29369 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT - PLUMBING-MECHANICAL 29369 C(]
BUILDING PROJECT IDENI IFICATION J V J
BUILDINGADDRESS: ��'++ SANITARY NO. APPLICATION SUBMITTAL DATI
a896Via arre,1 P�Qn a-Q 6 - 3 _96
O ER'S NAME:
PHONE CONTRACTORS CONTRACTOR'S NAME: LIC NO::
faffen �7ewrel 9?.0 pB0 Cffafmo ag.r�S 563$y CIaIS NIC CONTROLg
4RCH,TECT/ENGINEER: LIC NO: ADDRESS: El�/05�sormin f}ve, S4i� DO
CONTACT - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUMB MECH
eCoo er 8s6D6 Pel 'Z E' ®e
UL SEDCONTRACTo SDECLARATION Isry ELECTRIC PERMIT FEE
1 hereby affirm that I am d un
licenseder pro owes of Chapter 9(commencing JOB DESCRIPTION
aX with Secuor]000)ofUivisian3mit,Businessimllinsfiraions Cmde,andmy license is
°r in full foree and effect. PERMIT ISSUANCE
1ULicenseClass Lic.a L [I KITCHEN REMODEL
Date Contractor APPLIANCES-RESIDEbIT,AI.
� ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION - [I MULTI-UNIT ❑STRUCTURAL
[[--.. 1'ANF.IS
Z O n Z I undcrsund my,lans shall be usm m Public remoda MODIFICATION
O'7-0 UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-10N)AMPS IMPROVEMENT
E OWNER-BUILDER DECLARATION
yC 1 hereby affirm that 1 am exempt from the Contractor's I imense Law for the OVER 1000 AMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
x°6 U fallowing teas...(Section 703 L5,easiness and Prefessmns Cade:Any city or county ❑OTHER aJ at u
3,F- which r permit to consider,alter,int SIGNS ELECTRICAL
respites issu a pe posy demolish.r repair any structure
° pdonoiucensed e,also requires he thovisiosofthecant for such Conarrme.s o file a License
signedstatementSPECIALCIRCUIT/MISC.
;!Ian mot he numistal;acdpursuant totheprovisions 3them Business
License law(Chapter 9
.apo (commencing with Scetion]OOU).f Division3of the Business and Pofessiom Cram)or l'FNP.METER OR POLE,NST COMMERCIAL:
P. p that he is exempt therefrom and the basis for the alleged exemption.Any violation of N WBLDG/ADDITION DEMOLITION
Section 7031.5 by any applicant for a permit suhjects the applicant to a civil penalty of POWER DEVICES V' LUI--
❑TENANT Cti l m6i`FOOD SERVICE
sF.. t tome than five hundred dollars(5500). v
Iq�6Q pl,as owner of the property,or my employees with wages as mcirsole compernation, SWIMMING POOL ELECTRIC IMPROVEMENT
2� will do the work,and the mmcure is not intended oroRcred for sale(See.]0f4.Business ❑OTHER
W and Professions Code:The Contractor's License law does not apply as an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves[he..,and who does such work himself or through
his own employees,provided that such impovemems are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
aid.If,howevecthe building or Improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AR EA $/SQ.ET.
ter-builder will have the barren of moving that he did not build or improve far pur-
prom ofsalc.).
❑I,his ownerProperty exclusively contracting with licensedm nors m TOTAL:
constructct the mri eet(Sec.]044,,B Business and Pmfcssinna Code:)The Contrueuds hi-
cerem law docs not apply to an owner ofpopeny who builds m improves thereon,and QT'Y. PLUMBING PERMIT FEE
whocroristsforsuch projects with ocotnrucholt)licensed pursuusnm theGnatudoes 3 pt
License law. / PERMIT ISSUANCE
E]I ton excerpt under Sec. ,B&P C for this reason
•Owner Date ALTER-DRAIN&VENT-WATER IEA) �yyy VAf'L�-UATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(I'BCT.DEVICE /J SV a
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Ciminero,or Consenua self-inswe for Worker's Conniver- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of mhe labor Code,far the performance of the
arms for which this pevnit is issued. FIXTURES-PER TRAP
lyl have and will maintain Workers Compensation Insurance,as required by Section -
JV00oftheLiborCrde,for the peromtance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
M Worker'sC tp ns tin/�I atone(•-crani end P.1ic yt d a
Cartier:[-,J�KaXzLALT7'yy-Iicy No.yna0/fJ/ �� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This senior need not he comPlered it the permit is Frt.ne hundred dollars ISIIXp BUILDING DIVISION FEES
GREASE TRAP ^Q-Q�
err less) PLANCHECK ''E e1
I ecoifythm in the'Kenews.ofthe work fur which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
•Z whom Laws in not employ anyCalif mioJe in�lYtc wncr�> become W/?,t eyfj?Gtfnpen- ENERGYF
zO Applicant A-EC J 7 (7 WATER HEATER WNENT/ELF:CTR GRADING
rr fn NOTICE TO APPLAC •I .If,after making this Ccnificara of Exemption,you should WATER SYSTEM?REATING
a ; dedonse subject to the Worker's Cim persahon pnwisiom of the Leber Code,you must SOILS 11E
LkI r. forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
UO CONSc ONLENDINGAGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID
I hereby affirm that thereem is is aa construction lending agency for the perfonnance of Receipt p
lTr F the work for which this pemdt is issued(Sec.3097.Civ.C.) '
0 U Lendcrs Name TOTAL
Lender's Address 'TOTAL:� AI" y I certify that 1 have read this application and state that the above information is BUILDING ��6 Y•V 1C
N correct l agate to comply with all city and county omi unces and Vann laws reining to QTY. MECHANICAL PERMITPEE �y
Vz building construction,and hereby andante,represenutivea ofthiscity menterupon the SEISMIC 4B / 171
k+
rs above mentioned pm,voy for inspection Pm ow, ut•
PERMIT ISSUANCE.
(We)space to ade,indemnify keep hmmless the City of Cupertino aganst i
and ELEC 'EE 71 IS
liabilities,judgments,costs and expenses which may in any way regime against said City ALTER OR ADD TO MECH.
in comequence of the stoning of this permit PLUMB, •L �7
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS, eY
AIR HANDLING UNIT'(OVER 10.000 CFM) CONSTRUCTIONTAX $ 6611zI
Signature o'ApplicandComentor Date EXHAUST HOOD(W/DUC) - HOUSING MITIGATION TE
HAZARDOUS MATERIALS DISCLOSURE
Will thea,pliewit or fuwre building receptor mom ar handle hassNoas mammal HEATING UNIT(TO 100.00)BTU)
as divined by the Cupertino Municipal Code,Chapter 9.12,and the HvIdth and Safely
Cede,Section 25532(.)! HEATING UNIT(OVER 1(10,0tto BTU)
❑Yes ON. PAID
VENTILATION PAN(SINGL1i REBID) Dore or
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OFF OR 100.000 BTU) n /
emit hazmd.us air contaminants as defined by the Bay Area Air Quality Managamnent T L A 09Aa�O
District? K
❑Yes ❑No BOILER-COMP(OVER IN,"BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCEDATE
firma Health&Safery Code,Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL.MECH. SQ.FT.
buildingdms murtentlyhavers¢nam,that.isua res pans ibilimymnatifythc oecupanm V V tI \ /
of the menu whi m b Ito..poor m issuance of a Ccrtlncme of tRcfupaney. YT+<Jlyq•SIJ/
TAK J YN
Owner or nuthonud spam D.e •'TOTAL: ISSUED BY:
OFFICE