29075 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMRG ING-MECIIANICAI 29075
BUILD ING.PROJF,CT IDENTIFICA'I']ON
BUILDI G DORMS: �� / � SANITARY NO, APPLICATION SUBMITTAL DATE
NER yS hal::�� I//!'//�HONE4 CONT 'S E: LICq/Q: � L
o` r_lf+p//n!✓'1 NIC CONTROL
CdITECT/ENGINEER: LIC NO At S ❑
CONTACT: PHONE: BUILDING PERMIT INFO
/e-\�,x_ - i1�1�J1�/_ ❑ Consultant Fees Paid by Applicant(Initial) BLDG P PLUMB MECH
LICENSED CCO/NTRACfOR'S DECILAR,ATITIION_l! (O QTY. ELECTRIC PERMIT FEE ❑ ❑
I hereby affimt mal 1 am lianurd.oder pro.i.dom of
Cha 9(cmmnencing JOB DESCRIPTION
FODMZ with Section 7")of Division Sof the Businessand Professions Code.and my license e. RESIDENTIAL
, of[If and If /n/�p�, PERMIT ISSUANCE
GF-UU License5 I.ic.N 15 ❑SFDWL ❑KITCHEN RF.MODGL
N<4 Ume�Cumru<tnr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF,-PIPE
(..7y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT 1:1 STRUCTURAL
Z p in Z I undm
ersnd my plan.ehAl he used as public menial, MODIFICATION
pZ—O UPT02(NIAMPS ❑INTERIOR ❑CHIMNEY REPAIR
��FW Licensed Professional 201-I(NM)AMPS IMPROVEMENT
�y C� OWNER-BUILDER DECLARATION OVBH 1000AMPS ❑BATH REMODEUREPAIR []DEMOLITION
C a 1 hereby affirm Ihm I am emmpl fr..in the Comraclm's Licen,w Law for the
S°xd'0aU following mason.(Section 9031.5.Business and Prefeasions Cade:Any city or co.nYSIGNS ELECfHICAI. ❑OTHER
00'3t h which requires a permit to construct.alter,improve,demolish.or repair any structure
fqq"�so prior to its issuance,also reomer, nit,icun,forxucrm
ch Piuo file.signed stammer, SPECIALCIRCUDUMISC.
2 r
that he is licensed pursuant.the provisiansof the Contmcmr's License Law(Chapter 9
(commencing with Section 7")ofDivision 3 of the Business and Professions Carl TEMP.METER OR POLE INSTCOMMERCIALu
0.a o z that he is exempt erefmm
nt and me basis for e alleged a,mit,ion.Any vmmion of ❑NEW BIAG/ADDITION El m
XmN Section 90315 by any applicant for a permit ubjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
uuF11ZT not more than five hundred do)[.(Soup). IMPROVEMENT
_� ❑ 1.as owner ofthe titularly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
F- will da the work.and the structure is not intended to offered for sele(Sec 91004,Business El OTHER
.2
and Professions Code:The Connector's Licence Low ot does napply f,an owner of OUTLETS-SWITCHES-FIXTURES
a 3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,h.weve„M1e building or impnrvemenlo,old wimiroau,ar.fcoorpstion.the SQ.FII FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving mal he did not build or improve for par-
' prom of mI..}
71 I,as owner of the prolan,con exclusively connoting with licensed contractors to TOTAL:
construct the project(Sec.7044.Business and Professions Coale:)the Curiosities Li-
cense Law does not apply toanowner ofproperly who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who convects for such projects with a contrnctar(s)licensed pursuant to the Collimator's
License Law. PERMIT ISSUANCE SEP 23 1996
I am acmp,under Sec. B&P C far thism
rea
Data ALTER-DRAIN&VENT-WATER(EAI VALUATION
r WORKER'SCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE T 11i I
1 hereby affirm under penalty of perjury one of the following dcaiaations //✓I/ a
,]IM1ave and will muinminu CenificnmdConsemmxlf-insure for W'orker's Compcn- DRAINS-FLOOR,R(wEARFA.GOND'
