29964 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL .PERMIT NO.
BUILPINfi DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 29984
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
zho C+ q"AJ'A GT . C 3aG
OWNER'S NAME: PHONE: CONTRACTOR'SNAME: ,6� LIC ` N/C CONTROL
RCHVVITECT/ENGINFPR: LIC—000A P NO: / A DRESS.t � _ S.40 ❑
L J
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB -MECH
+ LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE !y`�
I hereby aRrm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
fIOy00 with Section]IMp)a(Division3of the Busincssand Professions Cade,an mylicenseis RESIDENTIAL:
FIS in full force and effect - PERMIT ISSUANCE ❑SFDWLRITCHEN REMODEL
�UIU�'d License Class S Lic.Nq!Pe pppLIANCES-RESIDENTIAL d_
f-U Dae Connector ❑ADDITION PLUMBING RE-PIPE
7y CHITECTS DECLARATION C$$sISIJj PANELS
El MULTI-UNIT C1 STRUCTURAL
y7J I understand my plans shall be used as public records MODIFICATION
OZ UPT0200AMP5 2 !• C]INTERIOR ❑CHIMNEYREPAIR
FSE u� We OPofessioal 201-1000AMPS IMPROVEMENT
�ypa�a�e OWNER-BUILDER DECLARATION OVERINXIAMPS El REM EUREPAIR ❑DEMOLITION
1 hereby affirm that I em exam
firm the Commences License Law for the
7y5 0 6 U following reason:(Section 7031.5,Business end Professions Code:Any city or county SIGNS ELECTRICAL ❑0 ER
to a 1y F which requires a permit at comment,chat,improve,demolish or repair any atrvcture
FSO prior as its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUITIMISC.
tE
that he is licensed pursuant no the provisions ofthe Contractors License Law(Chapter9
00 (commencing with Section 1110111 of Division 3 of the Business and Professions Cashel or TEMP.ME-=-BOB POLEINST. ro MFR
6 c C that he is exempt therefrom and the basis for Ne alleged eumpnian.Any violation of ❑NEW BLDG ITT N [I DEMOLITION
f+- Section]031. yy 5 banapplicant fomlil subjmnse ap
the m e civil penally of POWER DEVICES
nth r a pc ❑TENANT ❑FOOD SERVICE
.
ZZZq�. not more Non five hundred dollars(SSW). IMPROVE ENT
GO ❑Lesoe walk,thepmpeny,remycmntendeewithwages r Ne rsme co ,,asuman, SWIMMING POOL ELECTRIC
100
y will dothework,ands: snemureisnot s License afferit., ale(Sec.TU44,Business ❑OTHER
0.a and Professions Code:The Contractors's License law rices not apply s if owner h )UTLETS-SWITCHES-FIXTURES
property who builds or improves,suchthereon.and who does such work himself or through
his own emElnyaa,provided Nat such improvements are ret inxndW or offeml for NEW RESIDENTIAL ELECI'R SQ FT.
sale.If,howevca the building or impmvetnent is eolJ within one yam of atmpletioa the SQ.FT.FLOG Rig SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put- /7
Eau of alone � ✓�� ���l
El 1,construct owner of the pmpeny,,B exclusively convecting with licenxd comractota m TOTAL:
,La the project(Sec.o an Business iandmp rty who
Code.)The Contractor's Li- tY
cense Lawdoes not apply nman with
arofpmpeny who buildsorimt Loth thereon,and QTY, PLUMBING PERMIT FEE _ p0
who conwcns for such prajttls withaconvactoKs)licensed pumuamo the Contractor ryUF0� 7
License Law. PERMIT ISSUANCE LI'�CL
❑1 am exempt under Sec. ,R&P C far This reason
Owner Dore ALTER-DRAIN -WATER(CA) VALUATIO
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally ofperjury one ofthe following declemtions: `� � �(Js�a
❑ I have and will maintain a Claiicme of Consent to self-insure for Worker's Compen- DRAIN$-FLOOR,ROOF �/J�tAREA,GOND. STORIES TYPE CONSTRUCTION
satiun,as provided for by Section 37+111 of Ne labor Cade,foram performance of the
wo for which this pcmmit is issued. FIXTURES-MRTRAI'
I haveand will maintain Workers Compensation Insurance,as required by Seclinn '
] of the
Labor Codee,,for the performance of the work for
lwwbhaicchathis permit is issuueed.. GAS-EA.SYSTEM-I INC.4 OUTLETS OCG GROUP APN
My
Policy
Curier:rLN {[ moi�nc�Polcarrier cY Na'V�:I 0 ILQ J GAS-PA.SYSTEM-OVER4(EA)
T CERTIFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This xnionnttd nm has completed ifthe permit is for one hundred dalton(SI W) BUILDING DISION TEES
or lase.) GRPASETRAP PLANCHECK FE
Icenifylhatm the performance ofthe work for which this permit isissued,Ishell SEWER-SANITARY-STORM EA.200 FT.
