves thereon,and who does such work himself or Ihnmgh - -
his own employees,provided that such improvements are not intended or offered for NEW RESIDEM'IAL ELECfR SQ FT.
sale.If.however,the building or impm6ement is sold within one year ofcontplctimt,thee W[ :v. OOIt�AREq�1�,J ' S/SQ.f9'.
menco-builcor will have the burden of proving that he did not build or improve for pur-
pe. fsale.). � ,r
I,as owner of the Pmpeny,ams exclusively ctmtmcting with licensed contractors to TOTAL: APR 1.9 1996
conswct theprojec t I Weq Sm.7044,Business and Professions CThe Counselor v Li-
move
whocoawJmenotappiyman ownerofpopeny who or improves Contractors
racors QTY. PLUMBING PERMIT FEE
who contract,Lard fur such projects wills a cimtramorfnl licensed pununm to the Comrunors +
❑0
License Law. PERMIT ISSUANCE BLD '. INSPECTION DEPARTMENT
1 am exempt ander sec. ,R&PSC Loot this reason .
Owner
ALTER-DRAIN&VENT-WA'I'17R IEA)
- - o Date - _
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE?
hereby affirm under penalty of perjury one of the following declarations:
hau,am will maintain a Cenificam of Consent o self-insure for Workers Crimper- DRAINS-FLOOR,ROOF AREA.COND.
alien,as provided for by Section 37W of the Labor Cale,for the performance of the STORIES TYPE CONSTRUCTION
work tut which this permit is issued. I' - FIXTURES-PER TRAP -
• Fl I hove and will maintain Workers Compensation Insurance,as required by Section
3701 Labor Code,for the 11fiarmancenfthe work for which this permit is issued. GAS,EA.SYSTEM-1'INC.4 OUFLES OCC.GROUP APN
My Wurkerx Compensation lmsumnce cattier and Policy number are:Carrier.Carrier. -Policy Nu: )
CERTIFICATE OF EXEMPTION FROM W ORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR'.
(phis section need not be completed ifdm permit is forone hundred dollars($100) BUILDING DIVISION FEES
or leaaJ, _ GREASE TRAP PLANCHECK FEE
I certily that in the performance ofthe wr if h thisPnmit isissued,l shall SEWER-SAN11'ARY-S'T'ORM EA.200IT.
not employ any person in any marine so px� rue f h1 O he Workeri Compen- - ENERGY FEE
Z salon Laws .ali tela.Dote `e
Z Q Applicant _ 1 WATER 1117 ER WNENT/ELECI'R GRADING FEE
h NOTICE TO P of L -Item mf ixemption,you should WATER SYSTEM/BEATING
abecome subject to the Worker's Compensauon pmv i s of to Labor Calc,you must - SOILS FEE .,
W forthwith comply with such provisions or mis'permit sb lllsodernmd-revoked Wp'fER S1iRVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
U Q I hereby affirm that mere is a construction lending agency for the Performance of _ Date Receipt#
its Fthe work for which this pertoit is issued(Sec.3097,civ.C.)
Lender's Name
0TOTAL:
� Lenders Address ' � TOTAL: ,
Int 1 certify that I have need this appliatino and, a, te habove nomination is BUILDING FEE
Lor toe/) morat.Irt".to comply with all city and county end ances and state laws reining to QTY MECHANICAL PERMIT FEE 1-J z building constmc[ion.and botchy authorize rcprcsen soflbiacitytoentcrupmd,, SEISMIC ME
above- mioned prapeny for inspection purposes, rve PERMIT ISSUANCE• ^j
e)agree m strvq indemnify and keel bar less t City or Cupertino n,inst ELECTRIC FEE `1
liehilii s, dgments,costs and npensa whic m man ayacerneagoimlio iclCky ALTER OR ADD TO MECH.
in con equ ace of the gmming of this permi PLUMBING FEE
APP IC '1'UNDERSTAN 'AND W f LTH ALL,NON-POINT AIR HANDLING UNIT CL'O Bloom CFM)
' 501 R RF,GU '10 5 MECHANICAL FEE 1 ,
AIR HANDLING UNIT(OVER 10,000 CFM)kA tit CONSTRUCTIONTAX-
• .rgnamre of Applic Catm r )a EXHAUST GOOD(W/DUCT) HOUSING MITIGATION ME
HAZARDOUS MATERIALS SCLOSURG
Will the nPPlinmt nrflnutab uilding oscula [smrcmhmNleha urJnus my iel fI11ATING UNIT fTOIlIX1,11IX1 p'fl1) '
ns definN by the Cupertino Municipal CrNe.C plot 9.12,and the Health and Safety
Code,Smile.2.5532ha?- - HEATING UNFF(OVER 100.0 00 BTU) -
CYcx No PAID
VENTILATION FAN(SINGLE RESID) i
Will the oil senor or future building by the B use equipment.A; a or devices which Dam Receipt#
put hazardous air conmmimmue as JCLoncd by the Bay Are.Air Quality ManvgemOo BOILER-COMP(3HP(3R 100,000 NIU) -
DTAL:
iimiat? BOILER-COMPIOVER IW.IXp BTU)
❑Yn � ❑No .
) AIRCONDITIONRR.
I have reed the hamrdun mammis requirements undo Chapin 6.95 of are Can- ISSUANCE DATE ..
Terni.Hindi&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAI:�MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibility to notify We occupant ,
of Ne requirements which must be met prior in issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE,