29315 I APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY, '
CITYO CCUPERPINO BUILDING-ELECTRICAL PERMIT NO.
BUu.DINC DIVISION APPLICAI'ION/1'F.RMIT PLUMBING-MECHANICAL 9C
BUILDING PROJEC7T IDENTIFICA9'IIJN 29315 7 15
i .
BUILDING ADDRESS: SANITARY. APPLICATION SUBMITTAL DATE 11611 to444&,D LT Loi 1
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❑
CONTACT: PHONE: I//� BUILDING PERMIT INFO
1 ❑ Consultant Fees Paid by Applicant(Initial) -BLDG ELEC}' PLUMB MF. i
LICENSED CONTRACTOR'S DECLARATION /I QTY. ELECTRIC PERMIT FEF-
I hereby affirm that l a.licensed undo p '.'on. of Chapter 9(commencing JOB DESCRIPTION
1.
WM9ZO Ins ri 7000) fDiv'.' 3 f,h Bine, itPr f. ions CodganContestantmylcene in 'R ID TIA
- PERMIT ISSUANCE
Ffull f d eeffect.
C LL I„ - DWI. El KITCHEN REMODEL
QUZU 1' 'u Cl isx Lao' .# APPLIANCES-RESIDENTIAL ADDITION El PLUMBING RE-PIPE
m< Gate Contractor
1„
D. - ARCHITECT'S DECLARATION c PANELS ❑MULTI-UNIT ❑STRUCTURAL
Zb-Z I understand my plates shall he used as public records I MODIFICATION
O Z y: UP TO 000 AMPS
p [I INTERIOR El CHIMNEY REPAIR
ul Licensed Prnfcssiowl 201-10(0 AMPS IMPROVEMENT
QYF, OWNER-BUILDERDECLARATION
C h OVER 1000 AMPS L1 BATH REMODEIJREPAIR [I DEMOLITION
C 2 Q 1 hereby affirm that 1 am exempt fromm rhee Contractors License Law for the
I J following mature.(Section 7031.5,Bo.cines.and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
3 LL in which requires a pormi,to cnnamct.alter,improve,demolish,or repair any sanctum
; prior o its issuance,also tegoims the applicant for such permit to file a signed sediment SPECIAL CIRCUITfMISC.
f fy} that he is licensed pursuant mthe provisionsofthe Contractor's License Law(Chaper9
C y.of (commettingwith Smtim1700D).fDi,i,mn3 ofthe Busiacssand Prefic,nr,Code) TEMP.METER OR POLE INST. COMMERCIAL:
NAJ
W
2 O C that he is exempt therefrom and the basis for toe alleged exemption,An violation of
c p g p Any CI NEW BLDG/ADDITION C)DEMOLITION
XnLL Secrion]OJ LS by any applicant forapermir subjects the applicant toa civil penalty of POWER DEVICES
7-
o" ❑TENANT [I FOOD SERVICE
F Z} nmI more Nae Bve hundred dollaa y ramp!. ,
i_� ❑6othe owner k, ndshehe property,or
onacturmyemntended mattered
fin wages their sole 0a.4, usinon. SWIMMING POOL ELECTRIC IMPROVEMENT
p-. will Bothe work,ands: he Contin tors License Law
doesm of apply to
owner
of ❑OTHER
4 3 m and Professions Cale:The oyes therio License Law does not work
hi to if owner of OUTLETS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who dies such work himself orti through
his own employeese provided that such improvements are not intended m offered for NEW RESIDENTIAL ELECI'R SQ f4.
sole.If,hnwevu ill have
ofprmunt ithat he id non wild or fmmpletfor,the t ESQ.PT:FLOOR AREA EISQ.IrP.
will have the burden of proving that he did not build or improve for par-
p^x' owner
1'A6-3,9V5-
construct
owner-builder
constm t the project apply]046 B c d P f .C ori pr C I t :I
who co J rl fp pry h builds i' p C tit Q'I Y. PLUMBING PERMIT FEL'
who contracts for such pnJ nwth aamnuW OI licensed pursuant the Contrera r
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. CO A ,B&P C fonhi'rtason
ALTER-DRAIN&VE.NT-WATER(FA) VALUATION
Own
WORKER'S COMPENSATION DECLARATION s� O ���1
BACK FLOW PROTECT DEVICE V V
1e and will maintain
Penalty of ofComeneof Nefollowing arker'iom:
EI Ihave and will (or by Se Certificate37of Consenter Code.clifirsum for Camper-of the DRAINS-FLOOR,RODEAREA.COND. STORIES TYPECONSTRUCf10N
cation,as provided for mi Section 3]00 of Nc Labor Code,for the performance of the - nit All
11 r�
irk for which his Permit is issued,hit. FI%TURES-PER TRAP s L C
370 have and will maintain Worker'Compenm0on Insurance,which required by Section
My ofdminborpeNc,fonbeperfor canccofthework(ordeirthis permit is iwucJ, GAS-EA.SYSTEM-I IRCYONtETS rr�{ CGRSIUP AYN
Came,:keLv Compensation Insurance cameroli Policy number art: H IY_ aVa 1996
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 6(EA) 'JJ •,
CERTIFICATE OF EXEMPTION FROM WORKERS ...
