29047 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.LTRICAL PCRMITNO. 29047� O
BUILDING DIVISION APPIACATION/PFRMIT PI,UlIRINGL.
-MECHANICA
BUILDING PROjECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: ('HONE: ' CONTRACTOR 5 NAME: LIC NO:
NIC CONTROLN
,• ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
a 2 30 an- c.�uPTNo
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fells Paid by Applicant(Initial) BLDG .ECL' PLUMB MECH
❑ ❑ ❑
LICENSEDCONTRACTOR
maderSoDECLARATION QTY. ELECTRIC PERMIT FF-F.
1 hmeby aOTrtn that I am filic Bu under provisions of Chapter 9(commencing JOB DESCRIPTION
Wa0 Z0 with Seminn 70W)of the Businessland and Prcd.esinns Edo.and my license PI?RMIT ISSUANCE RESIDENTIAL:
F u]" in full foo—rd effect. ❑SFDWL ❑KITCHEN R17MODEL
aUuj License Class Liao APPLIANCES-RGSIDLN"flAL ❑ADDITION [I PLUMBING RE-PIPE
Q i Dam (Yours or
ARCHTTF.CI'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
p.7 m PANELS MODIFICATION
OO-i Z I understand my plans abaft he uaJ as public meant,Z1-� UP T02(M)AMPS [_1 INTERIOR ❑CHIMNEY REPAIR
(=,%CW Licensed l'mfessiumll 201-IINXIAMPS - IMPROVEMENT
J
OWNER-BUILDER DECLARATION
M C C Q I hereby affirm that I am exempt Gamma Contractor's License Law for the OVER f WOAMPS ❑BATH REMODEVRF.PAIR DEMOLITION
K3LV following¢avm.(Section]031.5,Businessand Proamsma,Code:Any city or county SIGNS ELECTRICAL. []OTHER
if iiI w� which tryuimx a permit to cYhswcl Bar.improve.demolish.or repair any structure 1 I
SIF Oa pdormitsieaance,also sthe fiction for such perznu Ic aligned srmemem
SPECIAL CIRCUIT''/MISC.
f y Ihatrekliceliallarsurall It sof Ne Gm I cense low(ChaPlrr 9
QE (commen'ing wish Serf p Di �in JnrrM1e IPmfassinnn CuJe)or 'TEMP.METEROR POLH INST. COMMERCIAL'
dyX o y
that he is cmpi r is a f al x prion.Any vialmion of ❑NEW BLDG/ADDITION ❑DEMOIA PION
W� Section] IS eq pati fora nhje sutra plicate roacivil Penalty of POWER DEVICES
❑TENANT FOOD SERVICE
nolo hu d II :{851NU t
1_Z>• IMPROVEMENT
_< I,as own of the pmpeny,s ryeonp y«s with wages as their sole compensation. SWIMMING POOL ELECTRIC
�F.ce will da the sit k,and the strut c is not intended or offered for ale(S« ss.]WL Business ❑OTHER
63 m and Professis s Code:The Contractors License Law does not apply to an owner of OUTLEfS-SWITCHES-FIXTURES
property who binds or improves thereon,and who does such work himselfor through
his own employees,provided that such improvements arc nut intended or offered for NEW RESIDENTIAL 13LECTR SQ FT.
sale.If,however,the building or improvement i.e.sold within one year ofcompalinn,the SQ.FT.FLOOR AREA QSQ.FT.
ser-builder will hove the human of proving that he did not build or improve for pur-
N of tiled.
r of the property,aexclusively contracting with licensed vNimcam m TOTAL:
consumer the proj«t(SeeTOW,nt Business and Profcoinns CWe:)lTeContmaor'sLi-
cese Law ds not apply m an owner of property who bui Ids or Improves thereon, Q1 Y.
