29722APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING . ELECTR
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHAI
BUILDING PROJECT IDBN9
BUILDING ADDRESS:
2.1.7
29722
OFFICE
ARCHITECT/ENGINEER: LIC NO,
ADDRESS:
"7ct(313
CONTACT: PHONE:
❑ Consultant FccS Paid by Applicant (Initial)
BUILDING PERMIT INFO
FP B MECH
yCy11aZ
FWB
�UZFU
Q i
' LICENSED CONTRACTOR'S DECLARATION
I hereby am That 1 am licensed under provisions of Chapter 9 (commencing
with Section 700(fof Division 3oRhe Businessund Podfisoons Cohl.and my licence is
in roll force and ellen.
License class Le.M
Date - Contracto
Contract...
QTY. ELECTRIC PERM IT FEE
JOB DESCRIPTION
BUIDEN IAL
DDITWI. El KITCHEN REMODEL
AION ❑PLUMBING RE -PIPE
❑MULTI.UNIT []STRUCTURAL
MODIFICATIONS
0 INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT
[I BATH RETtIODEURF.PAIR El DEMOLITION
❑ OTHI7R
PERMIT ISSUANCE
ES
APPLIANC-RISIDP,NTIAL
ARCHITECTS DECLARATION
IZOy> q Iunderstnnd my pl:ms shall housed as pnhlicrccnNs
OZ'S —Licensed!
PANELS -
UP TO 200 AMPS
F � t Professional
Yry OWNER -BUILDER DECLARATION
O w U I hereby affirm that I ant exempt from the Corrosion,', License Law for the
O d U following reason. (Section 7031.5, Business and Professions Cale: Any city or county
pF- which reyvires n permit to eo earau,,ler, improve, demolish, or repair any suvaurc
' N priorm its issuance. ukw reynires Ne xpplicam fortand,n outto lilensi,mol stonmma
Si that he is licensed pursuant o the previsions of the Contractor's License Law (Chapter 9
ecgGO (commencing with Section 7000) of Division 3 of the Business and Professions Code)Cc
d ea that he is exempt (here@om and the basis far Ne alleged exemption Any vinlmma of
N Section 7031.5 b on applicant for
y y pp permit subjects the applicant to a civil penalty of
t mom man five hundred dollars ($5110).
pQO (]I, as owner of the progeny, or my employees with wages as their. sole comlwasatlon,
GLGL�` willslomework, mad1he stmeturei,mu inumdolormffered fur safe(Set.]W4,Businua
and Professions Calc: The Conaactor's License Law does not apply to an owner of
6.i property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such imprmvemems arc not amended m oll'ered for
late. If, however, the building or improvement iasold within one year of completion, the
owner-builderadwill have the burden of proving that he tliJ not build or improve for pun
pone offside). „
❑ I, as owner of the properly, um exclusively nmntmcting with licensed contractors to
Consumer the project (Sec. 7014, Business and Professions CWe:) the ConOactors Li-
rte Law does our apply tat an owner of progeny who builds or impro+ren thereon.and
who common for such projects will, a Comrucmr(s) licensed pursuant to the Commences
License Law.
[dame orderSec PCfrt nt
Dm
201-1000AMPS
OVER IIMI0AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUI UMISC.
'TEMP. MU`FM OR POLE INST.
-
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT [I FOOD SERVICE
IMPROVEMENT
[]OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWIrI'CHES-FIXTURES
NEW RESIDENTIAL ELECT R SQ IT.
SQ. FIT. FLOOR AREA
�O
E/SQ. IT
TOTAL:
QTY PLUMBING PERMIT' FEE
PERMIT ISSUANCE.
ALTER -DRAIN&VENT - WATER (EA)
A VALUATIO
P� ^C
' {„I
WOR9aS COMPENSATION DECLARATHTN
I hereby offinn under penalty cf perjury ono lathe following cheleratinna
1:11 Ecla unJ will nothainaCenifieeofCoroenunscif-inaurefor Worker's Curnam-
s tion. a provided for by Section 3700 of The Labor Cede, for The performance of the
walk fur which this Permit is issued.
❑ I have and will maintain Workeras s Compensation Insurance, required by Section
3]00 of Ne farorCode. fonhe pertornanm of the work for which this permit is ixsued.
