29555 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PIR MI f NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 29555
— �.,S�.��N C xUlhDlrvC PRO 'T IDENTIFICATION
BUILDIN11,3E ESS."`4.a+ . V�VJ SANITARY NO. APPLICATION
�SSUBM1'ITAL DATE
OWNER'S[�J.pyMF` PHONE: CONTRACTOR'S NAM&s LIC NO: av#
ss•/ �`—� NIC CONTROL4
•ARCHITECT/ENGINEER: LIC NO, DDRF,SS: .❑
IS Zeb
CONTACT: PHONE: - BUILDING PERMIT INFO
x ❑ Consultant Fees paid by Applicant(Initial) BLDG- ELE PLUMB MF.0
LICENSEDCONTRACTOR'S DECLARATION; QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I Ire licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OC)
❑ with Sectinn]Otgp of UivisinnJ oflM Busincsx anJ Pndesxinns Cnde,and my license is
O O i'ERMIT ISSUANCE RESIDENTIAL:
FW. in full force and effect. �Z S4O ❑SFDWL - ❑KITCHEN RF.MODEI.
WUF Licen'e I - Co 11
so, ate Cnmmemr APPLIANCES-RESIDENTIAL [I ADDITION ❑PLUMBING RE-PIPE
F ARCHITECTS DECLARATION PANELS ❑MUI.TI-UNIT El STRUCTURAL
Z OP�Z I undersmnd my plans shall be used as public records MODIFICATION
OZ=f� UPT02fq AMPS []INTERIOR ❑CHIMNEYREPAIR
�hE'J Licensed Professional p5 201-10o0AMPS IMPI20VIiMENT..1 OWNER-BUILDER DECLARATION
ly 6 I hereby Baan that 1 am exempt from the Convector's License Law for the OVER hilt AMPS r7 ❑BATH REMODFUREPAIR 0 DEMOLITION
{Y O y U following reser.(Sermon]031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL. ❑OTHER
uv O I"' which requires o permit m crammuct,elle)improve,demolish,or repair any structure
primmi¢issuance,alsa requires thcapplicant fasuch permit a fileasignM>tatement SPECIAL CIRCUFUMISC.
52
ypiN+ that he is licensed pursuant to the provisions of the Contracar'a License Es. Chapmr9
WCOC (commencingwith Semion7000)oa Division 3ofthe xusines.sand Professions Co1c)or TEMP.METER OR IDLE INST. M '
d y m e• that be is exempt lherefmm Ind the basis far the alleged exemption,Any vial 1, n of - Y:W BLDGIADUITION ❑DEMOLITION
uX1 t�
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
y}
not more than rive hundred dollar,ESSEX).
❑TENANT ❑FOODSERVICE
a ❑1,sownerefthe pronorm employees with wages as their sole core IMPROVEM T
pe y y ,Business SWIMMING POOL F.LELTRIC
� O will dotheCode Tlad oaeisnors Livenstended nrawdored forsale
apply 7044, whereof ❑OTHF,R
W and Professions Code Iinf Conwereo License Law dos not apply to if owner of OUTLETS-SWITCHES-FIXTURES
6 3^ progeny who buil),or improves thereon,and who ntsa such work deed o l or through
for _
his awn employees,provided that pooh improvements ate not intended red m offered for NEW RESIDENTIAL.ELECTR SQ FT.
owssalepo,hower will have
building otin of Nosing
Lsat he
non build rimprovefor the SQ.FT.FLOOR AREA SQ fT.
owner-builJer will have the burden of proving that he Jid not build or improve for Aur-
posunasalc). '
El 1,os owner of the property,am exclusively convecting with licensed commcmrs to O' 1.: G4!\ I D
onsvuct the project(SCI.7044.Business and Promwintn Code:)The Clanwear',Li !lJ
terse law does not apply loan owncrofpropeny who builds or improves thereon,and QTY. PLUMBING PERMIT
whocenwcts forsuch projects with avenwcter(s)licensed pumuion athe Conwcmra It, APR -9 199
License Law. PERMIT ISSUANCE.
