29754 (2) ` • APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1.
CITY OF CUPERTINO BUILDING-RLE.CTR[CAI, t PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT' PLUMBING-MECHANICAL' . . 29754
BUILDING PRf IJECT IDENTIF'ICAITON
BUILDING ADDRESN _ _ SANITARY NO. APPLICATION SUBMITTAL DATI'.
OWNERS NAME: PHONE: COM RACTOR'S NAME ^-,� LIC NO.
0.2
/t /s/ W-f-3-6233
NIC CONTROL p
RCHITECT/ENGINEER: e '^ LIC NO'. ❑ 'f .
CONTACT: ' PHONE:' _ BUILDING PERMIT INFO
+
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
.: LICENSED CONTRACTORS DGCLARAT hap will -V
QTY. ELECTRIC PERMIT FEF.
Lim 70.ufftrmthatloref,.be uunder Cmvivionsofs fwa,r9(camniendng .LOB DESCRIPTION,
-
�Gu1mZ �Ih Section]fM%lJnflliviainn3af,NC Businessland Pmlbstians Code,and mylianais PERMIT ISSUANCE RESIDENTIAL:
fop wt fu 11 force and effect. ('�/ '7T - `-
OG�F ro, ,,- 76,2.. ❑SFfDWI. LARTCHh:N REMODEL
Q U(J Lmense Clusv hie,x !! �"' -
FF til Deie Cooper r APPLIANCES-RES1DEM'IAL' []ADDITION ❑PLUMBING BE PIPE
IN,M ri ARCHITECTS DECLARATION ' PANELS
❑MULTI-UNIT ❑STRUCTURAL
ZOj� MODIFICATION.
OZ
GUP To 200 AMPS ' ❑INTERIOR ❑CHIMNEY REPAIR
¢y
F � Licensed Pndessianal - 201-11X0AMPS - IMPROVEMENT- ,OWNER-BUILDER thItAT10N ,
6l 1 hereby affirm then 1 um exempt fromm the e Contractors License Law for the OVER I000AMPS � ❑BA'T'H REMODEIJItEPAIR+0 DEMOLI"TION
,U following renxon.(Semi,,.]031.5;Entities;and Professlom Cafe:Any city or county' ❑OTHER
tL F' SIGNS ELECTRICAL
which termites a permit ,,cvmmtct;almr,improve,ddnolish,or repair any,structure -
priour to its issuance.also matrons the ppl' tf r suchPermit t file a signed statement
SPECIAL CIRCUIT/MISC
y
that he licensed ed purses a the provisions flheContractor's License La (Chapter 9
00 (commencing with Seel la(ft ofEdvikion9 ofthe B : env andP f: sCgd)or - 9EMI'.MEMRORPOIFINS'L COMMERCIAL: -
athat he is exempt therefrom d me basis f i the alleged exemption.A y violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 70315 by my applicant fPermit subjects the ppli t too civil penalty of POWER DEVICES
zQ not none Nun Fvehundreddo11ars($5(0)r ❑TENANT ❑FOOD SERVICE
1, ownerofthe preplan, with wages as thelisolecompersation. SWIMMING POOL ELECTRIC IMPROVEMENT
❑ m v
O willdo the work, it theahucture flat),mermalmoRued forsele(Sce.]D49,Business r ❑OTHER
W 3 R and Professions Cole:The Contractor's License Low does ooi npplY Its no owner of - Oli7l_H I'S-SWITCHES-TIME'MRS -
6 property who builds or improves thereon,and who does such work himself or through
his own employees,pnwidad that such improvements arcnot imendcJ or offered fur NEW RESIDENTIAL F,LECTR SQ FT.
sale.ll;however.the building or iter..memaoddwithinone year',completion,the SQ.lel'PLWRAREA S/SQ.PI'.
owner-build
er will have the burden of proving that he did not build or improve for par- L a� 11U
pose often.). I "
❑ 1,as owner of the pm,my,am exclusively contracting with licensed contractors in. - TDTAC
construct the poijecusec.I(/W.Bmince,and Professions Colle.,The Canaanars Li- •e e 6
came Law dies not m apply an owner of prnpeny,who builds or Improves thereon,and QTY,, PLUMBING PERMIT FFF , 1996
who contracts for such p dens with a contraeor(s)licensed panuent to the Commann's .,
Liccnsc Lose' PERMIT ISSUANCE " Vr inure
El Ism exempt under Sea ,B&Pch,r nos rersnn
Owner
ALTER-DRAIN&VENT-WATER(RA) VALUATION
Use '
WORKEII'SCOMI'I:NSA'I'IONDECI.ARATION BACK FLOW PROTECT DEVICE .