COMPENSATION INSURANCE GREASIDINDUSTR.WASTE INTERCEPTOR 'el 1 f 'J, BUILDING DIVISION PEES
(This secrien cored mol bemmpleted if the permit k from a hundred du11ws S100)
" -"'
or less.) GREASETRAP - PLANCHECK FEE
I comity that in theDerfunnunecofthe workii whichrhie#sonar is ivsunl,leha0 SEWER-SANITARY-STORM BA.201 FR
not employ any poison In any manner so as to become subject toNe Workcnf Com(nm ENERGY FEE
z
Zi 'main Luwa of Caldi r a.Dare ' WATER HEATER W/VENT7ELECTR
O Applicant GRADING FEE
-
NOT ICE'PO APPLICANT:If:after making Nis Cenifiunte of Exemption,you nh arlA WAIV,R SYSTENU BEATING
become subject to the Workers Compensation provisions of the Labor Code,you mus, SOILS FEE
9Z forthwith comply with such pnoionasor Nis Nourn,holl be deemedrevoked. WATER SERVICE
6
7Z CONSTRUCTION LENDING AGENCY NEW RESIDIiNTIALPLMB. SQ.PT. PAID Date Re rip
U,0I hereby affirm thatthere is a construction lending agency for the performance of
work for which this permit is issued(Sec.3097.Civ,C.)
0 U Lenders Name Aios TOTAL:
Lenders Address
} G 1certify Nm I have read this application and slate that the above information ix BUILDIN
cmircct.I agree to comply with all city and countyordinaaces and state laws mlaing to QTY. MECHANICAL PERMIT FEE
U Z. building construction,andhcreby authonmreptessnmrives of Niscity locaeruprn the SEISMI
CV -
above mentioned property for impaction purposes. ELECTRIC FEE
PERMIT ISSUANCE. 6
(We)ugme m save,indemnify and keep harmless the City of Cupertino against
Iiabiluies,pal,arnts,oco,, almpenses which tmayinany way aecmexgainn mid City ALTER OR ADD TO MECH,
consequencein of the granting of this permit., PLUMBING FEE •�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL E it
SOURCE REGULATIONS. /
r AIR HANDLING UNIT(OVER IROKKI CFM) -
CONSTRDCTIX `
Signature of ApplicaradConlactur Waa EXHAUST HOOD(WMUCT) I IOUSING M I1'I GAT IO FEE, t k
HAZARDOUS MATERIALS DISCLOSURE
Will the uppliwnt or fmurc building occupam'rata nr bindle bumMonc mnteriul 1IEA'FINO UNIT CFO 100.000 BTU)
av delined byline Cupcmino Municipal Code,Chapter 9.12,and the lleallh.,,it SaWy
ode.Section 25532(u1! IIEAUNG UNIT(OVER 100TrE BTU)
❑Yes Fl No PAID
_ V ENTILATION FAN(SINGLE RESID) Date Rec'pip
Will the applicant or from building occupant use equipment or devices which
if
mit hazmNous air commutations os defined by rhe Bay Arca Air Quality Management BOILER-COMP LOT OR 100.000 BTU)
AL:
Dinner? BOILER-COMP(OVER 100,0011 BTU)
❑Yes ❑No
Ihave rtad the hmarNas materials requiretrtents uMer Chap¢r b 95 rf Ne Cali- AIR CONDITIONER ISSUANCE DATE
_
remain
Health&Safety Code.Sections 8505,25533 and 25534,1 utMentaM that if the NEW RFS IDENfIAL MECH. SQ.FT.
building does not currently have a mount.Na it is my respoosib b y to imply are mountain -
ofdiemerimmen.which revs,be me,priorm issamn ,ofa CerOfieme of Groupers, _
Owner or authurimJ agent Date T I SSUED HY:
OFFICE