29151 Ri
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OriCUPERTINO - BUILDING-ELECTRICAL - � PERMIT NO.
BUILDING DIVISION APPLICATION/PERNIIT PLUMBING-MECIIANIC'AL29151
BIIILDINC PROJECT IDBNTIFICA'1'ION '
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE 5 � Pit-lo"-74 .
1 OWNER'S NAME: PHONE: CONTRACTOR'S NAME: VIC N(I:
J�£L£Al cc /fdA P&7,1), Ct4 //IS)�i NIC CONTROL
ARCHITF.CT/ENGINEER LIC NO: ADDRESS ' ❑
afZW � F)ee-7"on�.4vf 5.V
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB /MECH
OherebyLICENSE[)CON'TRACTOR'S DECLARATION ❑ ❑ El1herebyoffofficerm licensed that T am m�der Provisions or Chapter 9(commemdmQTY ELE
g CTRIC PERMIT FEE JOB DESCRIPTION
W .
widi on Secti7000).f Division 3 efthe But.,and From ..
m.. ..Code,and my license is PERMIT ISSUANCE RESIDENTIAL
WOO
Caj-F- mfall forceadd effect ! ❑SFDWL ❑KITCHEN REMODEL
<—U License Class Lic.M �( APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING REPIPE- t[nZto Dole Conwctor�1
C ARCHITECTS DECLARATION []MULTI-UNR [I STRUCTURAL
FEZ I understand my plans shall be used as public records PANELS MODIFICATION
Z O UP O 2W AMPS
OZ— T
[I INTERIOR ❑CHIMNEYREPAIR
-
F u] Licensed l'rofca.,ianal 201-1000 AMPS IMPROVEMENT
`y OWNER-BUILDER DECLARATION OVER IOWAMT'S ❑BATH REMODEUREPAIR C1 DEMOLITION
C 6 I hereby affirm that 1 an exempt from the Contractor's License Law far the
W3 FU- following reawn.(Section 2031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL [I OTHER
y which requires a permit o construct,alcor,improve,demolish,or repair any structure 1
F'u'�; primo its issuance,also requires the applicant fnrsnch permit 1,file asignednmtetnew S PECIAL Cl RUG TOM ISC. ^
SWy Nat he is licensed pursuant to the provision,of fine Contractor's License Law(Chapter 9
ao0 (commemcingwith Section 9000).fTo,siou3,fthe Business and Profc,min,Code)in I EMP.ME'rER OR POLE INST. COMMERCIAL:
f,a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑N17W BLDG/ADDITION ❑DEMOLITION
W^m Section 7031.5 by any applicant for it permit subjects the applicant to a civil penalty of POWER DEVILS [][]TENANT ❑
[]TENANT C1
not more than five hundred dollars(5500).
FZy IMPROVEMENT
=Q MLus me work,
thebearmy.or is employees with wagexas lnei(See compensation. SWIMMING PWLELF.CTRIC
W will dothewons Code
The raince isnotintended ,offereddoes sal apply to
owner
os ❑OTHER
W 3 m and property
no
Cade:The me,door's License l do,sons nm apply m lI owner mf OUTLETS-SWITCHES-FIXTURES '
properly whooyees.0r improves demon,i Duro who does such work hinoder or,or through
his own employees.had"M that such improvements arc not inturiA,o uf4+W for NEW RESIDENTIAL ELECI'R SOFT -
ownelhowever r will ceeffie wdr pmvntont .oldwithinorcild or iprovetfar the SQ.FT.FLOOR AREA USQ.<T.
owner-bumlder will have the burden of tat he did not build or improve for pur-
,owbi
01,assow,ne ,
1,as ow, a of the property a xcl .any;nonacid` enawd convenors set TOTAL: PAID/�
comnma the project I ce.] d dc5yms aldol Tnc Cantra<toh Li- P nq I ^^
verse Lawcestme up . nerofpropcl'��t/1ce-ed pursuant
Cont m,and QTY. PLUMBING PERMIT FEE p
Tf
whoc,ntracts for sucp�DswiNuc�m2(rR)Iicemed punuannothe Contractor uC^
License Law. PERMIT ISSUANCE `` /2R
❑l am exempt under S .B&PC for this reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) 'e Vh VAL TION
-
Ihembyo WORKRSClynf ONSAT1ONDECLARAI'ION ' n BACK FLOW PROTECT.DEVICE Lurr�llN�
perjury one of the follawmg dmIm tions 'I
•❑I haveand will mainwinu Cenificatx nfConsento self-insurt forWwkds C.mpen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
wtlon,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP ,.
