29577 (2) APPLICANT TO FILL IN INFORMATION WITHIN'RED Li'w•ES-USE BALL POINT PEN ONLY
CITYOFCUPERTINO BUILDING-F,LECTRICAL PERMITNO.� {_�
5 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROD CT IDENI'IFICATLf1N
77
BUILUINOi ffS: SAND'ARYNO, qPPLICATIONSUBMMALDNIE
NER LONE: TNACI'OR'S N I.IC NO:
NIC CONTROL#
1
f ITEC! GINEER: LIC NO: F'S: E]e- 2
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NITPHONE: BUILDING PIiRMIT INPD
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16AIR., Z'a5"" ❑ Consultant Fees Paid by Applicant(Initial) NLIXy. EIL�ECCTTS PLUMB MEC
LICENSED CONTRACTOR'S DECLARATION , QTY ELECTRIC PERMIT FEE
I hereby affirm d,at I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Won -th Section 7")of Division 3 ofthe Business and Professions Cale.and my license is N
FOO in full force and effect. PERMIT ISSUANCE
'W� WL ❑KITCHIiN REMODEL
Rub License Class Lic.M APPLIANCES-RESID17N'DAL ADDITION ❑PLUMBING RE.PIPH
NZ w Date Contractor
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL
Z O m Z I understand my plans shall be used as public nand, MODIFICATION
OZ-Q UPT0200AMPS [I INTERIOR El CHIMNEY REPAIR
,at Fw Licensed Professional 201.1000AMPS IMPROVEMI31,1'1'
Y 1 j OWNIiR-BUILDER DECLARATION OVER IoAMPS [I BATH REMODEUREPAIR [IDEMOL]TION
W W 6 1 hereby affims that 1 am exempt from the Commi License Law for the
iyyi55 O S V following ream,(Section 7031.5.Business used Profession,Cure:Any city or county SIGNS ELECTRICAL ❑OTHER
ul3 w y which requires a penny m consuuet.alter,improve,demolish,or repair city structureF'u•O� pnortnits issuance also"mine,theapplicant Kovach aarrai ,a file.signedsmtement SPECIAL CINCUIT/MISC.
that he is licensed pursuant.,he provisions of the Contractors Licenw Lot-
(commencing with Section 7(100)of Division3 ofthe Businasand Pmlesomis Cale)or TEMP METER OR POLE INST.
G cy that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
x^,a• Section 70315 by any applicant or.p!rmil subjects theapplicannn a civil per ty of POWER DEVICES ❑TENANT [I FOOD SERVICE
more than five handred dollars($500).
F_ZY IMPROVEMENT
Stu ❑Lo One work.the pro ormfedfrale(Sm. 04mU Business
u miao, SWIMMINGPOOLELECTRIC !J
7 will do the work,and a The Couna outintended Livns n Law cos for,)).,Secs.an immer of ❑OTHER
Fm
unJ Pro(ess'inns Code:The Cnnuuctnr's License Law Jou nrn vpply m an owner of OUTLETS-SWITCHES-FIXTURES
�•'3.. property who builds or improves thereon,and who dsas such work himu9f or through
his own employees,president that such improver th am not intcnntW or offered for NEW RESIDENTIAL ELECTR SQ F1'.
side.If,however the buildmi improvement in sold withinane ycv oUaro ,tionthe �' SQ.FC FTOOR AREA LSQ.I
wncr-builder will have the harden of proving that he did Pro bmlr nr improve for par- (� tr, (��
pose of sole.). 1 $g�(7
❑1,as owner of the propeny,am exclusively commel ng with licensed contractors to TOTAL:
construct the project(Sec.Joao.Business and Professions Code:)The Contmcmrs Li- yk 1 c
can.Law does not apply,...owner of popsy who builds or improves thereon,and QTY. PLUMBING PERMIT FEF, 40 Cs ZZAS
who commas for such projects with a contracton%)licensed pursuant m the Conuacmrs
License law. 1117RMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER ILA) VALUATION
Owner Dam
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
1 hereby,tuff lin code,Franhy of prjmry one.1 the following Jcclamtions:
❑ Ihave and will mainmina Cenifcam ofConwnt to self-insure fur Worker's Compere- DRAINS-FLOOR,ROOF. ,COND. •STORM, PECONSTRUCfION
,mien,as Provided for by Section JIM of the tabor Code,for the performance of the a� 1
walk for which this permit is issued. FIXTURES-PER TRAP ••"
.C1 I have and wili mmintain Worker's Compansation last....rose,as required by Section
3700ofthe LaMnCode.forthe permormancofthe work((it which thispermh is issued GAS-G.SYSTEM-1 INC.4 OU'rid:Is J,1s�CG,Q11,(]UP APN
My Workers Compenmlion In,..come,anal Policy number ase: GAS-ISA.SYSTEM-OVER uLL VV'2� 1996
Carrier Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS' 'MI
COMPENSATION INSURANCE GREASEANDUSTRI.WAS I INTERCEPTOR .. s of lelRIJILDI�'G DIVISION PLiRS
(This section need not he completed if the permit is for one hundred dollars($100) GREASE TRAY
or Ica) PLANCHECK ITL
the Iy that in ancwork for which this issued]shall SEWER-SANITARY-STORM F.A.3W FT.