1 hereby affirm under penalty of perjury one of the following declaratiom F �•
I have and will mninmitia Certificate of Consent to seH-insute for Workers Campen- DRAINS-FLMR,ROOF,ARBA,COND. STO IES. TYPE CONSTRUCTION
cation,us provided for hy'Seaion 3]1X1 of Wa Lobar Gvlel for the perli,rmnncc of the - -
w -
ark for which this .it is rimed.. FIXTURES-PER TRAP
X '
have and will maintain Workers Compensntinn Insurance,as required by Section d
• ofthe Labor Code,I., the work far which this Canthitis issued GAS-HA.SYSTEM-I INC.4 OU'1'LIThS OCC.OROUP APN '
My Wmkc Tyr mipa-Ino.yn -camerolic,Ncy�lyr�%6 S GAS-EA.SYSTEM-OVER 4(CA)
t My woe f-✓�V -�,11aJ 07
' CERI'[IICA]17 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASNINDUSTR_I.WASTE INTERCEPTOR
(flus,ectian nmd not he completed if the permit is forom hundrod dollars(E IM) BUILDING DIVISION IEEE
or lets.) � l. GREASE'MAE' .
PLANCHECK FEE
Icenify Person
Ne any
sit ex
for subject
the W rkao'Conapell SEWER-SANITARY-STORMEA.2(OFL,-
nor employ any Canon in any moaner sit ns m become suhjecnn the Workers'Cnlnpen- ENERGY FEE'
Z cation laws of California.Dmc - '•' '-
O WATER IIEA'1'T:RWNF:NT/F.I.EC'TR
7 Applicant GRADING PER
a In NOTICHTO APPLICANT.IL after making this Camri,ate of Exemption,you should WATER SYS]EM/TRHATING
a ; become subject m the Workers Compensation prmisinns of the Labor Code,you mull SOILS LER'
fonhwitb comply with such previsions or this permit shall IN dented revoked.' - WATIiK SERVICE
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. {BQ.`FT. PAID
U O Thereby affirm that hem is a construction lending agency for the performance of Dote Recei p
0 F the work fur which Wit pennil is issued(Sec.3119],Civ.C.) '
O Lenders Name T
OTAL
W Lender's paddy
' _ TOTAL:I unity that have read rhls upClication unit shoe Wet rho abnvo infointntidn is BUILDING THEf/] cumetlagreemcomply with all city and enemy oNinnnces and smut laws rclmingto QTY MECHANICAL PERMIT FEEbuilding conswcted.and herehy authorize represematives ofthi.v city to ether upom We SEISMICFEEabove-mma oil prneny fur ox,ac so purposes. PERMI'I'155UANCE
(We)agree m ave.indemnify and keep harmless the City of Cupcnino against 31.ECTRIC I !E qDliahilities,judgmems,costs and exp,mc,which may in uny hyracrueugummorid City ALTER ORADD TO NEED
PLUMBINGFRH,APPLICANT UNDERSTANDS AN L COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(TO 10,000 CFM)SOURCEREr ATION /p�{^/� MECHANICAL FE�� AIR IIANOLING UNIT(GVER ID gCPM) CONSTkUC 10N A%
Signature of Applicum/Contrxcmr toEXHAUST 1400D(WMUCT) HOUSING MITI TION FEHHAZARDOUS MA'T'ERIALS DISCLOSURE Will the applicant or future building accul ant store or handle h spar oat material HEATING UNIT(TO BIB,000 BTU)as defined by the Cnpenlno"Memel Cli Code,Chapmr 1).12.and Ihe'I health and Safety
Code,Section 25532(m l HEATING UNIT(OVER boo,000 BTU) -
❑Yw K-No VENT]LATION PAN ISI NGLE RES ID) PAID
�C Dat RueiptK
Will he applicant or furore building by he B use equipment or devices which -
unlet?aNnus air contaminants us JefinM by We Bay Arca Air Quality Manugemem BOILER-COMP(3HPOR IW,000 BTU)
Dun
BOILER-COMI'(OVI:R 100,(X0B'FU) ,
:
❑Yes %fif No
1 hove rnuJ the hazntdous nwleriuls rc ts under Chu to fi 95 of Ne CA, AIR CONDITIONER' ++
,25533 n p ISSUANCIvy
AT-
fomia Health&Safety Cale,Sections 25505;8513 and 25534.1 understand net if We NEW RESIDF.NDAL MECH. SQ.FT. `
builJing does nrn cuncntlyhv tit Nat iti •a,onsibilirym notify therecupaat
;5-
of the try ' tents n he car tCriono ss cola Cenifcme O v andy. /W� y
Owt r oallorizedagent Dwe TOTAL: ISSUED BY'.
. OFFICE
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Design: 0220/88 IDe'7 no.
All tllmencionz 8 size designations 0 nor Is an original o cools and unless
must FONGMARL
Scc1a: I : 04=11 =
poen nra n di..'oim".fiti job
nn applicable
be bile fee
or own unless MARIAN FONG
Job all entl etljuctmant to fit job npplicaIaa Poe hes been peltl or Job Designer
mntlition,
. oitlm plecW.