29229 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CBANICAL 29229
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARYNO. APPLICATION SUBMI'I'i'AL DATE
1045 A�1 n1 z�q G
OJWkNAME: 4.25 A\\C}))VTRACfOR'S NAM��\\ �R LIC NO' S�O
[�l /y1,'7 IKK••l Q0 `` NIC CONA ROLA
HI'ECf/ENG,NEER: L LIC NO: C/ / ADDRESS. 1 !\ ❑
1,1 o J
CON'1'ACI': PHONii: BUILDING PERMIT INFO
-V ❑ Consultant I m Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WCZO with Sedian 700(Bof Division Julthe Imonenand Pm&scions Codc,ealou,hcereek PERMIT ISSUANCE RESIDENTIAL
in full force and IT - Q (AI a��D ❑SFDWL ❑KITCHEN REMODEL
QU�j Liccnx2. Lica Ie, APPLIANCES RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPC
F W Da¢ T'S DEC!
m a ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION
F y Z 1 understand my plans shall he used as public record. PANELS MODIFICATION
Z O,- UP TO 20()AMPS
OZ— E3 INTERIOR El CHIMNEY REPAIR
W Licensed Professional 201-I000AMPS IMPROVEMENT
S sj J
OWNER-BUILDER DECLARATION /�� VER 1000 AMPS El BATH REM '.1/R AIR_[�OEMyII frfjj)N
L C Q herehy aBlrm thin tan exempt from the Cnnvnctnr'x License t
xx o ❑OTHER
L U following resat.(Section 1031.5,Business and Professions Cole:Any city or cou l / rNS ELECTRICAL
W 31n y which requires a permit to constmc6 alcor,improve,demolish,or repair any strvetI, \/
C)� prionoits issuance,also requires the epplle,makrsuchpouri to l imasigned.ome a sh 'SPEC1ALCIRCUI3'1MISC.
ofthat M is licensed pursuant the provisions ofthe Contractor's License Law(Chapter 9 COMMERCIAL:
�yp0 (commencing with Section 7010 of Division3 ofthe Business and Profeslons Coaledor TEMP.METER OR POLE INST.
L ac thin he is exempt tla refinno and Ihe basis for the alleged exemption.Any violation mf U NEW BLDG/ADDITION D DEMOLITION
XM� Section 0031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWE DIiVICE4 ❑TENANT ❑FOODSERVICE
=0 of mom than five hundred dollars($500). IMPROVEMENT
Dl,as owner of the progeny.or my employees with wages as their sole cmnpensmioo SWIA§dGPOOL ELECTRIC
will do the work,and the structure is not intended m offeml for sale(Sec.1(W.nosiness El OTHER
13 m and Professions Code:The Comrectors License Law does not apply to an owner of OUTLETS ITCHES-IIXTURCS
property who builds or improve thereon,and who does such work himself or through
his own employees,provided that such improvements arc not imended or offered for NEW RHS1DE . 'LECTR SQ IT.
sale,If,Inumsea the building nr improvement isseld within one year ofmmPledon,the SQ.IT.FLOOR AREA 5/SQ.FT.
own
cnbuilder will have the burden of prnving ohm he did not build or Improve for pm-
pox of owns
❑1,acownermfthe progeny.ameinsively prides
with:)[Thadcontractors m
wormer the project(Sea."o an owner
rorty who builds
Codd:)The Cmntancod,and
c seontr drca not apply m an owner of property who builds or improver thereon,dd QI'y. PLUM I ERMIT FEE
who ox.for such projects with ammracmr(s)licensed pursuammthe Conuxmr's 'JAN 191996
0
License Lax'. \ PERMIT ISSUANCP.
D I em exempt under Sec. ,H&P C lirt this rw.mn
Owner lam ALTER-DRAIN&VENT-WATER(EA) X111 VI' (XUYChiA1fU`sT10N
WORKER'S• COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE'1 herchY affirm under Penalty of perjury one of We following dedaser s Co
cation.
as and irked for by Section
3usm of Labor
for
Worker's G,of the DRAINS-FLOOR,ROOF,A .A,CON o STORMS TYPE CONSTRUCI'ION
cation.as provided for mi Senior 311X)of the IaMa Calc,for @c performance,of the
work for which this permit is issued. FIXTURES-PER TRAP
Fl I have fthe
and will ode.e e Worker's ante wfffic w Afor which
us rcquircd t i Section
]100 of Ne labor Calc,for die performance of the work for which Nis pcnrdt is issued. GAS-EA.SYSTEM-I INC.JOUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier Policy Nn: GAS-EA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEBNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Phis section need am he..nnplemd i f the permiOs furore hundred bill ars(EIIX)) ONEASE'TRAP
or less.) P W NCHECK FEE
Iccnify0at in the performance ofthe work for which this permit isissufal i shall SEWER-SANITARY-STORMEA.200FT.
not employ any person in any inaamo xo nx m he-rde subject to the Workurx'Compen- ENERGY FEE
zZ xation Laws of California.Date WATER HEATER W/VENTMLECTR GRADING FEE
2 Applicant
i..i .Na NO'T'ICE TO APPLICANT:It,after making his Cenilicme of Exemption,you should WATER SYSTEMn HEATING
a , became subject to the Worker's Compeasmum provisions Of the Labor Crile,you must SOILS FEE
Lkl
forthwith comply with such previsions or this permit shall M deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH.' SOFT PAID
V0 I hereby affirm that is a construction lending agency for the perfornance of Date Re<eipta
I. (•-t the work for which this permit is issued(Sec.3091,Civ.C.) 30IAL.
O U lenders Name
,r W Lenders Adders
0. 1 staidly that I have road this application and stem be, he have information is BUILDING PTE
V) correct.T agree meamply with all city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT [ZEE SEISMICFEE
V Z building construction,and hereby authorize representatives ofthis city to enter upon the
ti ulawc-mentioned property for in.pection purposes, 1'IiRMI'P ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep headless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way acnes against said City ALTER OR ADD'10 NEED, PLUMBING FEE '
in consequn ec of the graming of thin permit.
APPLICANT U)' NISTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('rO 10,000 CFM) MEC14ANICAL FEE
SOURCE REE I DONS.
AIR HANDLING UNIT(OVER IOIXIHCPM) CONSTRUCTION TAX
tg tam ef A hcaHMConuacr Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION HE
AZARDOUS ngRIN.3DIS LOSUHIi
Will me applicant or to,..building«cupant smut dhundle hairdous material IIIiA'TIKG UNIT('lY)IIXIJXXI BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12.and rhe Health and Safety
Code.Sulin i 255321x)! HEATING UNIT(OVER 100,0011 BTU)
❑Ycs UNo VENTILATION FAN(SINGLE RISIU) PAID
Uam Rcmila
Will the applicant or future building occupant use equipment or devices which tlO1LER-COMI'(3HP OR IOQIXXI BTU)
emit hang daus air co mormi ams as defined by the Bay Area Air Quality Management TOTAL:
D...He,' BOILER-COMP(OVER 100,000 BTU)
E]yes No
I have real the harankus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER , L.�V ISSUANCE DATE
Taman Health&Safey Coale,Sections 25505,25533 and 255311 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building d«s na curiandy have a henant,tbm it is my rcsparoibility m nwify the occupmn
of me rquin menta which must be mer prior to issuance of a Certificate of Occupancy.
Oamammauthodmdagent Date TOTAL: ISSUED BY: +�+
OFFICE