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29391 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO HUILDING-ELECTRICAL. PERMIT NO. BUILDING DIVISION APPLICATIONIPF,RMIT PIA)MBINO-MECHANICAL I 29391 BUILDING PRO.IECF IDENTIFICATION BUILDING ADDRESS: �s _ SANITARY NO. APPLICATION SUBMITTAL DATE J 'C/mJ/I1NrrpyC ER'S N MBp 1 - PHONE: CONTR 'S NAM t f LIC NO: L`�` \u`�L.`P"•}WA n^ I COM'ROLp lei ITECT/ENGINEER; L 'NO, ADDRESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Feas Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby anion wt 1 ant licensed under prevision,of chapter 9 mommeneing LOB DESCRIPTION WOZ wtNSeelion]000)o(Division 3ofthe Ru.inessand Prefessiom Cede,undmyliceme is RESIDENTIAL' F.�O in full force and e I PERMIT ISSUANCI! aUZU License au DSFDWL O KITCHEN REMODEL n61 Dale ntmctor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE A 1 SDECLARATION ❑MULTI-UNIT ❑STRUCTURAL OZyZ y Ibe used in Public rtcords PANELS UPTO 200 AMPS MODIFICATION C ❑INTERIOR ❑CHIMNEY REPAIR ce v 201-u1WAMPS IMPROVEMENT CY OWNER-BUILDER DECLARATION OVIiµIOolIAMPS ^K W Q : 1 sy affrnt(hal 1 nm exempt from the Contractor's License Law for the ❑BATH REMODEVRIiPAIR DEMOLITION 3 a U follow rcamn.(Section]OJ I.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER LL which"slim permit to construct,alter,improve,demolish,or repair any nrucmre prior mita issuance,also ,In ares the applicant for such permit to file a signal smmnent SPECIAL CIRCUITIMISC. 2 "y that he is licensed pursuant to the prnvisions little Contractors License Law(Chapter 9 (commencing with Section]olgdnf Division 3 efthe Business and Professions Code)ar TEMP.METER OR POLE INST COMMERCIAL: ti q m that he is exempt Iherefrcm and the Exists for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION P� Semen]031.5 by any applicant for.permitsubjeas theapplicant t...ME penalty of POWER DEVICES OTENANT 0FOOD SERVICE =�. not more than five hundred dollars(8500). QQ1,as owner of Ne pmpeny.army. employes with wages as their sole compensation, SWIMMING POOL ELECTRICIMPROVEMENT aHit the work.end theswemre is nm imended oroffercdfor sale(sec.]1/14,puniness GOTHER and Professions Cndu The Contraewrs License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES pnpeny who builds or improves tumon,and who dos mch work himself or Bullish his own employees,provided(hot such inpmvemtro enanot amended or offered for NEW RESIDENTIAL ELECTR A.,/ r�u n sale.If,however,the building or inpnwement is sold within one year ofcomplction,the SQ.PT,FLOOµAREA 8/SQ.FII wnerbuilder will have the limen of Proving that he did not build or improve for pur- ❑M 1,a aowne LIAR 71996 1,sea owner of the Ser. 704,am.Business contracting with licensed mmcates h, TOTAL: construct the project(sec.]IN4,Business and Professinm Code:)The Cnmmemrs Li. cense Law does not apply to an owner of properly who huilds ser improves thereon,and QTY. PLUMBING PERMIT FEE who contracts for such projects with a contractors)licensed innuanl to the Contractor's CII Ur I;Uren IINC License Law, PERMIT ISSUANCE ss -Sc l am exempt under Sec. ,R&P C for this reason Owner AMER-DRAIN&VENT-WATER(EA) VALUATION Dan WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby affirm under penally of perjury one of the fallowing declarations: Ihavoard will maimainn Cenificmenf Conscmmself-insnrc for Workers Carlo. DRAINS-VLOOR,ROOF,AREA,COND. smian,as provided far by Section 3700 of Ne Lahr Code,for the perormonce of the STORIES TYPE CONSTRUCTION .,it for which this permit is issued. FIXTURES-PER TRAP O I have and will maintain Worker's Composition Inxnranco,as required by Strait, TIOOof the Labor Code,for the pedomtance of the work for which this permit is issued. 