29045 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY,
CITY OF CUPERTINO - ,s RUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. ,' 29045 C1 O A C
BUILDING PROJECT IDENTIFICATION. J 'f �J
R LDING ADDRESS: 1. 11
SANITARY NO. APPLICATION SUBMITTAL DAT
U
OW*UKS NAMEPHONE: COT r-R' NA LIC NO:
•
AS; 7
NIC
�y � ) O
.{/J� ` CONTROL p ARCHITECT/GNGINEER: L I- DR' M`- \ �V�
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fats Paid by Applicant(Initial) BLDG -*,LF9r PLUMB MECH
LICENSEDCOKIRACTOR:S DECLARATION QTY. ELECTRIC PERMIT FEE
I acreby at irn mat Ian,lianud under provisions of Chaplet 9(annmewing JOB DESCRIPTION
0O ZO venin seclion]IIINO nI'DivisianJ nflM Dueincss nnJ Professions Gde,and mylicenne is PERMIT ISSUANCE RESIDENTIAL: +
W f, in full force-nJ c" �"', :51 ❑MTrWL ❑KITCHEN REMODEL.
�UU Linen' Ia Lie is
APPLIANCE -Bit RESIDENTIAL' -]ADDITION - O PLUMBING REPIPE
tF L Dom Conn t -
FO,� - ARCHHTCTSDLCLARATION� PANELS ❑MULTI-UNIT ' sOSTRUCTURAL
ZOonZ 1 Noma)myd h IIh .oda:p bl' m
,,errs ` „ MODIFICATION
Oil IO 200 AMPS,
O INTERIOR '1 0 CHIMNEY REPAIR
FQ W Lice sell Professional' 201-1001AMPS - IMPROVEMENT
OWNER-BUILDER DECLARATION
pyER 11NNIAMPS El HAITI REMODEIIREPAIR DEMOLITION
C ik Q I hereby affirm that.I um exempt from the Cmm dm4 Limine Law for he -
���dJ'06 U Following reason.(Section](131.5,Business and Professions Code:Any city or county- SIGNS ELECTRICAL B OTHER
1+1'3 LL F- which reprints u permit m amnwd,uhec improve,'demolish,or repair any structure
t print toils issuance,tel.mrcquimvhcirpr icam forsacherm
pitto file a signed statement I SPECIALCIRCUITIMISC. r
Y thatheinlirmordptusoanuome pmvisionsofthe Contractor's License lrw(Chaptc,9
ad 20 (commencing with Section 7000)of Division 3o the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
a 6 ey Na he is excmpl merefmm and me basis for the alleged exemption.Any violation of _ NEW BLDG/ADDITION -0 DEMOLITION
WmN Seetion]031.5 by any applicant for a permit subjects me applicannoecivil l2nulty of POWER DEVICES ❑TENANT 0FOOD SERVICE
t more man five hundred millers IS5001.
FRY - OTHER fMFM
=Q Fl id pmpcny,rirmy employees withwagesasmei(Sce.c0mpenmtes, SWIMMING POOL ELECTRIC '
W P.O will do fie wink,and e; he Chianti
not i Liam r.fficandi Lam,do folim till to s Business O OTHER
tla. m and Professions Calc:The CDnlmtlr/S License Law does not apply to an owner of OUTLETS-SWITCHGS-FlX"NRFS
a 3 his op.,.y who builds or improves thsuch i and labs docs such work deed co or through
his own employees,provide)mat such improvement ace..,inrtndcd m pRcmF fon NEW RESIDENTIAL ELECTR SQ IT.
• wc.
1lf,however.Ihe building or improvement is sold within one year of completion.the MOORAREA ASQ.FT.
net-builder will have the barren of proving that he did not build or improve for pur-
prose of sale).
0 I,as owner of the Pmpery,an esewsively Imaracang with licen,ed contractom us /Y A/O V I
umswct the project(Sec.70114.Business and Profession Coill The Conrail Li- �w9 ,
c do
ca QTY, PLUMBING PERMIT FEE 5
who counsels fir such pnsjeuts with a conlranorts)licensed pu¢uunl to the Contraclnis na• I � J -
License Law. IT:ITMI'T ISSUANCE I a� VP uw
F7 la enenrpnnwer see. .B&rc moms mason �N'I Irv, l.. .