My WorkcY.+Compcnsmion Insurance Curtis P.1hey Nicy number arc:
Currier: Policy O
CERTIFICATE COMPENEXEMPTION FROM WORKERS'
COMPENSATION N INSURANCE
(Thiasemion need not he ammpincA ifthe pemlit is fonmehutdreJ dnlbus (EI00)
or IcssJ
ICs That inthe ffn..al of the work for which this
Y R the W. is
nallrundo,,).Law ofC.1istm in an, Do runner an us to become suhjunn mita WorkuK Compete
Z of Calil'nmia. Dec
� O A licam
Applies.,
PP
VJ NOTICE TO APPLICANT. If, Co making this Ciamas c of Exemption, yon should
ah became subject [.,he Worker's Compensation ter mit steal of the Lalwr Code you run
forthwith comply with such prrnisionsunhis permit shall he deemnal revoked
UZ CONSTRUCTION LF,NUINCAGENCY
D
rat Permit3W7. ding agency rorthe pertunnance or
U k for
V. F tete work rat semen rots permit is issued (see. 3(19], civ. c.)
_ OU Lendres Nome
Lender's Address
.fa I I Certify mat I have road this application and mate thht not drove infatuation is
. Z) correct. l agree to comply with all city and county ordinances and state laws milum,to
U building consiuction, and hereby authorize representatives nlthis city to en¢fupan the
drove -mentioned progeny for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Caperton against
liabilities, judgmems,enstsandespeaws which may in any wayaccrue against said City
in consequence of the grnming of Nis permit.
APPLICANT UNDERSTANDS VILL COMPLY WITH ALL NON -POINT
SOURCE TIONS.
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF, AREA, COND.
TSL
FsT
� �^
u '1�•
TYPE CON 'RUCTION
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INCA OUTLETS
LN.zfiNpOp
CCy
V
APE
GAS -EA SYS'1'CM-OVER4(P.A)
GREASMNDUSTRL WASTE INTHRCEPTOR
11 GI31V1910N P13E5
-B
GREASE TRAP
PLANCHIiC
SEWER -SANITARY- STORM EA. 2110 IT.
-
ENERGY PLL
WATER
WATER HATER WNFJJT/EL[CTR
GRADING PEE
WATER SYSTEMITRGATING
SOILS PEE
WATER 51iftVICli
PAID
Date RxeiptM
NEW RESIDENTIAL PLMIi. SQ. FE.
TOTAL:
TOTAL:
BUILDING FEE
QTY. MECHANICAL PERM IT FEE
SEISMICFEE
ELECTRIC LGE
PERMITISSUANCC
AL'T'ER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10,000 CPM)
MECHANICAL FEE
AIR HANDLING UNIT(OVF.R I0IXI0CPM)
CONSTRUCTIONTAX
Signature ofAppliciam'Concragoli J Dam
HAZAR S MATERIALS DISCLOSURE
Will the applicant or future building oecupout store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and Be Health and Safety
Gee Section 2553200!
E] Ye. 6 N
Will the to, corm or future building by the Buy A .At,Qunr Mieenwhich
nit hazallous air ctmaminams as deRnal by me Bay Arca Air Quality Management
�x iL
❑No
Ne hmannoua mmenals under Chapter (.95 of the Cali -
Safety Code, Sections 25505,25533 and 25534. 1 understand Nut if the
currently have u tenant, that it Is my responsibility m maly the aecvpantems which must be met pdorto issuance ora Cmifcam mf Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT 00100,0(1(1 TIME
HEATING UNIT (OVER Iis AS) B'TU)
PAID
Date Recciptk
VENTILATION PAN (SINGLE: RES ED)
BOILER - COMP (JIiPOR 100.000 BTU)
TOTAL:
BOILER-COMP(OVER If1,11(s1BTU)ad
AIH CONDITIONERISSUANCE
DATE.requirements
ISSUED BY:
NEW RF.SIUIiNTIAI. MF,CI I.SQ. PI'.ot
anzed agent Date
m TOTAL:
OFFICE
'""-` APN:
SITUS STREET:
SITUS NOM
AVE.CT,STAD:
N.S,E,W:
N0#
CITY:
ZIP.
LOM
ID:OT TI
OWNER: NOTTI
ONE
ADDRESS:
IY,STREET21P:
PHONE:
CONTRACTOR: SAME
UCX
29722
•
ARCHITECT:
LICENSE p
SUBDATE: 2/29/1996
TYPE:SFDWL
DESCRIPTION:
SNG.FAM.DWELL
PUCHKFIEQ:
CATEGORY:
DATED
DATEDUE:
Commercial
CA sq#It
CE-sgtlllg.
CN-sq#lta:
Residential
RN-sq#ItO:
E 400
RE sgpNq:
1-7
RUS-sgNltk
605
11
VALUATION: C
ISSDATE: 12/3/199
PLCHKDONE:
LATE CODE:
BLDGDEPT:
ENGDEPT:
PLANDEPT:
CMrl
CTRFIRE:
SANDIST:
HLTHDEP7:
STRCTENG:.
TOTAL:
INSPHOLD:
F--I
LJ
0
0
�24 7 L7-
F- -I
'Z
64*44-nW6 w441�
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