29279 APPLIOANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
I. BUILDING.ELELTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PING PROD� TIDEANIFIC 29279
't - BUILDING MECHANICAL
ICHANIFICA'1'113N
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMI'PLAT DATE
S`IS 12c (
O ER'S MIME: * PHONE: C(lM1yfy\Cf(IRS NA6IE:� �' LIC NO:
IcemaT/ F Y1M1^•GF' 11 F2730
SIC CONTROLN
A C ITEL4 NGINEER: , I,CNO:/ AD RF.SS: 7 M b �� . ❑
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ONTACT PHONE: (� - BUILDING PERMIT INFO
���• / ❑.Consultant F¢¢s Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
cam
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby M.that 1 licensed u d v f Chapter 9(gmmc ting _ JOB DESCRIPTION
Matz wuhS i 9gXl of Dn - Sof the Busies. rid Profs%%ion Cmleaadm licemnis
ADO ) y PERMIT ISSUANCE ,RESIDENTIAL:
H lullf uJdT
aUU U<cn: lass / Lic - ❑SPDWI. [I KITCHEN REMODEL
hGL Data Comas APPLIANCES-RF_SIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F,7m CHITECTS DECL 1 F PANELS
[I MULTI-UNIT ❑STRUCTURAL
ZpyZ I understand my plans shall be used as public mcoN.s MODIFICATION
oz- t UP TO 200 AMPS
L 0 [1 INTERIOR 2 CHIMNEY REPAIR
[-�F"a1 Licensed Prefasional - - 201-10MAMPS IMPROVINENT
5:ww- OWNER-BUILDER DECLARATION OVER load AMPS ❑BATH REMODEURF,PAIR MOLITION
yC C Q 1 hereby affirm that 1 am exempt four the Contractor's License Taw for the
X32F following or.(Section 7031.5,Bushes,snit Pmfmsinn%Code Any city or county SIGNS ELECTRICAL El OTHER
y which regains a permit to rondm,[.cher,improve,demolish,or repair any mocurt
�j prior to its issuance.also requires the applicant for such Permit file n.signed statement SPECIAL CIRCUIT/MISE. '
i,� that he is licensed pursuant o the provisions of the Contractor's License Use(Chapter9 _
W 2+00 Icomnmucing with Section7(XX)of Division 3 ofthe Business and Profession Code)or TEMP.METER OR POLE INST. COMMERCIAL'
6 a oaY that he is exempt Therefrom and the basis for the alleged exemplum.Any violation of [I NEW e1.DG/ADDITION [I DEMOLITION
ad:2 Section 7031.5 byanyzpplicant for a pernhodoects the applieanno.civil penalty of POWER DEVICES
r� not more man five hundred dollars($500). - []TENANT ❑FOODSERVICE
F`} IMPROVEMENT
�=6Q 0 I,othe worrof me propeny,nr myemplended with eredfor sale
ole compenmion, SWIMMING POOL ELECTRIC
F.. will An the work,and thenrunnrc is no intended or nl'fcmJ for sole(Sce9Ut4,Business - ❑OTHER
and Professions Cede:no Contractor's Liver,Law does not apply In an owner of OUTLETS-SWITCHIiS-FI%TUk135
6 3— poperty who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offend for NEW RESIDENTIAL ELELTR SQ FT. A A I
'sale.It.however,the building or improvement issold within one year efcompletion,the SQ FT.FLOOR AREA $/SQ.FT.
