29487APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL.
PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
29487
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: -
SANITARY NO. -
APPLICATION SUBMI'FAL DATE
�Zmp,OS
i
3`Inq6
OWNER'S NAM : HONE:
C{kvVTRACT 'S NAME: LIC NO:
N/
CONTROL#
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I' ITE` GINEER: - LIC NO:.
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CONTACT: - PHONE:
a_5O LLSC
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Consultant Fees Paid by Applicant (Initial)Ci�
BUILDING PERMIT INFO
BLDG ELECP PLUMB MECH
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LICENSED CONTRACCTOtRV'•S DUCLARA%1'ION
L hereby of irn mat 1 am licensed made, owi,iu. of chapter 9 (enmmaneing
wl mSection]000)o(Uivision3ofthe Busincasand Professions Code, ondmy license is
m full force and drat.
Licenx Ceps Lica 1jO---
Ume.-- �A1,, runor
QTY. ELECTRIC PERMIT I°'
JOB DESCRIPTION
RESIDENTIAL-
❑SFDWL �0KITCHGN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
[I MULTI -UNIT []STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ DEMOLITION
0OTHER
PERMIT ISSUANCE
-
APPLIANCFS—RESIDENTIAL
h Z
C
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
PANELS
�i n -
UPTO 200 AMPS
Ftp Licensed Professional
') OWNER -BUILDER DECLARATION
ad Q I hereby affirm that I um exempt from me Contractor's Licence Law for the
C. U following reamd. (Section 7031.5, Business and Professions Code: Any city or county
pF which requires a permit to construct, etre,, improve, demolish. m o,om, myorm,nom
prior issuance. alsorequlres the applicant far such permit topic asigned statement
201.1000AMPS
OV12R 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC. Utc
mat he is licensed pan.., In the provisions of the Commnors License Lax' lChap¢r 9
QQ(comnneveingwith Sfetlon](XX))ofDivl.lon 3of the Basin... trod Pndvonat, Code)or
y mat he is exempt Therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant toacivil Penalty of
2 iN+ not more men five hundred others (881X)).
SQp ❑ Las ownerof Thepropeny. oramemployces with wagesaideirxolecturn,mation.
F. will do the work, and the suumum is not intended oroffured for sale lScr.JOl4, Business
3 m and Professions Codc: The Contractor's License Law dxs not apply m an owner of
progeny who builds or improves thereon, and who docs such work himself of through
his own employees, provided that such improvements me not intended or offered for
TEMP MEIPR OR POLL INST.
COMMERCIAL:
❑ NEW BLDG/AUDITION ❑ DEMOLITION
,NANT ❑FOODSERVICE
IMPROVEMENT -
OTHER
POWER DIiVICES
SWIMMING POOL ELECTRIC
)'I'LETS — SWITCHES — FIXTURES
NE "RESIDF.M1TIAI. ELECTR S FT,
Q
s
.oxer If tri the buildingimprovement . Id withinn y fcompletion,tl the
e 6 Ido Ilhave te burden fp mg that heddnot b Id or improve for p -
El 1. fm progeny, 1: leycontracting with licensed t m.m
constrvct me project (Sec ]EFW Business and Professions Co.,.,The Conuacmr s Li-
se Lawdocsnatapply mantwnensf pmpcny whohuildsnrimpmvealhcm a.and
who contracts for such projects with a contractors) licensed punuam to me Comracrore
\ \ _
s„ \ 40
SQ. FL FLOG
(A}�\\•�1/.•
1
� p
s P
$/SQ. 1'I'.
�, ��
QTY. PL ' MIT PEE
PERMIT ISSUANCE
License Law.
❑lam exempt under Sec. ,B&PCfar this rea.cnn
ALTER—DR N&VE,NT—WATERfEA)
•BACK FIA PRO'f6Cf. DEVICE
Owner Uate
VALU OQ
, / � JU
�^
'WORKLRS COMPENSATION DECLARATION
,Q
unr penalty of perjury one of the following doelamtions:
I hereby affirmde
•LI'
~TYPE
CORA PI OR, ROOF. AREA, COND.
l haveand will maintain a Ccrtificaraof Consenut self-inwm for Worker's Compen-
cation, ac pnwidM fur by Satitn 3]W of the lahnr Code. fnr the performance of the
work for which this Mrmit is issued.
