29625 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 29625
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILUINGADDRESS: SANITARYNO. APPLICATION SUBMITEALDATE
OWNER'S AIME: PI]ONE: CONTRACTOR'S NAME LICNO:
�f )of �pm� N/C COME Rol.#
EcC111 CT/ NGINEEER /{) LIC NO: ADDRESS A/ ❑
117113 AVA01-0 m7w/ I/h)
CONTACT: PHONE: BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BL ELECT PLUMB MECH
G R �� 933 - ��i ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONjli�nn,e
ELECTRIC PERMIT FEE
]hereby aft m mm 1 am licen.ad made,pra.ixionx of chapter v aJOB DESCRIPTION
^^e.2 wilh Suwon AAq)df hsivion3of the Businnssaaa P...fc,nnc C,s1r.mdRESIDENTIAL:
WOO PERMIT ISSUANCE
W F In full force and effect. s 33' ❑SFUWI. El KITCHEN REMODEL
aUV I,iccnec Clacc Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F 2 W Dae Context
vs6a ❑MULTLUNIT ❑STRUCTURAL
A 'DETECTS UECLA ❑(
z Its dcnfa+a my plans.hull be used as public recordsPANELS MODIFICATION
OZ=Ez UPTO20DAMPS El INTERIOR ❑CHIMNEY REPAIR
F-�LW LicensN PmfesSimod 201-11"AMPS IMPROVEMENT
gYS_J OWNER-BUILDER DECLARATIONOVER IOq AMT'S El BATH REMODEIIREPAIR [3 DEMOLITION
tY gypu:] 1 hereby arm.that 1 ort exempt from the Ca meters License O keluwingrwwm.ScIden)03 L.S.Roston,and Pr+f¢sions GWe:Airy citSIGNS ELECTBICAh ❑OTHER
which require.a permit u+consvuct,ober,impmve,den+olish.cur rcpuir a
-E]�O priono its issuance,also requires the applicant]orsuch perroirao file a signed statement SPECIAL CIRCUIT/MISC.
that he is licenced punuam to the provisions of the Contractor%License Law(Chapter Y
W 00 (commencing with Section 7")of Division 3 of the Business and Pron,wimes Code)or TEMP.METER OR POLE INST. COMMERCIAL:
6 LLp K that he is exempt therefrom and the basis for the alleged exemption.Any violation of _ N BLDG/ADDITION ❑DEMOLITION
Km Scnion]OI LS by any applicant far aPermit subjx¢the applicant toecivil P<nulsy of POWER DEVICESN NT ❑FWD SERVICE
more Roan five hundred dollars($500). rwsi
F-=O ❑I,us owner of the prapcny,mmycmployees with wmgex as sM1eirmle compenvsion, SWIMMING POOL ELECTRIC HER
ENT
p. will Jothewurk.aal lheslmcmre is nm itnendedarmfieredfor sale(See.7041.Business 9
ELI3 unJ 1'mfeuinns Cada:The Cantrnemr's License Law Rows urn apply to an owner of OUTLETS-SWITCHIiS-FIXTURES i
property who builds or improves thereon,and who does such work himself nr through
his we employees,prnvidcd that.such improvements are not intended or offered for NEW RESIDENTIAL I?LECTR SQ I-T
sale.It,howeser,me building or improvement is sold within enc year afcomplaion,the SQ.IT,FLOOR AREA VSQ.PT
wnerbuilder will have Ne burden of proving that he Jia not build or improve for pur- ^
pass of sale.). V
TOTAL:
I.ae owner of the property,am exclusively contracting with licenced contrarian;1.