❑I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATIiR IRA) le., t vf. 1t
Owner Dam VA UAT
WORKERS COMPENSATION DECLARATION - BACK FLOW PROTECT.DEVICE 141.
m
I hereby affirunder permlty of Pe jury one of the fallowing dcvlumtions:
❑I coeand will maintain.Ceniticalanf Ccnsenuo sdLlnsurc for Wnrker'n Cnmpen- DRAINS-FLOOR,ROGF,AREA.GOND. S RIES 11 TYPE CONSI'RUCI'ION
section,as provided for by Section 37W of the Labor Code,for the performance of the
weak for which this pears is i,suetl. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700of the Later Cade,fan he pedincro netefdta work for whichthis permit is issued. GAS-FA.SYS MM-I INC.4 OUTLETS
OCC.GROUP APN
My ,Compensation Insurance carrierandPolicynumMre:rp -
Carrier:lInsurancewPolicy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GRPASUINDUSTRL WASTE INTERCEPTOR
This section need not be completed if the permit is for one hundred dollars($1110) BUILDING DIVISION FEES
or less) GRF,ASETRAP
PLANCHECK FEE
I eenify that in the perfotmmnce of the work for which Ibis permit is isoed,10m11
not employ any person in an manners.asm become subject the Werkers'Com _ SEWER-SANITARY-STYIRM PA. PT.
Z cation Laws of California.ate ) pen ENERGY PEE
zO Appiicam WATER HGTER WNF.NT/F.LECTR GRADING FEE
I,E NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEM/1'RFATINO
a5: became subject,.the Worker's Conamismion provisinns of the Labor Code,you must SOILS FEE
LU
Q forthwith comply with such provisinns or this permh shall he deemedrevlaked WATER SERVICE
7z CONSTRUCTION LENDlNOAGENCY NEW RESIDENTIALI'LMN. - SQ.FT PAID
L,Q I far abihodi thauhereisaconsmeti10 lending agency robe Performance of Date Receipt
IL �--� the work for which thispermit is issued(Sco.100,Cis.C) '
O (••t Lender's Name TOTAL:
WLender's Addres TOTAL:
,Ly, gy 1 certify that 1 have read this application and state that the above information is BUILDING FRE allis
:r h correct,l agree to comply with all city and county ordinances and suite laws tdming to QTY. MECHANICAL PERMIT FEE
building construction.and hereby uniform repreunmtives ofthis city acnterupon the SEISMIC FEE
above-mentioned properly for Inspection purpnscs' PERMIT ISSUANCE'
(We)agree to save,indemnify and keep harmles the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any wily accrue against said City AL9'I?R OR ADI]TO Mf:CfL
ideansequ ce.fill gaoling of this pcmtit. PLUM BING FEE
Sol, T UNDERSTANDS ANU VILL COMPLY WITH ALL NON-POINT AIR HANDLING UNl'1'(TO 10,000 CPM) MUCHANICAL FER
SOU ERF RATIONS.
tIp
4 � AIR HANDLING UNI'TGVER I(LagI CFM) CONSTRUCTION TAX
,no laf ApplicunV scar Date••• MIAUS'THOOD(WMUCN HIUSING MI'fIGA'1'ION PEE .
HA RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEM ING UNIT(TO 100,00,71 BTU)
Defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
ode,Section 25532m)? HEATING UNIT(OVER I00,0001 BTU)
E]Yes C]No
VENTILATION FAN(SINGLE RFSID) PAID Date ReceiptI
Will the applicant or antra building by the B use ea Air Qu or Minas which BOILER-COMP(3 HP OR 100,000 BTU)
emit harurdous sir contaminants as defined by the Bay Arca Air Quality Management TOTAL:
L&�nm
s E]No BOILER-COMP(OVER 100,000BTU)
e read the hazardous natvials requirements under Cha AIN CONDITIONER ISSUANCE D
q Chapter of the Cali-
&Safety Cade,Sections 25505.25533 and 25534.1 underswnd that is the NEW RESIDENTIAL MECH. 'SQ.IT. is
not currently have a morl,that it is my responsibility to notify the occupamments which must be met prior a ii,mera ofn Cer ilicamof Oteopancylho0red agent Dam TOTAL: ISSUED RY:��/"�
OFFICE