29115 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY.
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL. 29115
BUILDING PROJECT IDENTIFICATION J
UILLD ING AILD R I.S S: SANITARY NO. APP1\LIGATION SUBMITTAL DA'I'F
LV—
SM
PUONIr CO /42*
C'TOR:S NAME: �IC ND:
�fCI`P �[/J NIC CONTROL#
AZT.CT NCL : Ali
ADU O Lk I a e
CONTACT: `1 PHONES -' BUILDING PERMIT INFO
/,07 • f
ED Consultant Fees Paid by Applicant(Initial) ) F.CT PLUMB aQ,,11iC)i
LICENSED C"`ONTI{I RAIU`.•Cf""0"`R���5/UECLARA�'ff l0_NV QTY ELECTRIC PERMIT FEF.
1 hereby affirm that 1 mm licensed under pmvisioro of Chapter 9(commencing -JOB DESCRIPTION
GCy mfItS Section
,nd 000) fD,,Non3ol'Ihe Bminess and PmmWons Codgaalue,license is RF ID .NTIA .
00 PERMIT ISSUANCH —�
License Class LieM
� ❑SFDWL [3 KITCHEN REMODEL
U�j
I. ❑
NZk Date Contmmnr APPhIANCES-RE$IDENTIAADDITION ❑PLUMBING RGPIPE
F Goy ARCHITECT'S DECLARATION PANELS ❑MULEI-UNIT ❑STRUCTURAL
y OvJ Z Understand my plans Shall be used as public records MODIFICATION
OZ=f� PS �� El INTERIOR ❑CHIMNEY REPAIR
F-nE'W Licensed Prnfcslomal ftViOl IW AMT'S IMPROVEMENT -
OWNER-BUILDER DECLARATION OVER IOOOAMPS ❑BATH REMODEf/REPAIR ❑DEMOLITION
06 1 hereby uffum that 1 an,csempt from the Contraners Idecase I,aw for the _
LLO y U fallowing reason(Section 7031.5.Burin„s and Pnde,,am,Code:Any city nr county SIGN9 EL[CTRICAI. ❑OTHER
O which requiresa permit m camuuct,alter,improve,demolish..,¢pair any smnom
prior,,)its iS,U:mee,alxn reghires theopplicnm far such perntitm file a sigandwtoement SPECIAL CIRCUIT/MISC.
not he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
<O (commencingwith Section]000hof Division Sof the Bmimessand Professions Ccde)or TEMPNIMERORPOLEINST.
that he is exempt therefrom and the basis Por the alleged cnemption.Any viulatinn of W HLDG/ADDITION []DEMOLITION
ie Smian]031.5 by any applicant for a permit subjects the applicant m a civil penaltyol POWERDIIVICES
W^w TENANT ❑FOODSERVICE
ZQnot more than five hundred ry..,dollars y AXI). IMPROV EM•NT
Q I,rev owner of the pmpeny,or my nnployws with wages us,heinole compensation. SWIMMING POOL ELECTRIC T
_ will do Be,work,and do,stmnufe isnot intended oreffered forsale(Sec.]044,Rusinnss v to ❑OTHIiR .Ie'�,�
63 and Professions Code:The Contractors License Law does am apply to an owner of OVI'LETS-SWITCHES-FIXTURES -
property who builds or improve,Thereon.Sad wan does such work himself Or through
his own employees,provided that such improvements are not intended tar Offered for NEW RESIDENTIAL ELECTI1 SQ PC
sale.IL however.thc building mine,P revertant is sold within one yemofcompledion,The SQ,FT. TAOR AREA SISQ.FT.
pcaventer-builder will have the burden of proving that he did not build or improve for per-
ose of xalvene, - faYJ�J
❑L as o r of the property esdusivecantmning with liccns ctm,mctmn to p5l n p f�
nnrom Be,pnice, w.($ 7044,,Bm
uslns andd G
Pndcssions ,dc:) contract.,.,Pmrucmr's I.I.
