29989 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
- I BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29989
BUILDING PROJECTIDENTIFICATION '
BUILDINGADDRFSS: - - SANITARY NO. APPLICATION SUBMITTAL DATE
O E NAME: s ''y� PH 'E: CONTRACTOR:$NPJv1�E:A
I.ICNIO
l.+xv N/C CONTROL. :.
UtCHITECI/ENGINEER: IC NU: ADDRF_SS: ❑.
71 LeFCT
CONTACT:
I f� PHONE�7BUILDING PERMIT INFO
UIW XI
E] Consultant Fees Paid by Applicant(Initial) B{,DC` ELECT PLUME MF,Cx
LICENSED CONTRAcTOR1 DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 licensed J p .a of Chapter 9(commencing JOB DESCRIPTION
WOO with Section 0000)if Division 3o theNus aand lmfessio,Code ural any license is IDENTI
O PERMIT ISSUANCE
W E- in full force am effe WT`[
L ❑KITCHEN REMODEL
AL
G V U License ass Le.N APPLIANCES-RESIDENTIAL
vFi64 Dae Com t s 01 DDITION ❑PLUMBING RE-PIPE
'Dor DECLARATION PANELS - ❑MULTI-UNIT ❑STRUCTURAL
Zor,Z (undersand my.hats shall be wced as puhlic record, MODIFICATION
OZ-0 UP TO 2(10AMPS
[I INTERIOR ❑CHIMNEY REPAIR.
G•~� Licensed Pmfessi...I 201-IIMAMPS IMPROVEM1IENT
a,y J OWNER-BUILDER DECLARATION OVER 100(IAMPS C1 BATH REMODEIJREPAIR El DEMOLITION
C C Q 1 hereby affirm that I am exempt from the Contractor's License Law for the
3LLH following rcaso..(Semi,,]U31.5,Iiurincss and Professions Cute:Any city or county SIGNS ELECTRICAL (_1 OTHER
y which requires a permit to construct.alter,improve,demolish,or repair any dracme
;,pnono its issuance.also requires the applicant for such Permit in file a signed statement SPECIAL CIRCUIT/MISC.
fyp. that he is licensed pursuant to the provisions of the Commences License Law(Chapfer 9
u1a��0 (commencing with Sectiori]000)of Division ruffle Business and Professions Cii TL'MP�METER OR DOLE IN59'. COMMERCIAL:
t1 a that he is exempt Ihonfromand the It....for the alleged exemption.Any violation of �fB�--1y���E�1�1 BhDG/ADQITIYN ❑DEMOLITION
x
Section 7031.5 by any applicant for a permit.subjectsthe applicanttoacivil wholly of POWER DEVICES f`Y ' V 1 4
-'� AI�T ❑FOODSERVICE
not mom than five hundred dollars(S500). IMPROVEMENT
=0
El I.as owner ofdte propcny.or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC El tBrJ - -
wllld.th kand thewaumrfor int•ndedorofferedforsale(Sec]W4 Bu.iness
W m
and Professions Cdee,The Contractor's Lic6me 1 v does not apply to an owner(if OUT'LE'TS-SWIICIIES-FIXTURES 111 Nas
�'3.. property who builds or on,o e:their.. and who due:such work himself.,through
his own employees,providW that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ IT,
safe.If.however life building or improvement is sold within one yearofcompleami.the ^+ SQ.FT FLOOR AREA {/$Q.pT.
wn b ld willhave fM1 b rd fp gthat M1 J'J Lb Id p forput
-
Pose ( �] / .w�
po :1 .). - 7 b aR\
❑la the property.'ntexclusively cntrfg withien:d contractors at \ ���
anst Law
project tap neon ow drty sCW )ThC mm . In
m la J m hplyf T nt pinny h builds pones Corea and QT'Y. PLUMBING PERMIT FEF: - /Vy
who Leets for reelprojects wnh acontm t r(s)limned pursuant to Communist
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&1'C for thl moon
Own
ALTER-DRAIN&V -W TER(EA) VALUATION
Date
eiWORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT EVICE l(T`JlC
1by ffmru d pe ally of pe/ ry nc fthefull " gal cif tions
t] II e dIlaim CnI'am ofC 11 elf-Truce f W k 's Gmqu'm IlRNNS-FL ( OF,I,RK, D.