n
not employ any person in my mllonerstowasmM1econtu subject the WerkerV CmpnENENOY EL
JIZ•O
OZ salon Lima of Ctulifularm Dam WATER HEATER WNENI'/ELECTR GRADING FBI!
Z O Applicant
NOTICE TO APPLICANT:IL after making this Cerificam of Exemption,you should WATER SYSTEVIOREATING
(~ N Smome subject to the Worker',CompemmLaM
ion previsions of the ,r Code,you mum SOILS FEE
forthwith comply with such prosisionv or this permit shall bedwnmd revoked. WATER SERVICE
d 0
CONSTRUCTION LENDING AGENCY NEW RE.SIDENDAL PLM. SQ.FC PAID
V O INewby union Ilahem is a construction leodingogency forth,penbtoorm,of Dom Rrreiptp
H the work for which this permit in is,ved(Site XP7.Civ.C.)
�• Lender',Numc I''I TOTAL:
Wlenders Address - TOTAL - 1
UJ I rectify that 1 have read Nis application and state that the oNice information n BUILDING FEE GO
Hh aorrecr.I agreemeamply with all city and county ordinances and state laws malting to QTY. MECHANICAL PERMIT FEE 4C
U Z buildingcomaaclion,and lmrtby anchorin,mom,enholvesof this city to entelli,an he SEISMIC FEF.
abase mentioned property far inspection proposes. PERMIT'ISSUANCE
(We)agree m save,imem
lnify madkeep harmless the City of Cupertino again, HLIiCI'RIC FGC .`4^
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MEPLUMBING ITE
CH. ` r4 l
in ,.sequence of the gmalm,of this permit.
APPLICANT UNDCRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010,BfM)CFM) `e)A 41
SOURC F.GULATIONl. MIiC11ANICA1,FIiF, Y'1
�t AIR HANDLING UNIT(OVER IR000CFM) CONSTRU(TDON TA%
Sin4Lparold Johromaroct, bollo, / to V EXHAUST HOOD(W/DUCT) HOUSING MITIGATION HE
HA Z RDOUSMAI'HRIAIS DISCLOSURE
Will the applicant or future building occupanLsmm or handle corrections material HEATING UND'(TO 100.041(or BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,artd the Health and Safety
Cole.Section 25532mr? HEATING UNIT(OVER 100.000 BTU)
D Ya, [:I No VENTILATION PAN(SINGLE RES I D) PAID
_Dm e Receipt Of
Will the applicant or fnmre building occupant use equipment or devises which
emit hazardous air contaminantsas dctinedcd by the Bay Area Air Quality hlamlgcmem BOILER-COMP(JHP OR 100.000 BTU) TOTAL:
Disvim
❑Yea F)No
BOILER-COMP(OVER 10),000 BTU)
T have read the hazadtws posensls requirement,under Chapter 6.95 ofdtc Cali AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cole.Sections 25505,25533 and 25534.1 understand that if the NEW RES IDENTIAI,MECH. SQ.FT.
building does not euremtly have.mount,that's is my resgmsibility In notify the wcupvnt
of the mccimmena which no a be met prior m issuance of a Cenilicate of Occupancy.
Owner or,authorized agent Data TOTAL: '1 ISSUED BY:
OFFICE
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