29617 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII,U1NG-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMISING-MECHANICAL 29617
IIIl11,DING PROJECT IDENTIF'ICAT'ION
BUILDINGADDRESS.. SANITARY NO. APPLICATION SURMI'I'1'N.DATE
Oz no ist
O NER:S NAME: PHONE: ONTRACTOR:S AVE: ` LIC NOhq
LA NIC CONTROL#
1 ..HITECTMNGINEER: I LIC NO 41YDR25S ❑
�.sF `I `I Fr m 4U 7
CONTACT: /) .... . . ,_ PHONE: V`V r BUILDING PERMIT INFO
`Il�gp ❑e Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ECH
LUIENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby atnnn mal I.,it licensed older provkmn,of chapter 9 commencing JOB DESCRIPTION
1 Od'Z mSecdon]000)of Division 3 ofthe Businesmnd Pm&ssions Code.andmy licenscis RESIDENTIAL'
CZ
wi PERMIT ISSUANCE
f-U.0 m full fo¢c and t ❑SFDWL C3 KITCHEN REMODEL.
M Liccnsc _ LIa# APPLIANCES-RESIDEM'IAL []ADDITION ❑PLUMBING RE-PIPE
IFQ1 Dete CnntmeCL RATION
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCfURAI.
F m Z I understand my plans shall be used as public records PANELS MODIFICATION
OZ4O UPTO 200 AMPS ❑INTERIOR OCHIMNEY REPAIR
F-�E-ul LicenxJ Ymfessional lUl-IOW AMPS IMPROVEMENT
<afm_..1I OWNER-BUILDER DECLARATION OVER I000 AMPS ❑BATH RF.MODEUREPAIR CI DEMOLITION
a,C 6 I here# P
llirm Ihal I am excicI from the Conuacme,License Law for the
S O W U following reason.(Section]NLS,Business and Pn demure Calc Any city or emnlY SIGNS ELECTRICAL C1 OTHER ail k ru.A
3 y,F- which requires t m amswa,alter,intfile pair any swcturc \(��—�
h guilesne.also
prove,suchenniti orre
E�OQ, trite ficersedprsuant to thetes provisions o far Coataclt,rnnit in
Law(Chapter
SPECIAL CIRCUIT/MISC.
,E5y thatmehe nc len WpSectiol 7")of Divionso of the
Business
License Codter9
ia2p (commencing Section of Division the Business and ProfessionsClsle)or '1'GMP.METER OR POLE INS'I'. COMMERCIAL,
6 y o W that he is exempt therefrom and no basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL%1 LL Station 7031.5 by any elplicam for a twoon subjects the applicant to a civil no ,of POWER DEVICPS ❑TF.NAM E3 FOOD SERVICE
w ,mum than five hundred dollars($500).
SD (]I,ns owner of the property.ur my employms wim wagesu their tele mmpensauon. SWIMMING POOL ELECTRIC DOTTERVEMENT
F will do the work,and thextrai I,not intended or offered fur sale(Sec.7041.Business
tailand Prov, ons Code:The Contractors Licenre Law does not imply to an owner of OUTLETS-SWITCHES '1 D S
a 3^ property who builds or improves thereon:and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIUL•M'IAI.ELEC S
side.ILhawevegihehulldingorimprovementlxxeldwithinuneycxrofcompletion,the SQ.FT.FLOOR AREA SISQ.FT.