❑1 have and will main rim Worker,Contpiamminn Lawrence,it,re paired by Section
37W of the Labor Code far dm performance of the work far which Ibis permit is issued. GAS-FA.SYSTEM-I INC 4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are
Carrier. Policy Nu,A) 7A 2,s._ V;LL64 GAS-FA.SYSTEM-OVER 4(EiG
CER'I'I FICATE OF EXEMIMON FROM WOR KERS' GREASP/IKUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Phis section need not N completed ifthe permit is fivone hundred d,llora(SIM) GREASE TRAP
.r less.) PLANCHECK FEE
I cenify that in the performanccofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM F.A.2W Fr.
not employ any person in any manner,.a,to become subject,the Weaken Compar- ENERGY FEC
ZZ no.laws of CuLfiro e.Dam WATER HEATER WNENI'LELECTR
Applicant - - GRADING FEE
h NOTICE TO APPLICANT:If,after making Ibis Certificate of Exemption.you should WATER SYSTEM?REATING
a ; hewme subject w the Worker's Compensation provisions of the Labor Cale,you must SOILS PEP,
W
forthwith comply with such previsions or this permit shall be deemed invoked. WATER SERVICE ,
a, 0
P 'z CONSTRUCTION].ENDING AGENCY NEW RESIDENTIAL PLMB. SQ.W. PAID Data - Receipt#
VQ I for
affirm therohi isaconstruction lendle agency for the performance of
the work for wM1ich this permit is issdcJ(Sec.3(19"[,Civ.C.)
u' F'' Lender's Name TOTAL'
V Lenders Address 'TOTAL:
1 swirly that I have read this application and nate as the above information is BUILDING FEE
i�r taA toren.I agree o comply whh all city and county ordinances and state laws calming to QTY. - MECHANICAL PERMIT FEE
VZ building construction,and hereby armariac represenwhves of this city to enter upon the SEISMIC FEE
abrveanentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree o we,indemnify and keep harmless the City of Cupcnina again. ELECTRIC FEE
liabilitic.,judgments:costs and expenses which may in any way,cane against said City ALTER OR ADDTO MECH.
PhUMNING FEC
in asequence of the granting of this North,
APPLICANT-UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE - I�
SOURCE REGULATIONS JJ-_/I ,l
� rz,cf
�HzA�(_ AIR HANDLING UNIT(OVER to."CFM) CUN$'IRUCTION TAX
I., _q-, /A�/
Si awre oApplicant/Cmm
nncr {_, lac d EXHAUST HOOD W/DGCD HOUSING MITIGATION MIT
HAZARDOUS MITER
[ALS DISCLOSUR i
Will the applicant or future building occupant store whandle heaudos,material HEATING UNIT(TO 103.0110 BTU) t
m delisted by the Cm sono Municipal Cls.Chapter,9.12,and the Health and Safety
Code,Section 25532(.)? - HEATING UNIT(OVER IM."BTU)
Ycs F1N.
VENTILATION PAN(SINGER RCSID) PAID Data IlemiplN
Will the applicant or future building occupant use equipment or devices which
mit hazardous air cnmaminana as retired h he Ba Arca Air Quality Mona mmam BOILER-COMP OHP OR IM,M0 BTU)
Y I Y b TOTAL:
Districts BOILER-COMP(OVER IM.000 BTU)
❑Yes IT No
L ancestral the havNums material,cape amcnu under Clopm,695.1 me Cali AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sabot,25505.25533 and 25533,1 understand that if the NEW RESIDENTIAL MCC H. SQ.FT. -
building does not currently have a tenant.Nal it is my responsibility to notify the excuperi '
of the r afewoems which must be met poor to issuance of a Cenificate of Occummi
Owner or aothmz.ed agent Use T I ISSUED BY:
OFFICE