29699 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
- BUILDING DIVISION
APPLICATIONIPERIEITPLUMBING.MECDANICAI' 29699
BUILDING PROJECT IDENTIFICATION
RUILDINGADDRES: .. - SANITARY NO, APPLICATION SUBMITTAL DATE
'NEB's NA - PI10NE:. NTRACfOR'S NAME: - LIC NO:
7_,2 y
'��•- Q 1 NIC CONTROLa
CHITECf/ENGINEER: LIC NO: DDRFSS: ` ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑Tri Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLUMB MME-C�H�
LAI
❑ ❑ FS
LICENSED Coll RAC 'DECLARATION QTY ELECTRIC PERMIT FF,E
that m
I hereby nation I am littnud un c provisions of Chapter 9(corporations JOB DESCRIPTION
Z with section]000)uf Oivision3ofthe Bulinus and Professions Cede,andmy license rs RESIDENTIAL:
O O PERMIT ISSUANCE,
F in full force an tike {�
�UV Licen. lass Lica ��- 5i:5 ` ❑SFDWL ❑KITCHEN RE-PIPI.
H4L Date Contractor APPLIANCIis-RESIDENTIAL ❑pDDIT1pN ❑PLUh101NG RE-PIPIT
` ARCHITECTS DECLARATION
PANELS - OMULT6UNIT ❑STRUCTURAL
z O onz I understand my plans shall be used as Public records MODIFICATION
Oz—p UPT0200AMPS L1 INTERIOR GCHIMNEY REPAIR
F�f'ul Licensed Professional 201-I000AMPS INIPROV17MENT
Cao; . -
OWNER BUILDER DECLARATION OVER 1000AMPS [I BATH RBMODEURE IR 1:1 DEMOLITION
Q I hereby ualrm that 1 am exempt from the Contm,am'z License Law Retire 1 O L U following reason.(Semon 70315.Business and Prdfe,vsionx Code:Any city or county SIGNS ELECTRICAL OTHER
C'3 u:y which requires u penult m mnswct,tetter,improve,demolish ar repair uny stmeure
.F.^OQ prior to its issuance.also requires the applicant forsuch permit to fileasignedstutemenl SPECIALCIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractor's License Use(Chapter 9
11'�0 (commencing with Section]000)of Division 3 of the Business and Professions Cade)or TEMP.METER OR POLE INST. COMMERCIAL'
a ti c C that he is exempt therefrom and the basis for Be alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLIT10N
W u. Section]0315 by anyapplicantfora permitsubjects the applicant ma civil penaltyof POWER DEVICES.
not more than five hundred dollars($St10L ❑TENANT ❑FOOD SERVICE.
F^'Z��' IMPROVEMENT
�xd0 (] I,azownerof the pmputy,or mycmPlnyeu with wegezastheirsn4ecompensation, SWIMMING POOL ?LECTRIC -
IY�e will do the w.,k,aadmp,uucmrc is a0t imandedoroffcred mr,me(Sec.](W4,Business ❑OTHER
13 m and Professions Code:The Connector's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES 2- 20
progeny who builds or improves thereon,and who dres such work himself or through
his own employees,provided that such improvements are not intended or offered far NEW RESIDENTIAL ELECfR SQ ET.
sale.IL however.the building or improvement is sold within oncyearofcompletionthe SQ.E.FLOOR AREA $/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for our-
paze of sa c,)
E] ,�
L as owner of the prom perty,aexclu,uivaly contracting with llcenseil contractors to T'
onsuunt the project(Sec.7I14,L Business and Pmfersions Co...,The Cnnuoaors Li-
censeLawdoesnatapplymanownerofpropertywhobuildsorimpmrvesthereon,and QTY. PLUMBING PERMIT FEE
.who contracts for such projects with a commemgs)licensed pursuem to the Comramoev
License law. PERMIT ISSUANCE
❑ IamenemptunderSec. ,B&PCfar this reason
ALTER-DRAIN&VENT WATER(EA) , VALUATION
Pte
woe WORKERS COMpENSATION DECLARATION BACK FLOW PR(ITHCT DI VICE
Ih hereby mud penalty of factrY of the followingdeclaration: t
/• ❑I have and w'll maintain a Certificate ofConsent toself i .umfor worker's C -pen- DRAINS_FLOOR,ROOF AREA,COND.