se Luw this not apply to an owner of prnpenywhobuildImmal,mves thereon and QEY. PLUMBING PERMIT FEE
whmemnTri..uca projws withacommmor(s)IicenuJ porsuunlbNC Commcmr'x MAR 191f1J6
p
License Law. PERMIT ISSUANCE
I um exempt under Sec. ,B&PCiRa thkoduse. X77 {�
Owner Doc ALTER-DRAIN&VGNT-W - (EA) LII I' VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO'T'ECT.DIM tU` llur-gin o
I hereby affirm under penalty ofperjury one of Be,following declam2 b 4 tione ( Lr ,�
❑I have and will maintain a CerdficUm of Convent to self-insum for Workers Compcn- DRAINS-FLOOR,ROOF,AREA.Cb50-7 STORIES TYPE CONSTRUCT ION
Salim,as provided for by Swtinn 390)of the Labor Code,for the performance of the
workhayshichthispermitisissual. ' FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3]0)ofthe Labor Code,for the performance of the work lin which this permit is issued. GAS-G.SYSTEM-I INC.4 OUTLET OCC.GROUP - APN
My Work9� �gWe ad9W artier and PolicymW�+ey�{
Carrier. w(-Tf(nl0I/'/Je Policy Nn.: Lf N% GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATI?OF EXEMPTION FROM W ORKQRS'
COMPENSATION INSURANCE GREASEIINDUSTRI.WASTE INTERCEPTOR
(This section mordant be completed Vthe permit is for ane hundreddollars($I(MB BUILDING DIVISION HHS
G
or less.) REASETRAP PLANCFIECK PER
I employ
any p e,in the any m n manner
SO the work for which this pannit isa Cmufa all g
not employ any person in any manner eo ism become suajecu,)The Workcrs'Compen- SOWER-SANITARY-STORM EA.2(1(1 Fi. ENERGY FEF. Laat
0 Z Satinn I.mo of California.Date WATER HEATER WNENTII?LECTR
Z Applicant GRADING FEE
y NOTICE TO APPLICANT:If,arm,making this Ccdificme of Exemption,you should WATER SYS1 ENLTRGTING
became subject mind Worker's Comp iondun provision,after,Luton Code,you nmst E Oil's IE �.
D.1 forthwith comply with Such pmvisime,orchis prrat,haR he devotedrtv.kUJ. WgIER SERVICE -
�O
CONS'[RUCTION LLNUING AGIiNCY11 NEW RESIDENTIAL PLMB. SQ,IT. PAID
I hereby affirm that there is a consttucdon lending agency for the perfonaaaceof Dom Receiptk
Lf. e+ rhes work for whieh,his panni(is issued(Sw.3f19],Civ.CJ
0 U Lender's NantaInno` OTAL:
W Lenders Address TO' L:
HI codify that 1 have rtad this application and State,hate all information is BUILDING 175Ii
N wl.I ugrw to comply wire 111 city unJ county nrdlnnnws and ante rows rdadngn. Q'pY. MECHANICAL PERMIT FEE ^
U z building construction,and hereby auNorizempresemalives ofthiscity materupn the SEISMICP G
above-mentioned propcdy for inspection purposes. PERMIT ISSUANCE
(We)agree m save.orharm dyand keep hurmle,x the City dCupatinn agnins. ELECT
ITabiliths.judgments.costs and expenses which may in any way accme against Sold City pLTF.R OR ADD TO MECH.
in consequence of the grunting of this permit. PLUM G L' ��—
APPLICANT UNDL'RSTANDgADO 'WILL COMPLY WITH Ah1.NON-POINT Alli HANDLING UNIT(TO O,fNNI CPM) MECHANICAL.NEE
SOURCE R IONS. 9G
AIR HANDLING UNIT(OVER IO,OMI CFM) CONSTRIICTIONTAX
Sig roof Applicam/Contmc Date EXHAUST HOOD IW/DUCT) HOUSING MITIGATION IEE
HAZARWUS MATERIALS DISCLOSURE
Will lire applicant tar talar,building occupant store tar handle hazmslnua material IIIIATING UNIT CTO I Boma)BTU)
US defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cede,Section 25532(a)? HEM ING UND'(OVER 100,00)BTU)
❑Yes, CNo PAID '
VGMILATION FAN SINGLE RESID) Dam Receipt of
Wrdom,applicant oranaafiame building rectiby
ana Bay Area
Air Qualitment or y
deviceswhich
BOILER-COM OR Hq,000 RTU)
emit hazmdnns at,amtnminums as defined by the Bay Arcu Air Quality Mxnagcmc°t 'TOTAL:
D
istrict? BOILER-COMP(OVER 100.000 BTU)
No
read the hamdmil materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUAN ' TE
Health&Safely Cale.Sections 25505,25533 and 25534.1 undefsmnd that if the NEW RESIDENTIAL MECH. SQ.ET.
nomumn0y havea tenant,that it is my responsibility Io notify the occupant
unis which must he met prior to issuance of o Cendicam mfOccupancy.horired a ae ()am TOTAL: "tI ISSUED I3Y:
OFFICE