29449 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUSIBI,NC-MECHANICAL
BUILDING PROJECT IDENTIFICATION 29449
PUILo7N)A?E A �� �� � � I ����lho SANITARY NO. APPLICATION SUBMITTAL C DAT[
OWNE/k"NAME/:�r•/-'/!V-1/}�,x/l�J(� 1 PRONE: �a CO T C'rUR'S NAME: ,I7,IC�N1D/,
O 1 a �/h`q V I Iti- �2 O�V I V e � NIC CONTROL N
\RCHITECT/ENGINEIiR: LIC NO: 5S' ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that T am licensed under provision,of Chapter 9(cmanamelag JOB DESCRIPTION
a�Z with Section]000)of Division J ofthe Business and Professions Ce and my license is RESIDENTIAL:
-s in full fomeandeffen PERMIT ISSUANCE
20 (,(� ❑SFUWL El KITCHEN REMODEL
Llccon,Cil s , Lic.x APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
FZW Ilse L Comrannr
Q L ARCHITECTS DECLARATION y ❑MULTI-UNIT [ISTRUCTURAL
ZZ n Z 1 anderaanJ my plans shall be bottles public records PANELS MODIFICATION
O
UP AMPS INTERIOR EI RITAIR
F��t:M Licensed Pro(msiorad 201.10WAMPS IMPROVEMENT
Qa,yE; OWNER-BUILDER DECLARATION OVER HWAMPS ❑HATH REM�n�pTc'IIREPAIR ODEMOLITI N
C Q I hereby affirm that I am exempt(Tam the Contractors License Law for the 4 t e /�n�Vip Aft%
3 P.U following reason.(Section 703I.S,Business and Professions Cale:Any city or county SIGNS ELECTRICAL THE•R
a which requires a permit to construct.aher.improve,demolish,or repair any structure - 19//'(•O 1' iO L.ei'-Ne!
0 prior to its issuance,also requires the applicant for such Permit to rile a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant s)the previsions of the Contractors License Law(Chapter 9
^�� (ammnencing with Section Divioun 3 of the Business and Professions Code)or 'TIMI'M ETER OR TOLE INST. COMMERCIAL:
11y aq that be is exempt ilim,iran and the breis for the alleged c.vngaiom Any violwion of ❑NEW BLDG/ADDITION ❑DEMOLITION
% LL
Section 7031.5 by any applicant for a Permitsubject.%the applicant n a civil penalty of POWER DEVICES
manors than rive hundred Jollars(S5(AD. ❑TENANT ❑FOODSERVICE
Z 7• IMPROVEMENT
=Q ❑Lothe owner k, ad nmpramem.s emPwyceswith wages
eedfor thei(See compensation, SWIMMING POOL ELECTRIC
will Jothework,ands: he Condisnors License
osnot apply to
Business ❑OTHER
and Pmfexsions Cak:The Canvanors Licenac Law does not apply w an owner of OUTLETS-SWITCHES- I%TURFS
�'3 property who boilds or improves thereon,and who does such work himself or through
his own employees,provided that such improvementsore not intended or offered for NEW RESIDENTIAL ,.ECTR SQ FI'. -
sills,11 however,the huiding or improvement is sold norm one year of completion,the SO.FTb FLOOR AR17A VSQ,F,
ovoter-Infilder will Imsede hurdcnofproving had he did not builder iniprase for par- y A 1IfRLLf{�{Ts'
pose or.le.). �
❑1,as owner of the pneny,am exclusively contracting with licensed contractors to TOTAL:
m
umuuct the project(Sm..7(94.Business and Professions Code:)The Qmtmcwr'.v Li- AR 19 199
cense Law does not apply to an owner of propsny who builds or improve,thereon,and Q1 Y. PLUMBING PFEE 6
who coneracts for such pmjecu with a contracmgs)licensed pursuant to the Commcmrs E IT
License Law. PERMIT ISSUANCE C11 yr t,�,-c
[:] l am exept mands,Sec, ,B&P C baffik reason MIINU
N:I'Ilk-DRAIN&VE 'ER(E ) VALUATION
Owner Dam qqq
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTRCT.DEVI O
1 hereby o(Brm on
