29387 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL
BUILDING PROJECTIDrNITIFICA'1'ION 29387
BUILDING ADDRESS: nJ ,1 SANITARY NO. APPLICATION SUBMI FLAT,DATI
O ER'S EPHO G C RAC O 'S NAME: LIC NO:
SIC CONTNOL»
A HITE.CT/F.NGINEER: IC NO., AIIDRE S;41 f , ' ❑
O.
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ C ❑
LICF.NSEDCONTRACrme,Provisions
QTY. ELECTRIC PERMIT FEE
1 hereby affum that I am IiccnsW under provisions of chapter J(commencing JOB DESCRIPTION
i-pZ with Section Division she Business and Pmfessiom Gdm,and my license is RESIDENTIAL
i-,— in fail force and elf PERMIT ISSUANCP.
W' H :sea ❑SFDWL C]KITCHEN REMODEL
Q
License chss Lic
FZ47 Dam o .cmr APPLIANCES-RESIDENTIgI. ❑ADDITION [I PLUMBING RE-PIPE
Fy,7y ARC 1,� SDECLARATION PANELS ❑MULTFUNIT []STRUCTURAL
ZO22Z nll'Ce us public records MODIFICATION
0 rA�s E", Li nx m' . UPT0200AMPS ❑INTERIOR [:I CHIMNEY REPAIR
�..I OWNER BUILDER DECLARATION 201-I000AMPS IMPROVEMENT
Q 1 h y affirm that I am exempt from the Common's License Law for she OVER IM AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
$d
0,U dU following reams.(Section 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
u1 O which requires a permit to construct alter,improve,demolish,a repair any suuclum
prior to its issuance.also requires the applicant for such Permit file a signal statement SPECIAL CIRCO IT/MI SC. �zG
6E that he in licensed pntumt nh the provisions of the Contractor's License Law(Chapar 9 L�
a c q (commencing with Section 70(y)of Division 3 of the Business and Professions Crueler TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis fine the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m
Section 7031.5 by anynpplicam fora permit subjects Weupplicant macivil pcnaltyef POWER DEVICES ❑TENANT FOOD SERVICE
t mme than five hundred dollars($500).
k 6 I,as owner of the property, nt IMPROVEMENT
0 G ❑ pmlc y yot interdeswithwagesas their roto.Business SWIMMING POOL
will do the work,and the swcmrc is not imm�dcJ proffered f or sale(Su.]IN4.Business ❑DTfi[iR
4 :$ and Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FI ORES
property who builds or improves Lemon,and who dons such work himself or through
improvements own employees,provided that such improvemas are not intended or offered for NEW RESIDENTIAL ELrCcm SQ FT.
sale.If.however the building or improvement is sold within one year ofromplaimthe _ SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have she burden of proving that he did not build or improve for par-
pox of sale.). ,
1,es owner of the property,am exclusively contracting with licensed contractors to MAR 7 1996
connote'da project(Sm.7014.Business and Professions Code:)The Cumowim's Li-
coxLawdoesnmapplytoanownerofpropenywhobuildsOrimprovesthereon,and QTY. PLUMBING PERMIT v (FTE r1
who contracts for such projects with a contmcror(s)licensed pursunnno the Contractor's GIIY yr rrUrCiiIINV
License Law.
C]I am exempt under Sec. ,B&P C for this reason PERMIT ISSUANCE
1.
Owner
ALTER-BRAIN&VENT-WATER T!A) VALUATION
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm ueder Penalty of perjuryme of the following declarations:
❑I have and will maintain a Cmificam of Constant to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of Ne Lahr Code,for the performance of she
work for which this permit is ismed. FIXTURES-PERTRAP
❑1 have and will maintain Worker's Compensation Insurance,as requite by Section
3700 of the Labor Cale,for the perfommece of she work for which this Permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS �, 6b OCC.GROUT' AI'N
My Worker's Compensation Insurance carrier and Policy number am: GAS Currier: Policy No.: EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASSANUUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
fON,ectimhncedent be completed if the permit is forme hundred dollars is IW) GREASETRAP
or less.) PLANCHECK FEE
(certify that in the anyperformance
1.the work Re whichthisto the itisnamed.Ishill SEWER-SANITARY-STORM EA. Ff.
net employ any person in any rammer sn ns¢h became subject to the Workers'COmpcn- ENERGY FEE
Z Applicant
Laws of California.Dam
O Q A WATER HEATER WNPNT/ELECTR �,�.Q GRAUfNG FEE
r
NOTICE
ati Immm,a bJ APPLICANT:If,Co making this Certificate m of lLabor o dyou should WATER SYSTEM/TREATING
7 become mhjwua the Workers Compensation this provisdons abbe Lahr Cade,you man SOILS FEE
(enhwit cnmplY with such provisions nr this permit shall be JecmeJ revoked. WATER SERVICE
Qis
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L)0, I hereby affirm that there is a construction lending agency for the performance of Date Receipt»
{2rF-t Ne work fee which this permit is issued(See 3097,Civ.C.)
O P-o lenders Name TOTAL:
L) Leolm,Address TOTAL:
0. 1 certify that I have read this apps not ion and state that the above information is BUILDING FEE
rA Cramer l agree to comply with an city and county Ordinances and stoic laws relating to QTY, MECHANICAL PERMIT FEE
L) z building ronstmmion,and hereby motorize representatives Of Nis city m enmrrpou the SEISMIC HE
-� above-mcalamsi property for inspection purposes.
(We)agree to save.indemnify and I less to City of Cupertino against PERMIT ISSUANCP. ELECTRIC FEE
liabilities,judgment,cosy expensC ml, any way accmc againstsaid City ALTER OR ADD TO MECH. PLUMBING FER
in consequence of t of da noir.
APPLICANT Ih D. ND W . COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE _ aS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
eof Commctor (late EXHAUST HOOD(WMUCq HOUSING MITIGATION FEE
lIAZAkDOUS MATERIALS DISCLOSURE
applicant or future building Occupant store or handle humorous material HEATING ON IT ITO I Word BTU)
sideline t y the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Cade,Satlon 2.5532(x)? REATINO DNR(OVER 100,00011W)
❑Yes C)No
VEMI'ILAT'ION PAN(SINGLE RFSID7 PAID
Will tea applicant or fmure building common use _ Date Raeipt p
pp gmm Air otor devices BOILER-COMP 3HP OR IW,00f)BTU)
emit Mnzardaus sir cmnaminams as definal by the Bay Aree Air Quality Management (
District? TOTAL:
❑Yes ❑Nn BOILER-COMP(OVER IW,OW BTU)
.20
I have Mut the hamrdous iamtiuls requirements ueder Charter 6.95 of to Can. AIR CONDITIONER ISSUANCE DATE
forms Health&Safety Calc,Stations 255115,25533 and 25534.1 ualers mil tat if the NEW k1i,SIDF.NTIALMECH, SQ.FT.
hoiWing does not cumntly hive a moms,thus f is my responsibility m aaify the occupant
of the requirements which must he net prior to issuanre of a Cmifhcate of Occupancy.
Owner Or authorized agent Date TOTAL: ISSUED BY:
OFFICE