PLUMBING PERMIT FEE
does
who contracts for such projects witlw conmacmr(s)licensed pununot to the Contrucmd,
License Law. PERMIT ISSUANCE
❑lamer apt under Sec._ .B&P C fomhis naso
ALTER-DRAIN&VENT-WATER(EA) VALUATION
y Data
WORKER'S CO IPENSATION DECLARATION BACK FLOW PROTECT DEVICE
Ther yufrmunder pcnnl at'perjury acentric fallowing J«larmions:
nJ wdlmaiamins Cimadjamcof Consent Inuit-insipa for Wakcr's Compcn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONS'I UCr1ON
,mien,as provided lin by Section 3700 of the Laren Coca,for the perf mmuc.of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as inquired by Section
3700ofrhe LaMn Code for the performtivermthe work for which this perms,is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Came, Policy Na,: GAS-EA.SYSTEM-OVER 4(EA)
CER'T'IFICATE OF EXEMPTION FROM WORKERS' GItEASF/INDUS'I'Rh WASTE INTERCIiI'TOR
COMPFNSAI'[ON INSURANCE BUILDING DIVISION PI?ES
This section mad not be completed]ifthe permit is furore hundoddollars($I0l) GREASETRAP
PLANCHECK FEE
ser lass)
I cenifydat in the pedromtanmof the work for which this permit is issued,]shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as o become subject file Workers'Camper- ENERGY FEE
Z cation Laws of Crlifnmia.Data WATER HEATER W/VENT/ELECTN
Z O Applicant GRADING FEE
NOTICE TO APPLICANT:11,aper making this Cenilicam of Esempmmn,you should WATER SYSTEM/TREATING SOILS PEE
(a Q1 become subjecuo the Workers Compensation provisions of the labor Code,you must
forthwith comply with such provisions or Iris Nortahill be deetttW resident. WATER SERVICE
CONSTRUCTisitconstruction
[ON LENDING AGENCY NEW RPSIDF.NTIAh PCMB. SQ.FT. PATO
L)� l for
tri that there isxed(See.0l7.Cie.C)agency for the perGsmanwol Date Receipt
the work for which this pencil is issued(Sec.3092,Civ.CJ
lender's Num. 'TOTAL:
r W Landers Address l'OTAL:
0. 1 canny than I base must this application and state Thar the above infommtion is BUILDING FEE
f'h cosec,.l.9.to comply with all city and county ordinances and sea laws painting to QTY. MECHANICAL PERMIT FEE
V z building construction,and hereby authorize representatives of this city to enter upon the SE IS MIC IRE
above-mentioned propcny for impaction purpows. PERMIT ISSUANCE
(We)agree m save.indmnnify and keep hurntlass the City of Cupenmo against ELECTRIC PGE
liarilirics.judgincm.v.costs and capcnscs whichne,many wayoccru.againsr said City ALTER OR ADD'I,MECH.
PLUMBING FEE
an cooed g
m.of the ranting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CFM) MECHANICAL FEE
SOURCE EGULATIONS.
I-7- AIR HANDLING UNIT(OVER 10,IX0 CFM) CONSTRUCfLONTAX�
antura rl plif"o,Q hacmr V`—7-V
EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS '1'ERIAIS DISCLt15URF.
I Will capplicam of future h Jing oecupam mmor handle haundhomm.mrial HE
UNIT(TO IIXLWO BTU) u
ass de i y the Cupertino Municipal Code.Chaffer 9.12,end the Health and Safety
Cade.Section 25532(x)^ HEATING UNIT(OVER 100.000 BTU) �o
C]yes ❑No VENTILATION PAN(SINGLE RE,SID) PAID `
Date \ UI+Receipta'-
Will the dousaiircontntanantsl Mefined«che nt[lay use equipment Air ntordcvirnagamch BOILER-COMP(3HP OR Immix)if IU) -5 ry
¢mil hazardous air enmuminanl.e us fid ineJ by she[lay Arca Air Quvliiy Mnnugement � Al,'Ol'
•District' BOILER-COMP(OVER 100.000 RTU)
C3 Yet ON.
I have mad the hazamommincom,regmparmats under Chapter 6.95of the Cali- AIR CONDITIONER ISSUANCE DATE
fomite Health&Safety Code,Sections 25505.25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.ET.
building dons not currently have a cannot,that it is my respmsibility to notify the mampam
of the mi uiientcnts which most le tun priono issuance cru Cenificam of(lccupamy.
Owner or amhrdadagem Data TOTAL ISSUED BY:
OFFICE