penalty of perjury one of the following declarations: /
O l have and will maintain a Certificate ofConsem10 self-inure for Worker's Compere- DRAINS-FLOOR.ROOF.AREA,CON STORIES TYPECONSTRUC ION
.her,as provided for by Section 37W of the Labor Code.for the paGmnanct of the
w rk for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3 of the Lahbr Code.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My My
Cumersrk 's Cor P' i s�nce sortie For
iT NnYG� 2a�V GAS-EA.SYS'IEM-OVHR 4(EA)
ERTIIICATL OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION FEES
(ILisrxectinnmednut be-niifthe pemdr is forone hundred dollars($101)) GRFASETRAP
or IczsJ PLANCHECK FEE
I certify Nm in the performance ofthc work for which this Permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Worked Compen- ENERGY FEE
O Z sellon Laws of California.hate WATER TEAMS WIVE NVELECTR GRADING FEE2 Applicant
NOTICE TO APPLICANT:If,after making Phis Certificate of Exnnption,you should WAI'I7R SYSTEMn RENTING
("' ? become subject w the Worker's Ccmpen.lina provisions of the Labor Cade,you must tiO11S hili
Forthwith comply win such Provisions or this permit shall be deemed revoked. WATER SERVICE
=Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID Date Receipt#
LJ CIhcnby atr,.,hauhcreisoconshuction leadingagrncy for the performance of
the work for which this permit is Ismed(Sec.3097.Civ.C.)
0 U Leader's Name TOTAL:
D.1 Lender's Address TOTAL: II111LUING ME certify that I have read this application and.slate that the%breve information m
.F..%i comes.l agree to comply with all city and county ordinances and state laws renting to QTY. MECHANICAL PERMIT FEE
V Z SEISMIC FEE
building construction.and hereby authorize rcpreem
snives of this city to enter upon the
above-mentioned property for inspection purines. PERMIT ISSUANCE
(We)agree w save,indemnify and keep harmless rte City of Contains)against ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH.
in asequence of the granting of this permit PLUMBING FEE
APPLICANT OND
F ST NDS AND WILL COMPLY WITH ALL NON-POINT" AIR HANDLING UNIT(TO 10.010 CFM)
SOURCE REGULA I �I / /� MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.00 CFM) CONSTRUCT ION TAX
Strourre of Applic..VCaat.swr Date EXHAUST HOLD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAL. D 'CLOSURE
Will the applicant or future building over id,om or handle hazardous material HEATING UNIT(TO I00.0110 BTU)
os defined by the Cunmino Municipal CMI.C t 9.12,and the Health and Safety
Calc,Section 25532m)'! `J HEATING UNIT(OVER I00,000 BTU)
Cl Yet; VENTILATION FAN(SINGLE RBSID) PAID
Will the u Ileum nr Imre built in t me c t or dcvims which Dam licaeipt#
pp dby the
yapmen BOILER-COM11P fJf11'(JR IIp.Oq RTU)
mit hazardous air amhminant.m-JefinN by the Nay Arca Air Quality Management TOTAL:
Derma? BOILER-COMP(OVER 1 00.000 BTU)
L]Ys, _..
I have read the hvsardow rnawduls requirements under Chapter 6.95 of the Cali- AIR CONDITIONER I L, ISSUANCE DATE
fomiv Health&Safety Cale Sections 25505,255)3 and 25534.1 understand Phot ifhe NI7W RESIDENTIAL MECH. SQ.FT.
building does not arae have a tenant that's is my revEnsibility to ready the occupant
ol'ne myuimnenty wl net nein.In issunn fh Crmfic IO,,5im%
Owner or vmhodzed�¢¢ TOTAL: ISSUED BY:
OFFICE