owner-milder will have the Warden of proving that he did not build or improve lar por-
fa seof sale.lr
❑1,as owner of the property,am exclusively commning with licensed conlmmors to �T^L0 gGp 171996
onstmet the pmject(Sec.70ccL Business and Professions Cud,)The Conuucmr's Li
ave Law ears not apply to an owner of propcny who builds or improves thereon.amt QTY, PLUMBING PERMIT FEF,
who commas for such projects wim a centmetuds)licensed pursuant m the Convacmr's
License Law. PERMIT ISSUANCE 'I
I]I am exempt under See ,B&P C for this reman
ALTER-DRAIN&VENT-WATER(EA) VALUATION '
Owner - Date
WORKCR:S COMI-17NSAI'ION DECLARATION BACK FLOW PRO I ECT.DEVICE
1 hereby affirm under penalty of perjury one of the following doclamtions:
4J l have and is i 11 maintain u Certificate of Consent to sclbinsum for Workers Compel- DRAINS-FLOOR,ROOF AREA.COND. STORIES TYPGCONSTRUCION
sation,as provided Iia by Section 9700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Seltion
37N)WWv Labor Code,fit,T he��yIpn[egqiffplop,olees�rr5e if he work for which this permit ix I...ed. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My e,mai be
Cather (TfIC_1t F-FI"DEII(J�N Pel Iy No, 7 Hg= uD"A9 GAS-EA.SYSIIM-OVER 4(EA)
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASEIINDUSTRL WASTE INTERCEPTOR
COMP17NSAI'[ON INSURANCE BUILDING DIVISION IBES
(This section need not M completed ifthe permit is for one hundred dollars($I WE GREASE'I RAP
or less.)(This FEE
Icenlfy Thal int he perli,mmnee ofthc work so lu,hthis permit is ixsued,l shall SEWER-SANITARY-STORM F.A.200 FT.
not employ any person in any moaner sn as m become subject to the Workers Cumil ENERGY PER
Z ca tion laws efcalifamia.Par. WATER HEATER WNENT?LECTR
GRADING FE
ZZ Applicant F,
.N. NO'HCH'FO APPLICANT'.11,after making this,Certificate of Exemption,yon should WATER SYSTEMCTREATING SOILS FGG
F become subject to Ibe Workers Compensation provisions of me Labor Code,you must
forthwith comply with such provisions or this permit shall be deemW revoked. WATER SERVICE
Q
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID Date Receipt
U Q I hereby affirm that there is o construction lending agency for the performance of
IA Fy the work for which thlspe.It,is!,,led(Sic 3N7.Cl,C.)
TOTAL:
O U Leader',Name -
Lenders Address TOTAL:
y I certate th
certify that 1 have read min application and stat the above information is BUILDING ME
F f,f comm.I agree locomply with all city and cornny ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U ,Z building emnulmart.and hereby awhorireorov,untativesnflbis city to enteruponlhe SEISMIC PGE
above-mentioned property fair inspection purposes. PERMIT ISSUANCE
(We)agree a,save,Indemnify and keep hamless the City of Cupertino against ELECTRIC ItiE
lishlGtia.judgmenls,costs and expenses which may in any way reeve againxl said City ALTER OR ADD TO MECIL
PLUMBING ItIS
inthegranting this permit.
APPLICANT
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MIiCHANICAL FEE
SOUkCI?REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signature of ApplicantlConuuclor Doc EXHAUST GOOD ONMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thenpplicant or film.building occupamolomor Handle beware material HEATING UNITRO U0Nn BTU)
as defined by the Cupertino Municipal CMe,Chapter 9.11,and the Health and Safety
Cade,Section 255321x)! HEATING UNIT(OVER IDo"BTU)
❑Yes ]Nn 1. VENTILATION FAN(SINGLE RESIDI PAID Dole Receipt Is
Will the applicant or future building occupant use capital
or device,which BOILER-COMP OHP OR ItHUIN)BTU)
t hasallous air conm ummus us defined by the Buy Arca Air Quality Maregentenl 'TOTAL:
District? BOILER-COMP(OVER 100.0010 BTU)
❑Yes E]No
1 have read dte harallous materiels AIR CONDITIONER ISSUANCE,DATE
rcyuimmcnu ueler Chapter b.95 of the Culi�
fomiu Health&Safety Code,Sections 25505.M533 unit 8534.1 unde¢tand Nat if the NEW RESIDENTIAL MECH. SQ.Er.
building dow,Hol currently hull o tenant,that it is my respmssibihly m notify IhemcuPaul
I f IM1 venoms which mut bete ante of.Cer ilicme of Occupancy.
S�1yL ��i„a
Owner or With it agent Mute LISSUED BY:
OFFICE