29636 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPERTINO IBUILDING.ELECTRICAL PHRMITNO, n ^_�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L b b
BUILDING PROJECTIDENTIFICATION
BUILDINGADDRESS: / SANITARY NO. APPLICATION SUBMITTAL DATE
Z Zy Zo 511-, Anzf ,✓S �v2 . u 7PV
OWNER'S NAMIi: �f P�HO'N7E: > CONTRACTOR'S AME: I LIC NO:
N/C CONTRO
R THCg/F�GINIiERy� - LIC NO: ADDRESS: ❑
/ J: k—oly
CONTACT': rxoNC: _ BUILDING PERMIT INFO
SI/�✓en / h Zs7-��3Z ❑ Consultant Fees Paid by Applicant(Initial) B,LLDDG� ELECT PLUMB MECH
"V
LICENSED CONTRACTOR'SDECLARATION hap QTY ELECTRIC PERMIT FEE
1 hcichy affirm Ih:n 1 am licensed under provisions of Chapter')lcammem'o r, JOB DESCRIPTION
Dao whhll fre]defterDivisionJofthe Business and Pnsfesslnnn G.Ic,and my liccruc is RESIDENTIAL:
O O PERMITISSUANCE full force and offal.
W� m 0SFDWI. ❑KITCHEN REMODEL
UU License Clnsx" Licit APPLIANCES-RESIDENIAL ❑ADDITION PLUMBING RE-PIPE
Nzja Dula TSDElor
c' ARCHITECT'S DECLARATION PANELS
b, 2z ❑MULTI-0NIT STRUCTURAL.
ZO-„Z, IunJersmnd my plans sM1al[bussed as public mmNs - MODIFICATION
OZ-p uP TD 200AMPS10 NTERIOR ❑CHIMNEY REPAIR
License)Pmfessinwl
5xd C 11Q
OWNER-BUILDER DECLARATION
201-10)AMPS PROVEMENT
�OWU I hereby ]hot I e.camimp from No Cmaracmrs License Lew for the OVER 1000AMPS ❑BATH RID ODEU
REPAIR El DEMOLITION
following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W LL ya which requires a pewit re corewa,alma impro e,h Permit to
or mash any atemere
F� J In he its hared!Fut requites theapplicantsuchpewiuorite aicense gss(Cha meat SPECIAL CIRCUITIMISC.
Ihm he is Iiing wit pmsaum m the provisions of rte Conwcmra License law(Chapter 9 _
fs1 00Ica he is esowith Section]gnd of Basis for oldie Businesspton.Anvi Coda or TEMP.METER OR POLE:INS'L COMMERCIAL:
6 ry,M that he is exempt lM1ercfmm and the basis for the alleged exemption.Any l onion of ❑NEW BLDG/ADDITION ❑DEMOLITION
SecYXI y not mo 101l56y tiny hundred
dantfor a s,f$permit subjene the applicannoacivil pcnAty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
k., 1 morn than Ove hundred dollars y employees
'
QQ ❑ Las
othe work,the pmpcny,or myyemntended or
Nwages fend fae their wile vontpcusiness SWIMMING POOL ELECTRIC IMPROVEMENT
.H. will do the work,and u The cture,Cont is tors License Lawe does not e(Seeapply it)an, weer of
- �— El OTHER
W and Professions Qldo:The Contractors License Law dos.not apply ns an owner of OUTLETS-SWITCHES-PIX'1'ONES
property who bullet,art improves Ih and who Js such wnrf oThrough
' his own nnployeaI.pruvidrd Ibm salt moe
uch Impvemenls arc not imnnud.ddcA or off I'crcd fur NEW RESIDENTIAL BLECTIt SQ Irl'. -
sule.lf,however,the building or improvement is sold within one year incompletion,The SQ,P TL(NM AREA $/SQ.FT.
