29043 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES
•USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT,NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL I� O /�
BUILDING PROJECI'IDENTIF'ICAT'ION L 4{
BUILDING AUDRILSSl SANITARYNO. A1PPLICAMONSUBMITPALDATI.
Jv17 11/`
O : 'SNA E: / ,{, PHONE: TRACfq�$NAME: - L �J1��,NO
rAc C.0� 11/xV(- iOr+ r^s-r j /xGcuJT 7 (7�i�� NIC �)+T'Rol.x
ARCHITECT/ENGINM.R: LIC NO: A7p DRESSp ///� ❑ �//k (vYf
J.1 O Y r✓e u RY'i i
CONTACT: Puorve. BUILDING PERMIT INFO
// ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB. MECH
On Jp{oX, C/a) '7FZ—A77 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q'TY. ELECTRIC PERMIT FEE JOB
1 herehy affirm drat 1 am licensed Order provisions of Ch.peer 9(commencing JOB'DESCRIPTION
o�z said Section70f10)nfDiOlion3mftheBusinessandProfessionsCede.andm license is
f 00 y PERMIT ISSUANCE RESIDENTIAL:
in Iall force eneClas effect y7969Z ❑SFDWL El KITCHEN RF.MODEI.
Q; RR License Class Como APPLIANCES-RESIDENTIAL
F�W Unm Contruarr ❑ADDITION ❑PLUM BING RF.-PIPE
F ARCH)i t CT'S DECLARATION PANELS ❑MULTI-UNIT -OSTRUCTURAL
z O rn Z I understand my plans shall he used as public records MODIFICATION
O z^ UP TO 200 AMPS
r 4 t la Licensed Professional ❑INTERIOR El CHIMNEY REPAIR
W4 6 OWNER-BUILDER DECLARATION 20LIfNg1AMP5 MI'kOV1iMEN7"
- I hfrom ereby affithat 1exempt from the Contractors License Law for the OVER]"AMPS ❑BATH REMODEVREPAIR ❑DEMOLmobf
3 a U following rcaxn.(Section]11)1.1.5,Business end Pr.demons Cede:Any city count,came SIGNS ELECfRICAL 'I'Hh:R
Owhich requires n permit to consntuct,alter,improve,demolish,or repair r any stmaare
prinnoslicensMpu uretai epmvisilicantlhe Conmoornoicense aw(Chapt ant 'SPIiC1AL CIRCUI"1'/MISC.
�} Nat he is licensed pursuanun Ne provisions rf the Conuannr's License law(Chaptcr9
x'00 m
(comencing with Section 70000 of Division 3 of the Business and Professionsded Coor TEMP.MITER OR POLE INST. f `
a o c that he is exempt therefrom and the basis for the alleged cxcmption.Any vitiation of ANEW BLDG/ADDITION ❑DHMOLITION
Y•n Section 7031.5byanyupplicam for.pemalatibjuu theapplicannoe civil Penalty of POWER DEVICES (/7jr
er
not more then five hundred dollars($500).
TENANT ❑FOOD SERVICE
G Lan owner of me o n -
SWIMMINGPOOL[LECIMPROVEMENT
0 ❑ pr pe y,or my cnnployees wish wages ns tM1eir sole connpensation, 'TRIC
a, will do the work.and the strucwm is not intended oroffered for sale(Sec.7014,Business ❑OTHER FQrp-
W and Professions Code:The Commcror's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES ��/
4'3
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such iimpmvemems are riot Intended or offered far NEW RESIDENTIAL ELEC R SQ Ff.
sale.If,howevm the building or improvement is sold within one year ofcmnmlmion,the - SQ.FT.FLOOR AREA - $/SQ.FT,
mer-builder will have Ne hurden of proving that he did not build or improve for pur-
pax rf sale.).
❑ I,as owner of the propeny,am exdusivdy connecting with fill sal cardamons In TOTAL:
onstme,
the project(Sec.7044,Business and Professions Code:)The Cmitructors Li-
lease Law does not apply(a an owner of property who builds or improves thereon,and QT'v. PLUMBING PERMIT FEE
who countries for such projeeex with n courteous)licensed pursuant m the Contractor's'
License Law. PERMIT ISSUANCE.
