29901 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PERMIT NO. 29901� �0
BUILDING DIVISION APPLICATION/PERMIT PLUNIBING-MECHANICAL
uutumm;PRojEC'r IDENT'IF'ICATION
BUILDINGADDRESS: SANITARY NO APPLICATION SUBMITTAL DAIS
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, i WNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
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RCHITEC'INGINEER: LiCNO: ADDRESS: ❑ W
CONTACT: PHONE: BUILDING PERMIT INFO
l / ❑ Consultant Fees Paid by Applicant(Initial) LDG ELECT PLUMB MECH
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LICENSEDCONTRACTOR'S EILARA'rION QTY. EhECTRIC PERMIT FEE
1 hereby affirm mm 1 am licensed undo provisions of Chapter 9(commencing I JOB DESCRIPTION
yyUJ alZ with Section]000)ofDivision3rf the Hnsincas and Professions Code.and my license is RESIDENTIAL:
ad— DSFUWI. ❑KITCHEN REMODEL
1-00 PERMIT ISSUANCE in full t.me aneffect.
d
�UFLicense Class Lic.p
F6F. []ADDITION ❑PLUMBING RF.-PIPE,
NQS Dmnt
aCoractor
ARCHITECPS DECLARATION ❑MULTI-UNIT []STRUCTURAL
ZOtrsZ Iunderstand my plans shall be used as public records PANELS MODIFICATION
OZ�-0 UPTO 400AMPS [I INTERIOR El CHIMNEY REPAIR
W Licensed Prof...road 201.1001AMPS tV IMPROVEMENT
0.'C C 4 1 M1ereby affirm mWNER;OWNER-BUILDER pl UEme C n len tar's Licence Luw for the OVER 1(X11)AMPS ❑BATH REMODEUREPAIR DEMOLITION
xa�g 6 U following reform.(Section]03 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL E101 HER
�I
W 3 LL y which requires a permit to construct,alter,improve,demolish,or repair any soucmre
I"LL•�� aionoitsissmn[e.vlsorequires lheapplicum forwcb pc.it o flea signet swteinem SPECIAL CIRCUIT/MISG
pssp!vW!��p- that he is licensed purourna to the provisions of Ne Contoctors License Law(Chapter 9 J
1yC00 (commencing with Fnlnn]fXXry of Division?of the Business ant Pro@scions CoJcl rr TEM1'.METERORPOLEINST. COMMERCIAL:
that he is exempt there(..n end the bass far the alleged emmptiun.Any viol......of ❑NEW BLDG/ADDITION ❑DEMOLITION
Scninn 7011.5 hynny applicant fora permit wnhjeas the upplicannn ucivil penalty of POWER DEVICES i ❑TENANT' DFOOD SERVICE
F Z Y t more than Eve hundred dollars(3500). IMPROVEMENT
56 pl.anownersdtbcpopcny,nrmyentployceswilhwagcsasihcirsalccomp[nsatinn, SWIMMINGPWLELECTRIC
SFC will do Ne work.andmmtrvctum is not imm�JedmnffereJ(orale(Sec.]fH4.Business ❑OTHER
L 3 m and Professions Gale:The Cor slate,License law does not apply m an owner of ONLETS-SWITCHES-FIXTURES
Nunn,woo builds mimpolos...coon,-and who rices such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECIR SQ F-n
sale.If.moves.the building or improvement is sold within one year efrompiniom,the SQ.FT.FLWRAREA� LSQ.FT.