wner-builder will have the burden of proving that he did nor build or improve for port-
pose of srle.). APR
I,as owner of the Pmpcny,ran exclusively amtructing with licenswl cnntmcmrs m 16 199
co vwm the pmhvT I5ea.91H4,Business eta Rnfessimns Code:)'I'he Cnnwmar a Li - 6
cense Law Nses not applyman owner ofpmpcny who builds ur improves thereon,and QTY. PLUMBING PERMIT' FEE v
who contracts for such projects with a canaacmns)licensed pursuant)the Contractors C1)r LJt• l.ur
License PERMIT ISSUANCE er•f J 4VU
I ora exempt under Sec. ,H&P C for this mason s
nIO BACK FLOW PROTEENT DEVICE (FLA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE IY O�OOG_
0, I hereby nmw under Penalty of pe jury one of rte following decimations: _
r,,tt,,,,
or WorkcraCampem DRAINS-FLOOR,ROOF,AREA,GOND. STORIES 'TYPE CONSTRUCCION
as provided for by Section 3700 of rte Labor Code,for the pork6co c,of the
work for which this pemnit is issued. FIXTURES-PCR TRAP
1 have and will maintain Workers C,mpensalion Insurance,as required by Section
3700 aids,Lmor Code,for the performance ofthe work for which this pemtil is issues. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUI' pPN
My Worker's Com,..udon bummer,artier and Policy number um:
'Currier. Policy No.. GAS-EA.SYSTEM-OVI7R 4(EA)
CE9TIFICAT17 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASEANDUSTRL WASTE IM'HItCIJTOR
flldasoclinn readout be completed iflhe permit lsl'aranc hundred dollars($Its)) BUILDING DIVISION PEES -
or lova) GREASE TRAP
PLANCHECK THE
IIoy any lhot ourrte Perficurnmar.mymanoro,ifit,work astobcfor wubjectch o penthe ionW is CL[shaO SEWER-SANITARY-STORM EA.200 FT.
not employ any perssm in my manner so as m become subject m the Worker Compen- ENERGY FEE
0 ,'� ration Laws of California,])ale WATER HEATER WNENT/ELECTR
Z Applicant GRADING FEE
ti NOTICE TO APPLICAM:If.after making this Cenificme of Eaemption,you should WATER SYSTEM/fItHATING
a , become subject m Ne Worker's Compeualion provisions of the labor Code,you meq SOILS FEE
W fonhwiN cmnply with such provisions or this pewiuhall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. Q. PAID
UO afford
I hereby thm themem is is acomwcuon lending agency for Performance of ` Date Receipp
V. r. the work for which this permit is issued(Sec.30G,Civ.C.)
G U Lenders Name
TOTAL:
� Lenders Addrcsx
96' fy 1 certify that 1 have recd this application and sal¢that the uhavc information it BUILDING FEF, �•
V, correct.l agmeit)comply with all city and county ordinances and rune laws totaling to QTY. MECHANICAL PERMIT FEE.
U building consmsliaa:md hereby announce representatives ofthis City In enmru no the SEISMIC FEE
move-menlioned properly for inspection pu pores' PERMIT ISSUANCE(Wc)agme m cave,indemnify unit keep harmless the City of o Cupctinagainst d ELECTRIC FILE C; I
Iiuhiliries,judgmcros.costs and expenses which may in anyway accrue against.said City ALTER OR ADD TO MECH,
in consequence of the grunting of this permit. PLUMBING FRT. I to
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('ID 10,0dI CPM)
SOURCE REGULATIONS. MECHANICAL FIDE IGO X,
AIR HANDLING UNIT(OVER 10,000CF10) CONSTRUCTION TAX
Signature of ApplicanVConoacmr Dull EXHAUST DOUG(WIDUCT) X �„� - HOUSING MITIGATION FL'E
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplicint or future building..pool smreorhtndle humorous mmerial HSTING UNIT(TO 100,000 B1'U)
as defined by the Cupertino Municipal Code,Chapter 9.12,..it the Health and Safety
Cade,Seclum 255321.)^ HEATING UNIT(OVER IM."BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) / PAID ,
Dale RleciptM
Will the air co ora m(more building occupant use cquiir Qu or device.which BOILER-COMP GHP OR 100.001 BTU)
it m air nmleminanls as definal by Ne Bay Area Air Quality Management TOTAL.
Dmm�cY BOILER-COMP(OVER 100,M)BTU)
. ❑Yes � ON. ,
I have read the hlualloua mmerials requirements under Chapter 6.95 of the Cab. AIR CONDITIONER
9 touchilyty ISSUANCE DAY/
food.Health&Safmy Code,Sections 25505,M533 and 25534.1 understand thm If The NEW RESIDENTIAL MECH. SQ.PT.
buildingdocsnalcuwhichomoently have aIm et Pnal.ismyce(If.oodaNcpancy la
of the requircrnemx which muxl be mel print to issuanea of.o CenlflCnle of Occupancy
Owner nor amharimd agent hale 1 ;, �l ISSUED BY:
OFFICE