ter STORIES i TYPE CONSTRUCTION
moon,as pmvidM for by Section 3900 of the Labor Csde,for the pa fo rn once of the
wt k for which this pemtit i5 issued. Fl%TURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Gyle,for the mformance of the work for which this permit in issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCCGROUP APN
My Work llNypaijloJlklh�nmranS�G'c dPolicyn,y, pbfq�aO�OG GAS-EA.SYSTEM-OVER 4(EA)
eerier:./�_TIlf JXJ// Nn.: I WORKERS IJ
CERTIFICATE, !`EXEMPTION SATO INSURANCE
WORKERS'
COMPENSATION INSURANCL GRFASFIINDUSTHL WASTF.IMF.HCEITOH
Mais section nccd not he completed if the permit is furnace hundrcddollars($Ilk) HODING DIVISION FEES
or lea) GREASE TRAP CHECK ME
I cenify that in the perfors.ntt fdo work for which this permit is issued.lshell SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so lin to become subject to the Worker'Camper- F: FEB
ZZ satin,laws of Calaumia.Date WATER HEATER WNENT/ELECTR
0 Aldicuit GRADING FEE
y NOTICE TO APPLICANT:If,alter making this Certificate of Exemption,you should WATER SYSTEM/IREATING
f-' ; becameabjce[to the Workers Compensation provisions of the Labor CNet you must SOILS IEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
G A
CONSTRUCTION LENDING AGENCY NFiW RESIDENTIAL I'LMB. SQ,FT. PAID
U Q I herebyaffirn that thin .,ucnnsvuctin i lendingageney for the performance of Data Remits#
Qthe work for which his permit is issued(Sec.3097.Civ.C.)F-' Under',Name TOTAL:
U Lenders Address TOTAL:
1«nily that 1 have read this application and state that the above mmurmaion Ix BUILDING FEE
f+ lin collect.l agree to comply with all city and county ordlmences andstate laws relating to QTY MECHANICAL PERMIT FEE
U building cowuction,and herebyauthodze reprnemutivcsnf lbi.city to corerupon the SEISMIC FEE
above-mentioned properly,for inspection purposes. PERMIT ISSUANCE
(We)agme ,,sn ,militarily and keep hamdcss the City of Cupertino against ELECTRIC FEE
e
Iiabilitics.judFments,costs and expenses which may in any way.cane against said City ALTER OR ADD TO MECH.
in marsequeree of the granting of this pvoint. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0310 CFM)
SOURCE REGULATIONS. MECHANICAL IEE'
AIR HANDLING UNIT(OVER 10.(IDOC"D CONSTRUCTIONTAX
Signa..of APPlicanVCanuacmr Data EXHAUST HOOD(W/DUC I HOUSING MITIGATION FEE
HAFARDOUS MATERIALS DISCLOSURE
Will the applicamor future building occupant,terenrhundle huzurdons commool HEATING UNIT(10100,000 BTU)
as defined by(be Cupertino Municipal Cade,Chapter 9.12,and the Ilcallh and Safety
le.Section 25572(x)1 "Z HEATING UNIT(OVER 100.000 BTU)
❑Yes No
VENTILATION PAN(SINGLE RESID) PAID Date ReceipCp
Will the applicant or future building occupant use equipment or de,.ices which
t shmsrdou.s air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(JHI'OR IW,IMNI BTU)
SSstricR / TOTAL:
' ❑Yes BQILER-COMP(OVER Iq),gN)BTU)
I have rtad die hataNuus—s materials requirtmcros under Chapmrti.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fomite Health&Safety Code,lection 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FI'.
building does mine. fl have.tenant,that it is my responsibility.ratify the oecuparl
of the1 hicyrCC.fiLtract pnor m oil...ce of.ear,llcayl oy�x<.p y.
�/ iYln LJ// l0
Owrc�r authprlud agent I Ie TOTAL: ISSUED BY:
OFFICE