Owner Dale
ACI'1iR-GRAIN&VENT-WATER(EA) VALUATION
WORKERSCOMPENSATION DECLARATION r BACK FLOW PRO'fEC..DEVICE,, -
• I hereby affirm muter penalty(if p,qury one of the following declarations:..,
El [have and will maintains Ccnifieme of Consent mxdf-insure for Wprwas Con,pcn- DRAINS=FLOOR,ROOF AREA,COND. TYPE CONSTRUCfIM
sation,as provided for by Section 1700 of the Lothar Code,for me pmlfosteence of the STORIES
work far which this permit is issued. TEXT'ORES-PER TRAP -
0 1 have and will maintain Worker's Compensation Insumr6,as required by,Section
37004the LaWr Cs,�le,for the rierlummnce o(me work for which this permit is issue). GAS-EA.SYSTEMd INCA OUTLETS .GROUP APN
My Workers Compensation Insumncc canner and Policy number are: ,
Caricc Policy No.: 'f GAS-FA.SYSTEMAVER 4(EA)71 -
CERI'IFlCATL OF EXEMPTION FROM WORKERS' GREASEgNDUSTRLWASTEINTERCEPfOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This sactionnc d not be completed ifmb per mit is form.Lundin!dollars;(5100) GREASE TRAP
or It,,,.) PLANCHECK FEE
I cenify mat in the performance rfthe work for which this permit is issued,!shall SEWER-SANITARY-STORM E.200 FT. -
not employ any person in any man n as�`become�sukiF�me Workers Criterion-t - ENERGY FEE
Z sation Lows of Cnlifximic Date g�-'T WATI2H HEATER WAENT/ELECTR
Z Applicant GRADING ITE
z NOTICE TO APPLICANT.IL after makingthis Cenificata of,Exemption,you should WATER SYSTENUREATING
F•' N bsubject ecome subjecn the Worker's Compensation provisions afore Lohor Code,you mut _ SOILS FEE
frrbwimcomily with such provisionsonhis permit.hull b,deemaloc,oard. WATIiRSBRVICE
Q
� z e CONheir la'1'ornme.NalNGAGENCY NIiW RESN1iNl'LAL PLM B. ,SQ.IF, PAID
U 0 Thereby uflirm hit their is nconnmeOnn lending agency for the pe,in rmunec of Date Receiptp"
�. the work for which ihiv pcnnil is issue)l5cu.31n].Civ.C.7
Llw0 .. 'TOTAL:
eat :Name
VLcnJc .Mines, 'I'O'1'AL: _
1 enify that I have read thin tppl tel and slam that the ah Torn:tion is - BUILDING PEE '
rF-t Z) correct.l agree to comply with all citymd county'ocdmunces undsnmc laws relating. QTY. M FCHANICAL PERMIT FEE '
C„) Z haddingcrinntmdion,i it botchy xuthorire rcpresnnmiven ofthisdtym
,,cnrapon the SEISMIC PER
am
Mme- entionedm
tpery for insrycutur putpnses. . s - PERMIT ISSUANCE
(We)agree u,save,indemnify and keep Ill the City of Caperinu against ELIiCI'RIC FI:E
liabilities.judgments,costs and expenses which may in any way accrue against will City ALTERORADDTOMECH. t
in consequence of the granting of this permit. PLUMBING FEE
APPOANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO In"CFMj MECHANICAL FEE
St/U�,RlC :RF•ULA'f10N5.
.`��:r� � AIR HANDLING UNIT LOVER I0.000CFM) CONSTRUCTION TAX ,.
Signature ol'App`liccaantlCCooutrurucho are EXHAUST HOOD(W/DUC ) HOUSING MITIGATION FEE
HA]ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building«cupanumre orhrrache haerNons material HEATING UNIT(TO 100.000 BTU)
as defined by the Carlson.Municipal Code.Chapter 9.12,and me Health and Safety
Code.Section 25532(0)1 HFATING UNIT(OVER 100.001)BTU) '
.0y car, ONo VENTILATION EAN(SINGLE RESID) - PAID
Dam Receipt a
Will the applicant or future building occupant use equipment or devices which•
c -
thavarrous air contaminmu'as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,00x)BTU)
DYcs ❑Nm
DisOmt]. BOILER-COME(OVER 100.00)BTU)� •
'I have revel the hvarJrius urnenuls.,a.mmen¢'hnder Chapmi 695o the Cali- AIR CONDITIONER ISSUANCE DATE
I'omiu Ilealm&Saba,Cade.Sections 25505,25533 and 25534.1 uadsnstund thin it the NEW RESIDENT]AL MP.CH: 'SQ.IT. 4, '
or thengilotsnrnls which
bust be met
of aCrunficareatlhc,prawy. t t
of the I L It h must be �t poor colo Coil t IO cupam:y. '
Owner or amhnrixW agent Dutc - � TOTAL ISSUED BY:
OFFICE