owner-builder will have me burden of proving that he did not build or improve for for-
,so
oo "
°galee �l 'JAN 25 1996
I,as owner of me po.70,1,B siness and contracting with licensed rontmemrs to ` TOTAL:
wmwm He project(Sec.9M4.Business and Professions CdeU The Gaetano/s Li- , ,v
sense law does not apply to nn nwnen,fp,o,ry who builds e,ru,Novcs thereon,and Q1 Y. P. UMB INC PERM IT FEF, O�IY.UP Vl+i"L-f111P1
who connotes for such projects with a eommena(s)licensed pursuunuo the Contractors % V
License law. O
Iamexemptunder Sec. ,B&PCfmddsnassm PERMIT ISSUA ��_�i�-\- \\
Gore, -Date ALTER-BRAIN&VI' WATER(EA7 VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.ftVIC O
1 hcmby affirm under Penalty of pe jury one of the fallowing declarations:
❑ IhaJe and will maintain uCertifiwle of Conseeun self-insure for Wnrkuk Cnmpen- DRAINS-FLOOR,ROOF,AREA WD STORIES TYPE CONSTRUCTION
.anion,as povided for by Section 9900 of the Lim Code,for the Ise,m unt.of the ,
work for which this permit is issued. • FIXTURES-PER'TRAP
❑1 have and will maintain Worker's Compemalion loon.,as required by Saation
3700 ofthe Labor Code,for the pcuhrour ace°foe work for which Of,permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP ANN
My W..ver'_e Con"ismion Ins amone carinr and Policy number am:Curren Policy No.: GAS-EA.SYSTEM OVER 4 EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
BUH.QfdjNy1ON FE s
(lTia section need not bccompineJ it me permit in for one hundred do11ar%(5I W) GREASEIRAP
tor le".) PI,ANCH[CKF
Icenifythmm He Niformanceoftbe work for which His permit is issued,Ishan SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any mannsubject counter so as to become subjeco He Workers'Compen- ENERGY
ZZ station Laws of California,Data WATER HEATER WNENIT/ELECTR
Q Applicant - GRADIN FE
y NOTICE TO APPLICANT:11,vfar making This Cenilicme of Exemption,you should WATER SYS'IE'.MGKHA'1'ING SOILS FIiL'
a ? bemno He puion. bo
coe s.bjttWtulme,Compensation
ovof the lar Code,you musi ^
forthwith comply with such previsions or His Permit shall beoe
dme i revoked. WATER SERVICE .
[)
V O CONSTRUCTION LENDING AGENCY NEW RRSI DENIIAL PLMB. SQ.IT, PAID ale Receipt p
1 hereby affirm mat Hare is a convection Tending agency for the performance of
U. the work for which this permit is issued(Sec.309],Civ.C.) '
F' 1<nder's Name - TOTAL:
V Lender's Address - TOTAL:
f G I certify that 1 have read this application and surtethat the above infomwlion is
It UILDI PIPE �a
Z) correct.l agree to comply with all city and county ordinances and state laws relmingm .QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby authomu rept-cwt titres of this city In enter upon me MHS 1.o•
M FTS
abovemenlinned prnpeny for inspection p.,.,,. PERMIT ISSUANCE
(We)agree to as ,indemnify and keep hsnnle,,the City of Cupertino against ELECTRIC
liabilities.judgments,cods and expenses which may in any way accoc against said City ALTER OR ADD TO MECH.'
asequence of me granting of this pc PLUMBING FEF.
APPLICA 'T )NDP STANDS ANI -L COM LY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQlXA1 CFM)
SOUR ULA" $' MECHANICALFEE
/ /��� AIR HANDLING UNIT(OVER II,IIW CFM) CONSTRUCTION TAX
Si naare of APPlis Canaan 'Dae EXHAUST HOOD IW/DUCT) HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURE
Will he applierm or l"mare building occupant%tour handl,hmardou%ninaboul HEATING UNIT(TO 100,003 BTU)
as defined by the Cupertino Municipal Code Chapter 9.12,and the Hou.th and ty Safe
Code.Seefiom 25532(x)? _ HEATING UNIT TONER 100.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Date Receipt
Will the applovwrrbr future building occupam mac eyuiPnnanl nr device%whicM1
thvardous air contaminants as defined by me]toy Arca Air Quality Management BOILER-COMP(3HP OR IOO.IaW BI'U) IY)IAI.
DiLmquiminems
i ? ' BOILER-COMP(OVER 100,000 BTU)
No ,
AIR CONDITIONER
I mad He haiuNous materials mquiremcros under Chapter 6.95 of the Ceti- ISSUANCE DATE
��
Health&Sa(ery Code.Sections 25505.25573 surd 2.55]4.I undersnnJ that Hum ,NEW RESIDENTIAL MECH. SQ.PT. T)
not currently have a tenant.that it is my respnmilelity to notify me occupant
mems which mast be met prim to issuance ofa Certif icamofOccupancy.himind agent Dam TOTAL: ISSUED BY:
OFFICE