29496 (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,CIIANICAL 29496
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRIIi.SS:
^+l� SANITARY NO. I APPLICATION SUBMuITT`♦A_1,DAT[
1, V
OWNER'SNAM@PH IN'THACT R'S NA li: LIC NO:
['t-� NIC CQM'ROLb
•ARCHITECT/ENGINEER: LIC N ADDR' S: - ❑
t9�
CONTACT: PHONE: Q
BUILDING PERMIT INFO
❑ Consultant Fees]laid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aRrm Thur I am licensed antler provisions of Chapter 9(commencing JOB DESCRIPTION
17 C Z with Sxti.n]0007"'Division 3 oHhe Hu incl arolProfessimix CWe ane my license is RF_SIDENTIAL:
F1_ full forec ap 1 PERMIT ISSUANCE:
Wt '^ > ❑SFDWL ❑KITCHEN REMODEL.
aU�j Lscn l.ic.p APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RFPIPIi
e �a Date Cano-acert
F'q AHCHI'I'IiC'1'$DECLARATION�y�--��a��%k PANELS ❑MULTI-UNIF ❑STRUCTURAL.
z0oz Iundersmnlat,,imsshall be used as puM1lic rerords� MODIFICATION
UPT02W AMPS
OZ�O ❑INTERIOR - [I CHIMNEY REPAIR
E-�1'W Licensed Professional 201-1000AMPS IMPROVEMENT
W Sig z fY 0.'6 1 hereby uffinn OWNER-BUILDER
am exdmpERomTme C ntra�ots License Law fur the OVER 1000AMPS ❑BATH REMODIr.'y-R•EPA(1/R`Q MNOOLI
s iU following Sectio^]031,5.Business and Professions CWe:An cit ,count ❑OTHIiR
5� g reason.(. Y Y o Y SIGNS ELECTRICAL
al'3 W F' which requires a permit o amsrdim utter,improve,demolish,nT mpair any mmaarc 6�4k4 £`
�,�o0 that heslcense.c,nleant to 1v1the provisions
o foeoteli Contrarnitmcensde e Law(Chaptert SPECIAL CIHCtII'TIMISC.
f!!jp. thatheielic,wit pursuant 10th,provisionsoHhe Contractor's License Law(C Covent or
�aa�p0 !commencing with Seninn]O80)nf Division JoHhe Business and Professions Code)ur TEMP METER OR POLE INST. COMMERCIAL:
a d c eC that he is exempt therefrom and the basis for 1M alleged eaemPtion Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�m Section]031.5 by any applicant for a permit subject the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FWD SERVICE
rot mom Dun five hundred dollars($500).
1-Z Y IMPROVEMENT
x61]1,as owner of me pmp,ny,or my employees with wages as their sole cnmpennati.^. SWIMMING 1'(101,ELECTRIC
fy� willd^the work,ondthe strucmreisnm intended oroffered forsalc(See.7(A4,Business []OTHER4)
, amore and Professions Code:'Lha Contmet.rs License Law does not apply In an owner of OUTLETS-SWITCHES-FIXTURES
S�' properly who huilds or improves thereon,and who does such work himself nr through
his own employees,provided that such impmvmnent are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If.however,the building or improvement is sold within one year.fmmpletion.the SQ,14.FLOOR AREA $ISQ.IT,
mamer-builder will have the burden of proving that he did nm build or improve for xvr-
poaenfxale.).