'sation,as provided far by Section 37M of the Labor Code,for the pedmnernec of the STORIES TYPE CONSTRUCTION
work for which Cis permit is issued FIXTPER TRAP
E] 1 have and will maintain Worker's Compensation luxurious,as required by Section
3700 ofihe Labor Code,for the performance of work for which Cis permit is issued. -EA.SYS' C OUTLETS OCOGROUP APN
My Workers Compensation i.surarec turner and Policy hater neo:
Comer Policy No.: AS-E 'T N-OVER 4(EA) .
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE REASMNDUSTRI.WASTE INTERCEPTOR
BUILDING 5 ON FEES
lThis.utlien,real not be cnmpletal ifMe permit is for one hundred dollars($Ilp)
GREASETRAP
or less.) I PLANCHECK PEE
Toy a n,that In Thr any
of as
work for which chic.credoisers'C issued,.scull - 1~
nm employ � to subject the Workers' b1:WER-SANITARY-STORM En.200 FF. ENERGYFEE P Y anY Penta any ma mer xt ax lu
ZZ safim laws of California.Dalen WATER HEATER W/VENTMLECR
O Applicant GRADING
y NOTICE TO APPLICANT:If,after making this Cenificae of Exemption,you should WATER SYSTEM/TREATING a SOILS hEE, heroic xiri to the Work,, Cnmpemation......Wons of In,Lalurt Code,you nmsf
forthwith comply wi,h,.ch provisions orchis pemiii shall MdermeJ rtvokW. W'A1IR SERVICE
a5
CONSc ONLBNDING AGENCY NEW RESIDENTIAL PLM1I B. SQ.FT. PAID
z
7 Thereby affirm that them
cre is isaconstruction lending agency for the performance of t eceipLp
V,P Ce work l or which this permit is iswcd(Sec.3097,Civ.Cf -
C) f•' Lendce,Name 'TOTAL:
W Lenders Address A : \ e
} 1 certify Cat 1 have read this application and star thanthe aMve information is BUILDI �.r
ycontact.l agree to comply with all city and county ordinances and state laws relining m Q'ry, MECHANICAL PERMIT FEE
U 7. building construction,and hereby authorize homesrnhnivex ofthis city to enmrupon Cc SP,ISMI
abovcmondoncd propcny for invlxrti.it purpoxer
(We)agivems.ec.indemnify'and keep haralcss Ce City of Cupcnsno against PERMIT ISSUANCE ELI CFE O
liabilities,judgmenq cents and expenseswhirl may in any way arcate againn said City ALTERORADDTOMECH. 'Q
in consequence of the greating of this permit. PI. 1 G .F,
APPLICOAT UNDERSTANDS,ND WILL COMPLY WITH ALL NON-POINT ATR HANDLING UNIT(TO 10,000CEM)
SOURC//✓./'��EGUtfnTIONS. (//} MECIIANI LITE
1 O / e(L— � 1 _q AIR HANDLING UNIT(OVER IRg1p CFM) CONSTRU ON TAF
Sighma of ApppllieenUC�/onf/raclfor4 (1!! T l axle EXHAUST HOOD(W/DUCT) HOUSIN MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
W,11de...lharm,,future fioildn,oeeupant xmrc he handle h.eanhasmnterial HEATING ON 11(10 I UQ00189U)
as defined by the Cuprdino Municipal CWe,Chapter 9.12,and the Health and Suf6y
CWe•Section 25532(x)^ ��l /// HEATING UNIT(OVER 100.001 BTU)
❑YesPAID
/\ VENTILATION I'AN(SINGLE RF.SID) Date ceiptp
Will the applicant ar future huddling.ccips nt use equipment or devices which _
cit hea00 B
Yes N
nd00%air tournaments defined by the Bary Area Air Quality Management. BOILER-COMP(311P OR MOM BTU) TOTAL:
diancTl "BOILER-COMP(OVER 100,0TU)
u
1 have read 0e h rdmaterials AIR CONDITIONER
requirements J Cleaner b to of the Cal ISSUANCE DATE
pas
a tie &Sefury Cuba,S t :255.5 25530 d 25514.i d f d that f the NEW RESIDENTIAL MECH. � SQ.l>I'.
builder t unemlyh a ferret tett" y pt .bl'ty tV tfSfY��"" cupant
ofnf Lhe��w�h�i be,ret prim Ln issuance of a C m�teycc�ybe,ret prim Ln iszuancc of a C m�icy 1�y
Owner t Can.d agent Date TA CEC ISSUED BY.
OFFICE