❑ I am exempt under Sec. ,B&P C for this reason
Owner Date ALDER-DRAIN&VENT-WATER(RAI VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICEI
I hereby offirm under penalty of perjury one of the following declarmions:
❑I have and will maintain o Certificate of Consent to self-insure for Workers Corrigan- DRAINS-FLOOR,ROOT(AREA,COND. STORIES TYPE CONSTRUCTION
scrim,as provided for by Section 3700 of eh,Labor Code,for the perfomusnce.1 ehc
work for which this permit isoclinal. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation becomes,ant re m I b Section
37000f the Lobo}Cnde,fon he performance ofthe wo Mim'e qrn X aatol. GAS-HA.SYSTHM-I INC.40UTLET$ OCC.CROUI' APN
My Wn s mNn prion 1 nc cam r and Polis n
Carrie: P,liey Na: O 'OI Ji GAS-EA.SYSTEM-OVER t(I3A) ,
CERTIVICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRL WASTE INTERCEPTOR
(Thissectimiscanlnat be completed iflhepefail is forma,hundred dollars($10o) BUILDING VIVISION FEES
or less.) s GREASE I'RAP PLANCHECK FEE
I ccnify that in the Performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM F.A.2W FT.
not employ any perum in any mamar so as Ili become subject to the Workers'Corlper- ENERGY FEE
Qz wtior laws of California.Date WATER IITATF.R W/VENT/ELELTR
Applicant - GRADINGFEE
NOTICE.'fO APPLICAN'11If.uftannakin,this Cenili,me ol'Exemption,you should WATER SYSTEM/TREATING -
abmome subject to the Worker's Compensation provisions of the IaMr Cede,you..at SOILS FEE
fonbwiN comply with such provisions or the,peraitshall be deemedrevoked. WATER SERVICE _
0
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ian PAID
UQ ' Iherchy affirm rhm therein.ornsvuetinn lending agency forthe performance of 1 - D/c Receipt is
er the work for which this Permit is Issued(Sec.3097,Cls.C)
Q b'e Lender's Name TOTAL:
LUkI Lender's AddruA
TOTAL:
Pr I ccnify that I have read this application and state that me above information is BUILUIN EE
1501 cortcdlagrec to comply with all city and county ordinances state laws relining to QTY. MECHANICAL PERMIT FEE
U Z huildinge..swction,ardhershy authorize representatives of this city to tale,upon she. SEISMIC .E
above-mentioned property for inspection purposes.
(We)agree to v,indemnify and keep harmless the Ciry n(Cupeninn against PERMIT ISSUANCE ELECT C FEE
liabilities,jud n roeDand expenses which may in any way accrue against said City ALTER OR ADD TO MCCR
i I consequ f ming ofthis perni0 PLUMB FEE
APPLIC 1' )F STA SAND WI .COMPLY.WITH ALL NON-POINT AIR HANDLING UNIT 7010,000 CFM)
OUR . Ef - MECHANICAL �E
i• .-'jJ AIR HANDLING UNIT 10.000 CF&D CONSTRUCTION 1X
is...re of Applicant/Con iron Date EXHAUST HOOD(W/DUCT). HOUSING MITIGATE ME
MATERIALS DISCLOSURE
Will the appllcam or fnure building occupant store or handle hamrdnus material- HEATING UNI'T('I'0100,003 IIT U)
as defined by the Cupe titin Municipal Cole,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100.001 BTU)
❑Yes Fl No -
VENTILATION PAN(SINGLE RESID) PAID its_
Date Ree t#
is
Will the applicant or Towne building occupant use equipment or devices which• BOILER-COMP(3HPOR I W.(IW BTU)emit hazardous air connotations as Outlined by the Bay Area Air Quality Management
District? TAI: /
7 Yr,. [INo BOILER-COME(OVER 100,000 BTU)
Ihave read the hamrdnus maedds mquiremcnts under Chapter 1.95 of the Cali- AIR CONDITIONER ry I$ CIL
fomia Health&Safety Code.Sections 255115,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT. GI IY
boldingdoes...currently have a trnu n,Out it is my rvi mosibiluy m notify Nocc
e upant G)- `UFEkYIfYA to
of the requirtmcnt,which coast he met prior m issuvncc of a Cenfl7c:ne of Occupdncy. 1
Owner or emhorized agcm Dam TOTAL: ISSUED BY:
OFFICE