attion provided for byS i 3100 aid Labs Cod forthepert of the STORIES q'YPB CONSTRUCTION
for bch does permit is issued, FIXTURES-PER TRAP
I he d 11 he k Compe:t I c req led n i Sat nn
3]W off the Labor Code.
c.far Nm
e perfoancc of the work for which thispermit v issued. GAS-HA.SYSTP.M-I INCA Ol1Il.RT5 OCC.GROUP APN
My Worycr's(W vn ation nsumncec'nice and Policy
Carrier:_1.0 Policy No.: _ GAS-EA.SYSTEM OV6Rd1EA)
Cl: IIICATE OF EXEMI ON FROM WONKIiR '
COMPENSATION SURANCE GREASEANDUSTRI,WASTE POT
RCEI'TOR e'k
_ BUILDI6G DIV] FEES
(This section need not be completed if the permit is(erotic hundreddollarn(SIM) GREASETRAP n
' or less.) A PIANCHECK FEE
I certify that in the performance of work for which this permit is issued.)shot] SEWER-SANITARY-STORMEA.20a E.
not employ any person in any m to b'sT p 'eco to the Workeri Campion. NERGY FEE
ZZ cation La. Calif, nits.Dote WATER HEATER W/VENT/ELECTR
Q Applicant ` A q _ GRADING FEE
.N. NOTICE'PDAPPLICAN'1` ? / sf\-\N
a > fee subjau0 the Worker. mn,a satins pmvisims of the Inbar Code,you must 1 SOUS IIiE
foM.alf comply with.wrth promzmns or this penton shall be cleaned revoked. WATER SERVICE
a0
U O CONSTRUCTION LENDING AGENCY NEW RESIUENTIpL PLMB. SQ.E. PAID Date Rcce p
Iherwhich this Pe them issued(Secu iD.Cing agency for the performance of
the work for which this permit is issued(Sec.J09],Civ.CJ
OE'er' Lendcis Name _ - OTAL:
U Lender,Address TOTAL:
0. I certify that I have read this application and state that the above information is BUILDING hlAi
correct.1 as.m comply no all city and county ordinances and state laws relating Int Q'I'Y. MECI IANICAL PERMIT FEC
U Z building comwaiat.and hereby anho arepen
easmtivesof ter
this city to eaupon the SEISM IC FEE
above-manta ned property for inspection Purynses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hermlesz the City of Cupertino against ELECTRIC tEE170
liabilities,judgment,costs and expenses which may in any uny accrue against said City ALTER OR ADD 10 MECI{,
asequence of the Granting of this permit. PLUMBING NEIi
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNI1'90 IgB(f)CFM) '
S URCE ft[CULATION.. MECHANICAL FEE c
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TA
Signature of ApplmmI ancon \� EXHAUST HOOD(W/DUCf) HOUSING MITIGATION FET:
RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT('1'01 Op"BTU)
to,defined by Ne Capetian Municipal Cod,Chapter A 12,and the Health and Safety
Coda Section 25532(u)'! '' // H EATING ON IT(OV ER 100.000 B'1'U) '
❑Yee' yaNP VENTILATION PAN(SINGLE RESID) PAID
/�' - Dom Receipt if
Will the applicant or future building occupant use equipment or devices which gO1LER-COMP(3HPOR Ip1.IX)O BTU)
mit hazardous air contaminants a,defined by the Bay Area Air Quality Management TOTAL:
L,nals BOILER-COME(OVER 10100E BTU)
read the hvardousmnmriuls requirements under Chapter 6.95 of the Coli AIR CONDITIONER IS ANCE DATE
&SolbtyCole,Section.,25505,25533and25-534.I unrsmmd that if the NEW RESIDENTIAL MECH. SQ.E.nal currently have a tenant that it i,my rezpaobility to notify Ne occupantmems muyh met prior m issuancepj�\Cenifi meof(keag
hr agent14 Data Tf ISSUEDB t
OFFICE