rat employ any person m any manner en m to hecom au6 l he Workni Compen- ENERGY FEE Go
,Z ation laws o oro,Date - WATER HEATER WNUMMLECTR
Applicata GRADING F
rN•l NOTICE .IG i4• L'ITAnmlaion,you should WATER SYSTEMrTREAGNG
a become object to Ne Worker's Compenation provisions of Ne labor Code,you must - JE
OILS
[kl forthwith comply with such provisions or this permit shall he deemed revoked, WATER SERVICE
A CONST RUCTIONLENDINGAGENCY NEWRESIDENTIALPLMB. SQ.FT. ID
U O Dam Raciptg
1 hereby mfum the there is a cnnstrvction lending agency firma perfutmunce of
•l the work for which this permit is issued(Sec.3119].Civ,C.)
lU'', Lendeee Name TOTAL:
Liz 'Lender's Address -
I cenify that 1 have read this application and arae thanhe above information is UILDING M- t�
L0 carat.l agree to comply with all tiny end counry ordinances and state laws totaling to QTY. MECHANICALPERMIT PEEISMIC FEE
U Z buildingeonsl ction,andherebyauthoriaerepresenlativesoflhisciiymenieruponthc,
VLahmve-mentioned prpeny for inspection purposes, PERMIT ISSUANCEoiiii
(We)agree to ave,indemnify and keep hairless the City of Cupertino agmao LECTRIC FE
liabilities,judgmcna,casts end asperses which may in any way attire against raid City ALTER OR ADD TO MECIf.
in conxqu
`1
of the grantingofl 's permit. UMBING FE
APPLIC 1UNDERSTAND. �DD71LL COM)?. WITH LLLLLa(/N/pN-PLOIINT p1ft HANDLING UNIT(T010,000 CFM)
SOU 'BnREGULATION$ Ic.� /�-I/ ECHANICALF
��/ AIR HANULING UNIT(OVER 10.000 CFM) ONSTRUCTIONS AppI7 UCoranor Date EXHAUST HOOD(WIDUCT)HAZARDOUS MATERIALS DISCLOSURP. OUSING MITIGATIO FEE
WII lheapplicata or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupcnino Municipal Code.Chapter 9.12,and the Health had SafelyCode,Section 25532(a)? HEATING UNIT(OVER 1110,0110 BTU)
Yes ❑NcVENTILATION FAN(SINGLE RESIO) ID
Un. Rec tg
411 ' Will the applicantor Tulare building occupant use ea Air Quordeviceswhich BOILER-COMP CHP OR IM."BTU)
emir haallous air asmhminums as Defined by the Bay Arca Air Quality Management plo
D
istrict? BOILER-COMP(OVER iffl. 0 BTU)
s Fl No ..
e load the haardous materials Is under Cha 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
require pier
@ Safety Coda Sections,met i is my and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.
...t currently hwe a mlwtt,Nat it is my rsgmsihiliry m nnlify the occupantmenw which mull be met prior no issuance of a Cenifiare of0selplan,
mamN agent _ Data TOTAL: I ISSUED BY:
OFFICE '
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