orovua the project ism.](44,Business and Professions Calc:)The Contractees Li-
censelawdoesnotapplytoanownerofpropertywhobuildsorimprovesRereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with u cnmractar(s)licensed punuam to the Comrxmr s T,'T
License Law. PERMIT ISSUANCE Y•�
0 I an,exempt under Sec. ,B&1'C for reason
Owner DALTER-DRAIN&VI?NT-WATER LEA) V 9LUATION
n
WORKER'S COMPENSATION DECLARATION
N RACK FLOW PROTECT.DEVICEAPR 2419
I hereby affirm under Penalty of pe juryoneofthefollowing dockers Compares-
Ihove andwill for byneCion 37 a of theConsent
Laor Code.flim for Workers fthe DRAINS-FLOOR,RWp.AREA.COND. -�/ STORIES}111\V TYPE CONSTRUCTION
wti kf as provided for by Senior 3]00 of Roc labor Calc,for she performance of the 1 1 Ur
k far which this permit is issued. FIXTURES-PER TRAP
91 have and will maintain Worker's Compensationhev Insurance.to,,which
h hisreqmitby a nSection
371M)of the LuMsr Cole,Tombs per(onnancc of the work for which this Permnis issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My Worker`jCompscreJs�'''�t��o�h"s�tnzan��re cunfe,and Policy number are. GAS-EA.SYST'EM OVCR4(CA)
Curie'�.[�AtrgPPolicy Ne.:-LI�i]J ^
CF,RYIPICC OMPE SATIO INN PRANCE ACKFF S' GRE.ASE/INDU51'Rh WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISII)N PEI?S
(Thicrectionneed not he completed ifthe parrut icfaranehundreddollurs 1510)) GREASETRAP
or Ics) PLANCIIECK PEE
I certify dost in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.2M Ff.
not employ any pero
son in any manner so zo bm
ecae subjecuo the Warkee Comped- ENERGY ITE
Z ration Laws of California.Date WATER HEATER W/VENT/ELECTR
GRADING
z Q Applicant Mr.
NOT'ICETO APPLICANT IL altar making this Cenihcae of Exemption,you shnuW WATER SYSTENUTRCATING
heceme subject to the Worker's Compensation p ncisions of the[,.her Code,you moa SOILS FECAN
forthwith comply with such provisions or this permit shall he deemed revoked. WAIERSERVICE
aQ
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ter. PAID
VQ (hereby affirm that there is a construction lending agency for the performance of U ecmplK
tr. he work for which this Permit is issued(Sec 3097.Civ.C.)
us U 1<ndees Name TOTAL:
UlLendees Address TOTAL,:
P. I certify that I have read this application and stare Lha t dMse inform tion is BUILDING FEF.
F' N nsnect.I agree m comply with all city unit county ordinances: state laws relating In QTy. MECHANICAL PERMIT FEE
V2 building construction,and hereby uulhoixe reprewnmlives of scitymemeru'rothe SEISMIC ITE
ab ccmentioned prnpeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,Inderal ly unit keep ho unless tl fry ofCupertino against ELECTRIC MEof
liubilines.judgmentc,costs and expenses which may in an ayaceme against said City AITERORADDTOMECH. PLUMBING FEL?
in asequence of the grunting of this permit.
APPLICANT STANDS AND WILL COMP,Y WDTf AL.NON-P INT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL
SW L )NS
�.- AIR HANDLING UNIT(OVER IO,fgq CFM) CONSTRUCTION TAX
:gnamrc fA cant nmr for re E%HAUST HOOD(W/DUCID HOUSING MITIGATION FEE
H 'J.Aal. ,MAfERIALS DISCLOSU E
Will me applicant or fe building occupant muse or h dale hazardous material HEATING UNIT(TO 101.000 BTU)
un defined by the CaNnine Municipal Code,Chapter 212,and the Health and Safety
Cosle.Semite 25532(a)? PRATING UNIT(OVER 100.000 BTU)
Cl yes; [:1 No PAID
VENTILATION PAN(SINGLE BESIDE [)are Receipt or
Will the applicant or future building weapons use equipment or devices which BOILER-COMP(UP OR 100.000 BTU)
4istim,17
mit hawdeuc air contaminants m defined by the Bay Area Air Quality Management TOTAL
BOILER-COMP(OVER IW.00)BTU)
❑Yes ❑No
Ihove read the haevJaus ma¢nal.rcyuircmcnty under Chapter h.95 of me Culi AIR CONDITIONER ISSUANCE DATE
mMa Hcuhh&Safety Calc,Sections 25505.25533 and 25534.1 undersumd that if the NEW RESIDENTIAL MECIL SQ.FI'.
building door net currently have a lemon.that it is my responsihillry m notify the occupant
of the requirements which must he met prior to issuance uta CcriOcnm mostropancy.
Owner er authonzed agent Date TOTAL: ISSUED BY:
OFFICE