29100 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. fin9.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 200
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS:16
O SANITARY NO. APPLICATION SUBMITTAL DATE
OWNE 'SN PHO COn,fRACTOR'S NAME: LIC NO:
2 m j0LF`y is fc�A.{.1 r, NIC CONTROL#
1RCHiT /ENGI R: LIC NO: AU SS r T 1�-�r 1� �F'�W ❑
C x/74 VEL_
CONTACT: PHO : BUILDING PERMIT INFO
r T� - ❑ Consultant Feeg Paid by Applicant(Initial) gLpq r PLUMB M�EyCHH
LICENSED CON RA R'S DECLARATION QTY ELECTRIC PERMIT FEE _ xId.
I hereby affirm that 1 am licensed under prmisions of Chapter 9(commencing JOB DESCRIPTION
O0Z with Seetion](X)0)o(DivisionJnhhe Business and Professions Code,andmylionxis
y�00 PERMIT ISSUANCE, RESIDENTIAL,
6Ui Interned
ZHZ]' Licenlse Class effect. Lic.# ❑SFDWL ❑KITCHEN REMODEL
yQS Dor Contractor APPLIANCES-RESIDENTIAL DDITION El PLUMBING RB-PIPE
F.O mARCIiITECI-S DECLARATION PANELS MULTI-UNIT [I STRUCTURAL
z p 1 onderamnd my plans shall he used as public records MODIFICATION
0z UP TO?0D AMPS -
r.r.no no u7 Licensed Prob.iowl El INTERIOR El CHIMNEY REPAIR
ay 301-IGWAMPS IMPROVEMENT -
Oat I am exemptEfr DECLARATION l
1 hereby affirm that 1 am exempt from he Counselors Licence Law for the OVER I(XXIAMI'S ❑BATH'REMOUP.VREPAIR D DEMOLITION
ip5�O L U following reason.(Section 7031.5.Business and Professions Code:Any city or esomy SIGNS ELECIRICAh ❑OTHER
W LL r_�rr which acquires a permit to consumer,the spec improve,demolish,or repair any swstatement MAR
25
.. ��
JJJd Chit heor ilts censed purse rego"vee previsions o for Contramen ctors
LicensFile ae Law
Capt em SPECIAL CIRCUI'i'/MISC. IPi11{�-'{--Vq-�'
;!(y hot he is licensed pursuant to the previsions of the Cnmmctoh License taw(Chapter 9
aG� (commencing with Section]000)of Division 3af the Business and Protean...Cade)., TEMP.METER OR POLE INST. 'COMMERCIAL
4 that he is exempt therefiom and the basis for the alleged exam tion.An - �'
o P 6 P y violmion'of
Section 103LI by any a applicator Para ❑NEW'BLDG%ADDRIONV 0DEMOLITION
pp permit subjects the applicannnocivil penupy of POWER DEVICES
} not I'mrethne fivehundred
1ordollars
,calli. El TENANT ❑FOOD SERVICE
Q ❑ Lmehe work,the tsetse,or myet amended oithfered us their mlecmn4,Bu6mees SWIMMING POOL ELECT RI IMPROVEMENT
will do the work and the she Contture is not amended or nlw dos not a(Sea.]814,owner of
El OTHER
and Professions Code:The vwn then' License Low does not apply s if owner of OUTLETS-SWI'TCIIES- URPS
L 3..
Property who builds or improves r such i and who does such work himself 1 hnntgh - -
his awn employees,e provided Nut such improvements arc not intended or oleion.far NEW ktiSIUCM'IAI.ELELTR SQ
owner
ne.ILhower will hveth burden
odpement issoldhewithinion build or improve
puts 104, $Q.FT.FLOOR AREA LSQ.FT.crhuilder will have the buNen of proving that he did not build or improve for put-
pose of sale.).
owner of the property,ran exclusively contracting with licensed roommates m I�1, l O
onumct the project(Sec.7044,Business and Professions CedO The Contractors Li.
nee Law does not apply to an owner of prolorny who builds or improves thereon,and QTY, PLUMBING PCRrZT FEE
whn cammetx fur such projects with a cont mesus)licensed pmsuantto the Contmnnr's
License Law. PERMIT ISSUANCE
❑1 am exempt under Seo. B&P C for this reason
O s N- wry= -.-%ST S ALTER-DRAIN&VENT-WATT R(EA) t -
O/_ VALUATION
WORKERS COMI'ENSA' ON DECLARATION�ro BACK FLOW PROl'EC'1'.DEVICE
1 hereby ef0rm under penalty of perjury one of the following dedamtion.c. V
�Q Ihave and will mainmina Cenificmc of Conxnun self-insure fur Wnrkcra Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND.