STORIES
CONSTRUCTION
IT
F1 I have and will maintain Worker's Compensation insurance n. mt,mmd by Section
3X10 of The labor Code, for the perfnmmnee ufthe work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
C amOn Pulp, No
GAS — EA. SYSTEM-IIN 5
OCC. GROUP
AI'N
GAS—EA. S EM VER 4 (EA)
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
This section need not Csacompeted it ' the permit is fnr one hundred dollars ($100)
orleso.)
GRXASE`1NWT/qti I ERCEMR
tlUI6DIN VIS
PLANCHECK FE'
NFEES
GREASETRAP
SEWER — SANITARY — S'IT)RM ;A IT.
Laity thmhr thepednrmancenfthe work for which this permit is issued,[shall
n npl. ni ppp anso as to become subject m the Workers'Compem
ENERGY FE
WATER HEATER W/VENT/ELECfR
,�
tion Law "Ca Tomia?Q3y
Applicant sem.. e A �,Q_.CLA
GRADING F .
1 ,
NOTICE TO APPLICANT: IC after makingmis Certificate of Exemption, you .hnulJ
become subject to the Workers Compensation provisions of me Lsbor Code, you most
forthwith comply with such provisions or this permit .shall be deemed mvaked.
µ'q'IER SVSTLM?RLiATINC
WATER SERVICE.
SOILS FIC!
NEW R6SIDEM1TIALPLMB. SQ. FT.
�z
Q
CONSTRUCTION aeras LENDINGAGENCY
[ hor Ihm len ding agency Bootee pafnnwnecof
PAID
Dao Raei
P:
the work for which this permit is issued (See. 309]. Civ. CJ
which anisiamn(Sec. 3
Name
T AL:
BUILDING F
ULenders
Lender's Address
O 1
yI
ecnify mat I have mad this application and scam that the above information is
QTY MECHANICAL PERMIT F
Sidsc C ' _
pj
i z
correct. l agree to comply with all city and county owinances and state laws relating to
building constriction. and hereby aummiae mpresenhaves of this city to enter upon me
above.mentioned property for inspection purposes.
(We.) agree to cave, indemnity and keep harmless the City of Cupertino against
LLE E
- PERMIT ISSUANCE '
)OUTER OR ADD TO 'CI.
Eabiliues,judgmentc, costs and expenses which may in any way accrue against said City
in consequence of the granting o!this permit
-
PLUMBING FE
AIR HANDLING UNIT (TO 10,00 CFM) ,
MECHANIC/.PEE Itc
APP ,(CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S R sREGUTA' yS.
AIR HANDLING UNIT(OVER 10.000 CFM)
CONSTRC TAX
1 L
l�
Signature of ApplicanVContranor Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOT) W/DUCT)
HOUSING MITIGATI NFEE
HEATING UNIT LTO I(i BTU)
-
Will the applicam nr mom baildingowcupanl.mrenr handle hmardnu. material
as definal by the Cupertino Municipal Cale, Chapter 9.12, and me Health and Safety
HEATING UNIT (OVER 100,000 BTU)
Code, Sudors 25532mf`
❑Yes FIN.
PAID '
Dam Rem t X
VENTILATION FAN (SINGLE RESID)
use . Air u nr devices which
will the applicant nr..1. future a bnildiag by
mit hnvrdnnc .... taminums as define) by me Baa Areu Air Quality Mvwgen¢m
DisWcR
❑Yes ❑Nn
BOLI ER—COMP (311P OR 100,01X1 BTU)
FAIL:
BOILER—COMP COVER 100" BTU)
AIR CONDITIONER
I have read the hamrdous romerialsrequirements under Chapter 6,95 of me Cali-
ISSUANCE
NEW RESIDEN9IAL MIiCH. SQ. IT.
Coal. Health & Safety Calc, Section, 25585, 25533 and 25534. 1 undersand that if the
building does not currently have a tenant, That it is my responsibility to notify the occupant
of the requirementn, which must be met prior to issuance of a Cenificme of C e pancy.
ISSUED BY:
-
Owner or vulhorifed agent Data
OFFICE