1 GAS-EA.SYSTEM-I INC.4 OUTLETS CA OCC,GROUP APN My Walker's Cordsawr m.Insurance cunderlaid Policy numheram: Curlier: Policy No OAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF 1I!MP IONFROMWORKERS' COMPENSATION INSURANCE GREASEIENDUSTRI.WASTE INTERCEPTORor ital.) BUILDING DIVISION FI!ES (This sationneeJ nil he mmplcted if the pe.all,Europe hundred dollars IS hold GREASETRAP 1'IANCIR!CK FEC (cenify that in the anyperformanceof the work for whichthis detrains issued,rCoIshall not employ any person in any mannermaxmbecome subject mile Werkerk Compen- SEWER-SANITARY-MRM EA.211018'' ENERGY HE 0Z smian Law of California.Date WATER HEATER WNENTIELF.CTR 77 O Applicant 2 GRADING FEE Grp NOTICE TO APPLICANT.11 after making this Cenificme of Exemption.you should WATER SYSIEMOIH!ATING become subject to the Workers Compensation pmvidam,of the labor Code,you most SOILS FEL! fmhwitbeintply withmreh pnsvisimnorthis permitshull hedeemed revoked. WATER SERVICE d z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.FT. PAID U I herfor by affirm which is a agency for the performance of Date ReceiplN the work for which this permit Is issued(Sec.3097,Civ.CJ _ U. V Lender's Name D TOTAL: Leaders Address TOTAL: 0. I cenify Brat 1 have read this application and state that the aMve information is BUILDING IEE rn correct.I agree m comply with all city and county ordinances and state haws relating m QTY. MECHANICAL PERMIT FEE UZ building construction,and hereby mahatim repreuntativesofthis city memerupon the SEISMIC FEE .a ahovo-mentioned properly for inspection purposes. PERMIT ISSUANCE (We)agree to ane,indemnify trod keep hion les.the City of Cupertino against ELECTRIC IEE b liabilities,judgments,costs and expenses which may in any way records,against mid City ALTER OR ADD TO MECH. in conagaence of the g..t,ngnl'Ihis y�m' i PLUMBING PEE APPLICANT U' S NDS toD ^ILI.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0301 CFM) SOURCE � ,CS. MECHANICAL FEE AIR HANDLING UNIT(OVER 10,00I CFM) CONSTRUCTION TAX S I of Cnmmcmr qac EXHAUST HOOD(W/DUCT) ACMDOUS MATERIALS DISCLOSURE / HOUSING MITIGATION FEE Wm to plicanl or Rome building occupant store or handl heranlous materiel HEATING UNIT TO IW.oIN)BT117 m defined by t c Cup`ldam Municipal Code,Chapter 9.12,and the Health and Safety Coda Scedon 25532(,)?, HEATING UNIT(OVER Ilgl.00)BTU) El Yd, DNo VEM'ELATION FAN(SINGLE REMD) PAID Will the applicant or future building occupant use equipment or devices which Date Receipt p emir haaardous air commitments as defired by the Bay Area Air Quality Management BOILER-COMP QHP OR BIEN BTU) District? O Yes ON. BOILER-COMP(OVER 100,000100,000 BTU) TOTAL: 1575 1 have renin the harardou.s material., AIR CONDITIONER ISSUANCE DATE r5,15533 ad under Chapter 6.95 of the if the bunia Health&Safety Cada,have 25505,255JJ and 25534.1 a notify the that if 0c upant — NEW RISIDEMTAL MECH. SQ.PT. r buildingildrea et.whichrivailly have be it prior ismyreapomibihitytlitem'OetuN ry. • of the reyuiremhems which must he mel prinrmissuvnce nfe Cenificme of Occuryncy. Owner or uuthmited agent Date TOTAL] ISSUED BY: OFFICE