xtiun.as PmvidW for by SeaionJ]Wnf the Labor Code,for Bre performence of the
STORIEL TYPECONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 the Labor Cole,for the 11famonce ufthe work for which Nis Permit is issued. GAS-E.A.SYSTEM I INC.4 OUTLETS OCC.GROUP APN
lvy arkers Compensation Insurance carrier and Policy mmaber are: s
me Policy Na: GAS—EA.SYSTEM-OVER 4 EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASVINDUSI'RL WASTE INTERCEPTOR
(Tak,actitr readmit bo completed if t hepcnnit is foram hundred dollars($a n) B .DIN ISION FEES
or len.) CREASE RAP PLANCHF.CK P:' O
I certify that in the perfoommeof the work for which this permit is issued,IshalI SEWER-SANITARY-ST(IRM EA.200 FT
not employ any person in any manner sitas m bttome suhjea to he Workers'Cormer- ENERGY
OZ action laws of Califon.Data WATER HEATER W/VEM/ELECTR
z O Applicant _ GRADIN F r�
ug NOTICE TD APPLICANT:IL it,,making his Cenificme of Exemption,ymt should WATER SYSIENIGRIIATING
became mbjmt m he Workers C.on,mution provisions of he Lahr Chic,you must SOILS FEE
W C forthwith comply with such provisions or this permit shnllM deemed revoked. WATERSERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID
V O Thereby affirm thavhere is n ematracom lending agency f the Performance of Date Receipt
UL C+ the work for which this permit is issued(Sec.3097,Cl,C.)
O V Lender's Name TOTAL:
WLendef's Adams, TOTAL;
- Qt 1 ccnlly that I have read this application end tire that the shove Inlbnnutinn is BUILDING FEE
Zi cancer I agree to comply with all city and enuntyoNinances and sma lows relating to QTY. MECHANICAL PERMIT PEE
'U 4 building construction,and hereby suthnrim representatives ofhiscity center upon the SEISMICFEE
ubov>mentioned property for inspection purposes.
PERMIT ISSUANCE .�
(We)agree m save,indemnify and keep harmless the City of Cupcnst id City ELECTRIC FEE
Iiaconsequenco ents,of
costsand expenses thisPermit.
may inany way acerae against said City ALTERORADDTOMECH. L3
in conugncnce of rhe granting of his permit. PLUMBING FEB
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO10,1100 CFM) �O
SOU .E REGULATIONS. MECHANICAL FEC
AIR HANDLING UNIT(OVER 141100 CFM) CONSTRUCTION TAX
Signature ofAWllcar/Contrunor Date EXHAUST HOOD IW/DUCT) - HOUSING MITIGATION PEC
HAZARDOUS MATERIALS DISCLOSURE
WIIl theupplican mfumre building weapons more or bundle hezuNnuc mnterlul HEATING UNIT(TO IIXI,Oq)D'TU)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
Code.Section 25532fa)? - HEATINGUNIT(OVIik IIXfIX,l BT,)
C3 Yes [j No
VENTILATION PAN(SINGLE RESID) PAID
Will the sit commmaor future Receipt 4
wrfuture building occupant use equipment or devices which it hazallou nit contrariness az Jefind by the Bay Area Air Quality MarwgBOILER-COMPOHPOR 100.000 BTU)
emem TOTAL:
DrancR
❑Yes [D No BOILER-COMP(OVER HIL"BTU)
I have mad he hezallous m:nerLIP requirements under Chapter695 of the Culi-
AIRCONDITIONER ISSUANCE DATE
(omiu Health&Safety Code,Sections 255115,8533 and 85]4.1 undemm�J that il'thr NEW RESIDENTIAL MECH, SQ.IT, y
hnilding hrea not eurren0y haveatenun4@but hie my reepamlhility at notify,the wcupunt
of the requirements which moat he mrt prior to iasurre,of a Certificate of occupancy.
Owner or umhoriud agent - Data TOTAL: ISSUED BY: -Yam F•
OFFICE