❑ L ax own,ntf the prnMrt,In .dusively...testing with licensed contractors to TO .`•L. r
,mtstmci me project(Sce.]814,Business and Professions CWe:)The C.nt acmrs t., v
cense law dive.snot apply to anowner.fprolwxty who builds or improves thereon,and Q'TY. PLUMBING PERMIT FEPE
who..nteas for such pmje.ls with a cnmvattor(s)licensed pursuant In the Contractor's In n
License Law. PERMIT ISSUANCE f r_ �s O
❑l an exempt under Sec. ,B&P C for this nation 99
ALTER-DRAIN&VENT-WATER II:A) V(1LVALUATION
Owner Date Qp�y4 U
• Wt under p COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE k
1 e and w ulEmt under penalty of perjury one of the insure fur dcdamsnns
[have and will notationItSection icate3700 id II Lab to Code,! ro for Workerefforn'essof'h- DRAINS-FLOOR,ItOOF,AREA,COND' STORIES TYPH CONSTRUCTION
satin,„as hick his
I'or by Section 391X1 nl the Luber Code,for the perlirrmance of rho
nod,for which this permit ix,stared FIXTURES-PIiR'TRAP
have ad Lawill mainmin Worker's Compensation n work
hi a required by Section
3100 of the lab.rCWe,fm the performance oHhe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4OLD'LETS OCC.GROUP APN
My W.rltar's Con Insumnceyyrir dPolicy 1
ca den 1YYd1�(iil4e r h c gicyNv: GAS-EA.SYSTEMOVER4(EA)
'FI TI KATE OF EXIDIVE ION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUS'1'RI.WASTE INTGRCGI'IY)R
BUILDING DIVISION IBES
(This section raced nn,he oxrmplm,d it the permit in broad hundred dollars($I CHI)
or less.) GREASE'1'RAI' PLANCHECK PET:
I certify that in the performance ofine work forwhich thin permit is issued,Entail SEWER-SANITARY-STORM EA.2W FT.
nut employ any person in any manner so as to become subject to the Worker,Consist ENERGY E E
OZ nation Laws of Califard..Date WATER HEATER W/VENT/ELECfR GRADING FEC
Z O Applicant
NOTICE TO APPLICANT:1f,afro,making lhix Certificate of Exemption,you should WATER SYST NUTREATING SOILS II?E
rr'IN become subject in the Wodca'sCompcmmion provisions of the Lohor CWe,you most
fnmhwith comply wish snch pnwininnx nr thlepurmit shall he deemed revoked WATER SE RV ICI,
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ,FT PAID Date Receipt#
V 0 I forwhaffrm Hatmem issued(S .30 len ding agency for H<performance of
FIll. " the work for which this pcnnit is issued(Sm.J09].Civ.C)
Le
mice,Nam. TOTAL:
WLeadeeHAddess TOTAL. BUILDING FEE
eerily that I have read Has application aslam that the.tats,inf0rmaion is
F” y correct.1 agree rat comply with all dty:md ounly ordinanrex and smte Inws renting m QTY, MECHANICAL PERMIT 17EE
U 2, building construction,and hereby authorize Aprescalativendfdo%city l0 enterup.n the SEISMIC FEE
ohne-mentioned property for impemion p.tion s' PERMIT ISSUANCE
(We)agrcc to save,indemnify and keep hmmless me City of Cupertino against ELECTRIC PEE
liddLidcs.judgmcma coon and eapcnus which may in any way...against said City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of the granting of His permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT ALR HANDLING UNIT(TO 10.000 CFM)
MECHANICAL FEE ISL
S URCE REGULATIONS.
AIR HANDLING UNIT(OVER @WOCFM) CONSTRUCTION TAX
Signawre of Ap ' .matin I Dam EXHAUST IIOOD(WMUCT) HOUSING MITIGATION FEE
NA ARDOUS MATERIALS DISCLOSURE
Wit Hp, ntc. fuwre building occupant store or handle hazardous material ` HEATING UNIT(TO 10,000 BTU)
as defined by the Cupe Munici WI Code,Chapter 9.12,and the Health and Safety
CWe,Section 25532(a)! HEATING UNIT(OVER 100.000 BTU)
❑Yes F7 No VENTILATION FA N(S INGLE RESI D) PAID
Umc Rwcipt p
WIII the r co or future building occupant use equipment or devices which
mit hazardous air contaminants ax Jdincd by the Bay Area Air Quality Management HOLLER-COMP(311POR 100.(XlO H'TU) TOTAL:
1 L1,
BOILER-COMP(OVER 101.000 BTU)
s ❑No
read the hazardous materials reyulument under Chapter 6.95 of me Cali- AIR CONDITIONER ISSUANCE DATE
&Safely Code,Sections 25505,25533 aad,25534.1 uadersund Hal if He NEW RELDEN'1'IAL MECH. SQ.ET.
nm.uirenlly havea wat,mot it is my responsibility m unify the occupant ment whi.h must be and prior m isxuoncc of o C.nifie:nc of Owupency.
houred agent Dare ( L. ISSUED BY:
OFFICE