builder will have the burden of moving that he did not build or improve for parr- Jfp
owner . Ar 3
cr.(the prnNcny,am exclusively[omrdcting with licensed......cors to
construct the project(Sec.7004.Husine,and Professions Code:)Thu Coad ucmr's Li- 996
cense Lowliestnot apply to an r..nerofpmpeny wnobuilds orimproves daemon,and QTY. MBING PERMIT FEE UrL
who contracts for such projects with a mmrnclor(s)licensed pursuant to the Collimator's
License law. PERMIT ISM1,64 7 f I,Visa,
D 1 exempt undo Sat. .B&1+C far mi:ream.. _
ALTER—DRAT VE — TER(HA) VALUATION
welva a, D
\ WORKER'S COMPENSATION DEC-ARAI IO N' BACK FLOW PROs'6(32,lirl
I hereby We.under penalty of perjury one of the following decimations:
I have and will maintain a Certificate of Consent towIf-insure for Workers Confer- DRAINS—FLOG OOF .GOND. STORIES TYPH CONSTRUCTION
atiou,as pmisked for by Section 3700 rf the LrNa Cndc:fm the performance of the
work for whichthis Neurit is issued. FIXTURES—PERTRA
I have and will maintain Wal Compensation Insurance,as required by Section
3700 ofthe labor Code,for the performance oftha work for which this Permit is issued. GAS—EA.SYSTEM-]INC. UTLETS WC.GROUP APN
My Workees Compensation Insurance canter and Policy number art:
Carica Policy No.: GAS—EA.SYSTEM-OVER 41P)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRLwASTE INTERCEPTOR
COMPENSATION INSURANCE I I ING DIVISION IBES
(TBl.kmetion neednolhecnmpletnd lrthel+vrmit is forme hundred doll..s(SI00) GREASETRAP
or late.) PLANC E
I cattily that in the performance of the work for which this permit is tissued l shall SEWER—SANITARY—S ORM HA.2m)F1'.
not employ any pecan in any man......1.be[omc shbject to the Workers Coo per- ENE G EL
z arrom Lwsrf California.Date WA I'ER I BEATER WNENT/ELECIR
2 Applicant — l +F
Of!) NOTICE TO APPLICA NI':IL uFeenmaking this Cend rim of Exemption,you should WATER SYSTEM/I'REATING
I-' ; become suhjttu.the Woderx Compcnati.n 1mvisiuns of ren Labor Cndc,you area SOILS FEF.
Wforthwith comply with such provisions or this permit shall IN,deemed rev.ked. WATER SERVICE
Q
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Date Receipt a
U O Iherthm
Yaffinn ot mere isoconnrveuendi
nn lng ageneY for pm merrrman
lce of
LL
F the work for which this permit is issued(Sec.3097,Co,C.)
Lender's Name TOTAL:
LULenders Address TOTAL:
y I cavity that I have read this application and state that the refuse information is tlUl ING FEB
FI,, comit.I agaefit comply with all city and county ordinances and state laws relating.. QTY MECHANICAL PERMIT FEE
UZ htildingconstrvetion,and herebyaumorim rupee senmdves of tbisclty m emerupm the SEIMIC IEE
above-mentimmil popery for inspection dawlen. PERMIT ISSUANCE
(We) got.to as..indemnify and keep harmss
lethe City.f Cupenin.against ELICIT IC FEE
liabilitia,judgments.ttuts mal expense;which may in any why acerae against said City ALTER OR AILD I'0 MECH. PI.UMBI �kE
in couse,me,c of the grunting.(this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 10,000 CPM)
MECHANICAL FX
SOURCE REGULATIONS.
AIR HANDLING UNIT O)VL'R 10,001 CFM) CONSTRUCTIONIA
Signature rf AppreanUContruetor Data EXHAUST HOOD I WMUM HOUSING MITIGATION F'?
HAZARWUS MATERIALS DISCLOSURE
WdEffie applicant or furore huilding.ceapamsmre rr handle hmmrdrus....anal HEATING UNIT(TO 100.000 BTU)
as defined by the Cupcnino Municipal Corte,Chapter 9.13,and the Health and Safety
Cale.Section 255320)! HEATING UNIT(OVER 100.000 BTU)
❑Yes DNo VENTILATION FANS INGLE RESID) PAID
Dam Rcmipt a
Will the applicant or future building occupant use equipmenl or devices which BOILER-COMP(3HPOR I W.00(i
nit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes 1_1 No
Ihave rtW the hvzvdous..Hot,regmiremems under Chapter 6.95 of the Cali- AIR CONDI'I'IONBR
ISSUANCE DATE:
Forms Health&Safety Crude,Sections 25505,25533 and 25534.1 understand that if the N17W RESIDENTIAL MHCH. SQ.IT.
building docs not cumndy have a tenon.that it is my responsibility to nodfy me rccupatm
of the raryirememx which must he met prior to issuance of a Cenificam of Occupmn[y.
Owner or um@alreit are, Dam TOTAL: ISSUED BY:
OFFICE