29841 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY t
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL //1
9 8 41
BUILDING PROJECT IDENTIFICATION LNV 1.
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT(
a4. i coca v F do �q6
OWNER'S NAME: PifONE: CONTRACTOR'S NAME: LIC NO:
!' " S a /.4 N/C CONTROLp
ARCHITECT GINEER: LICNO: ADDRESS:;v� - /'r �� ❑
CONTACT. - - PHONE: - BUILDING PERMIT INFO
/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
M0Z wish Section 7000)of Division 3 ofthe Business and Professions Codc,and my license is RESIDENTIAL
pFNTIAI:
40 ver *� PERMIT ISSUANCE
in fullforce and effect., J REFDWL TCHEN REMODEL
ItLT
Liccnsc Class Lia.1 APPLIANCES-RESIDENTIAL []ADDITION MBING RE-PIPE
Q a Data Conuacmr
FCy ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
Z p P1 Z I understand my plans shall t used as public records MODIFICATION
0Z C UPT02MAMPS [I INTERIOR ❑CHIMNEY REPAIR
F�Y u1Licensed Professional 2014000AMPS IMPROVEMENT
�ai s OWNER-BUILDER DECLARATION OVER IgX)AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
tL 1 hereby air,,.that I am exempt farm the Contractor's License Law for the
O6 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL DOTTER
LL 40 as which requires n permit m consumer,.lair,improve,demolish,or repair any...tore
priArm Int issaance,also requires theapplicaut retouch permit o file.signed smmment SPECIAL CIRCUIT/MISC.
)!(} that he is licensed Formulato the pnvisimnsofthe Commerce.License Law(Chapter 9
W�CO� (commencing with Section 9000)of Division 3 ofthc Business and Professions Code)or TEMP.MEIY.ROR FOUR INST
Ca. toCOMMERCIAL
m he is exempt durafrom End the basis fur the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLHION
Secmn 7031.5 by any applicant for s parnit subjects the applicant toe civil purd,of POW 17R DEV ICES
ry not num than five hundred Jollurs(SSW). ❑TENANT ❑FOODSERVICE
IMPROVEMENT
Q ❑I,ss owner of the progeny,nr my employces with wages xe their some<ampcnsntian. SWIMMING POOL ELECTRIC
Q will Jo the work,and the structure is not intended or offered forsale(Sec.7044,Business - ❑OTHER
and Professions Cade:The Contractor's License Law door not apply to an owner of OUTLETS-SWITCHES-FIXTURES
EE progeny who builds at improves maroon,end who does such work himself w through
his own employees,provided that such improvements aro tan intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,the building or improvement is sold within one ycwofcampldlon,the SQ.FT.FLOOR AREA USQ.IT.
owner-builder will have the burden of proving Nat he did not build or improve for put- - !11pose classic). �
❑1,eco owner of the property,um collusively convecting with licensed cmuraetors to TOTAL: a.. 4y C' hp
conswn the project(Sec.70W4,Business and Professions Cade:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE AV
whocommcts fwsuch projects with acentmctonOlicensed punu.nno the Contraaoes J'1 j 6 19
License law. PERMIT ISSUANCE /� 9
❑Iumexemptunder Sec. ,B&PCfmmkreason city Ir_ 6
Owner Dote11
ALTER-DRAIN&VENT-WATER(Eco V(-Ly LUATION
r r(fJv
WORKERS COMPENSATION DECLARATION PACK FLOW PROTECT.DEVICE .!
I handy affirm under penalty of perjury one of the fallowing declarations:c' CoOQ•yv
❑(have and will for bynee..37W offhaLabr Cask,far
for Worker's Co of he pRAINS-FLOOR.BOOP,AREA,GOND. $TORI I'YPF.CONSTRUCTION
radon,as which
this
far ra Section d. of the labor Cole.for the performance of the
work for which Nis pemdt is issued. FIXTURES-PER TRAP
have and will maintain Wwkcrx Compensation Insurance, required tI Section
J]q)runic Labor Cude,for the performance of the work for whichh mit ithis per ,issued. GAS-EA,SYSTEM-1 INC.4OUTLETS - OCC.GROUP APN
My Work 91,�,�p�(I��pyltimk{¢synn4 vier and Policy naurq�ep�/Se%d
Cartier.�JLCCL!- /7/M] Pat ic No.: bC C 7 7G GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASMNDUSTRL WASTE IN'TERCEPfOR
BUILDING DIVISION FEES
(TTie section need not be completed if the Permit is for one hundred dollen(5100) GREASETRAP
or len.) PLANCHECK FEE
I codify that in the perfoamanc oflhe work for which this permit is NsaW,l shall SEWER-SANITARY-STORM EA.300 FT.
rad employ any person in any manner m as to become subject m the Worker'Compen- ENERGY FEE
Z ration Laws of California,Dam WATER HEATER W/VENT/ELECIR
Q Applicant GRADING FEE
zy NOTICE TO APPLICANT If,after making this Cerinieais of Eumptioa,you should WATER SYSI'ENUTREATING
become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE '
a �
CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT. PAID
Ll Thereby affirm that there is aconswcmn)ening agency for thearaommawrof O Recciptk
LIn PNe walk far which Nis permit is issued(Sec.3097,Civ.C,)
klnder's Name TOTAL:
L) Lender's Address - TOTAL:
{ass Ci I certify Nat I have read Nis application and state that the above information is BUILD,
4...t Vl counsel.l agree in comply with all city and county ordinances and stare laws relating to QTY, MECHANICAL PERMIT FEE
Uz yvildingtantamount.and hereby amhome representatives of this city'.enteruprm the SF.ISMICFEE
'above-mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and kap formula.the City of Cupeninn against ELECTRIC FE
Iiabilitimjudgmenn,costs and expecons which may in anyway aceme against said City ALTERORADDTOMECN.
in consequence of the granting of this permit. PLUMBING F,E
eq
APPLICANT UNDERSTANDS A ILL.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO TO."CFM)
SOURCE RF LATIONS. MECHANIC LPEE
d4lAIR HANDLING UNIT(OVER 10,000 CFM) CONSTRD IONTAX
Signaureo AfrdutanUCnnwcea One E%HAUSTHWD(W/DOLT) HOUSING 1TIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store,handle Innocuous material HEAPING UNIT(TO 100,000 ITU1
as deRned by Ne Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)? HEATING UNIT(OVER I(0,000 BTU)
[I Yea ❑No VENTILATION FAN(SINGLE RFSID) PAID
Data Receipt M
Will the applicant or future building y the Bt use equipment it devices which
mit haeallous air contaminants as Jefind by the Bay Area Air Quality Management BOILER-COMP(JHP OR 1 00,000 BTU) TOTAL:
Disuict?
Yes ❑Na BOILER-COMP(OVER 100.000 BTU)
❑
I have read the hmmslous no erials requirements under Chapter 6.95rf the Cull- AIR CONDITIONER ISSUANCE NiTE
'forms Health&Safety Cale,Se 0 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
huiIdmg dawn cunendyhiv to n dad it is responsibility m notify the acupent
rf Ne i cots chat the et price m' ore Cenifr/Ie�Dcnyp.ttcy.
rr a( oNonud agent ffrrLL// I/ue TOTAL: ISSUED BY:
OFFICE