29044 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL, PERMIT NO. O
BUILDING DIVISION APPLICATIONIFERMIT PLUMBING-MECHANICALCT'
BUILDING PROJEIDI;NI'IFICATION
44
BUILDING ADDRESS: SANITARY NO. APPLICATION SOB MITT AAT[
Oa cL C_�0 I°
OW R'S NAME: HONE: NTR�CT {NAME: LIC NO:
evl t'I r� 5 e GJ I I L / /( N/C CO ROL p
•ARCHITECT/ENGINEER: LIC NO: ADDRESS - S #v-< ��y�0+ ❑
CONTACT. PHONE: 7,YY O` BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUMB NIECE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I Earthy effort that 1 am licensed under prnvisiom of Chapter 9(cgmmetieing JOB DESCRI ON
CWZ with Section 7000)of Division 3 of the Business and Professions Cade,and my license
FOO in lull force vnd effect. y ice s is . PERMIT ISSUANCE RESIDENTIAL'
C r Li ❑SFDWL ❑KITCHL'N REMODEL
G V V cense Class Lic.N
��w Data Convector APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCIII I ECT:S DECLARATION PANELS
I. to ❑MUhT6UNIT ❑ TURA
Z O�2 Z 1 undcrswnJ my plans shall M used as public recordMODIFI
s MODIFlCATION
OZ— UI'TO M3 AMPS ❑INTERIOR EI CHIMNEY REPAIR
9 Licensed Professional - 201-1000AMPS IMPROV13MENT
as OWNER-BUILDER DECLARATION OVER IOO)AMPS
I-+a 6 1 hereby off rte that I am exempt from the Contractors License Law for she [I BATH REMODEIIREPAIR C1 DF.MOLRION
3 a u following rcaon.(Section 7131.5,Business end Foursome,Code:Any city or county SIGNS ELECTRICAL ❑OTHER
.R.O Cj which requires a permit to construct,altar,improve,demolish,or repair tiny structure
g prinrm to...nonce,:dsa reyuues Aw.pplicten far mcL penninCI
g fila a signed oatmamt SPECIAL RCUIT/MISC.
or, Nm he is licensed pursmed 1.the provisions of Ne Conuactors License Law(Chapter 9
CSO (commencingw.NSec'io...tg3)of Division 3 time Business and Professima Code)., TEME METER OR 'INST. COMMERCIAL-
ry, eG that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
uXl WSection 7031.5 by arty applicant far.wrbril sobjmts the applicant to a civil penalty of POWER DF.VI t ❑TENANT ❑FOOD SERVICE
Zyp. not---,ban five hundred dollars($5110). IMPROVEMENT
Sp ❑ 1.as owner of the properly,or my employees with wages as Neir.ose at cr rnou WIMMING POO,EL TRIC
p. will douse work,and the structure is not intended oscillated for sale(See7044,Rusin se []OTHER
W and Professions Code:The Contractor's License Low does not apply ova.!air of OUTI. SWI CHFS-FIXTURES
a' progeny who builds or improves thereon,and who does such work houself or through
his own employees,provided that such impmvemcrns are ran intended or idfered for N ESIDF. IAL ELECTR SO FT. T n
sale.If,however,the building m improvement is sold within one year of completion. SQ.FT.FLOOR'AREA Ct S/SQ.PT.
owner-builder will have the burden ofproving that he did not build or imprme for r
pose of sow NOV
13
❑ 1,its owner of the progeny,am exclusively contracting with linens nmrucar. TOTAL: N 1995
construct the project(Sec.70 .Business and Professions Code:)Toe tors .i S�JU
cause Law does not apply to an owner of property who builds or improves the QTY. PLUMBING PERMIT FEB ^
who wntremsfor sucE pmjces with nominations)licensed pursuant to the Co r Vr�y Ur LIJf' e�
Lt...law, ors PERMIT ISSUANCE tHJ)�V
0 l am exempt under Sec. ,B&PC formis rcaam
ALTER-DRAIN&VENT-WATER(BA) VALUATION
Ow lar Dae
WORKizR'S COM PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby efarm under penally of perjury one of the following declarations:
Ej I have and will maintain v Cenificao c(Comenuo self-insure for Workers Camper- DRAINS-FLOOR,ROOP,AREA,GOND. STORIES TYPE CONSTRUCTION
sation,as provided for by ScOnat 37M of the Labor Code,for the perfoonanw of the _
a for which this permit is issued kFIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurnnce,as required by Section
]1Xl of the Lubar Gyle,for the performance of the work for
mwhich
this
�p�erand i c issued. GAS-EA.SYSTEM-I INC.4 OUI LEES � OCC.GROUT' APN
CannoMy t Font lion liastsmngca(�letolcy NOand Y�✓Q /sorsrS�S GAS-EA.SYSTEM-OVER 4(HA)
TT�TyyCERTIFICA//TEE Of'[DiE.•NUMON FROM WORKERS'
COMPENSATION INSURANCE: GREASFANDUSTRL WASTE INTERCEPTOR
_
(ThLs section need not he unnplWed Of she pennl3sfor one hundred dullnrs(511X)) GNEASE TRAP
BUILDING DIVISION FEES
or less) PLANCHECK FEE
I cenify that in the performance ofthe work forwhich'his permit is issued.Ishall SI:WEB-SANITARY-S'roRM CA.200 lT.
not employ any person in any manna,so as tg hcc.m.subject 1.the Wmkard Comfort- ENERGY FEB
,Z saOgn Lawsof California.Date
OO Applicant WATER HEATER WrvENT/ELECTR GRADING FEE
r~N•r NOTICE TO APPLICANT If,after making this Cenilicate of Exmmption,you should
WATER SYSTEM/TREATING
1••' ' become subjecuo'he Worker's Compensation provisions of the Labor Cale,you mus, SOILS FEE
W `-t forthwith comply with such provisions or this parent shall he deemed revoked. WAGER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NCW RESIDENTIAL PLMR. SQ,PC PAID
UO I for by which
thi thatthemi issued( eeion 3097.Cis,agency for the performance of Data Receipt#
W � Ne work for which this permit is issued(Sec.3119'!.Civ.CJ
O Landers Name _ TOTAL:
Lenders Address
y 1 certify Na'I M1ave reed this application enJ stau thm the above information is �- BUILDING FEE
h correct.l agree to comply with all city and county ordinances and state larelating to QTY_ MECHANICAL PERMIT FEE
U � building construction.and hereby authorize reprosentatives.flhiscihy to enws ter upon the SP.ISMICPEC
abova-mentioned pmperry for impaction pugsous PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC HE
liabildies,judgmems casts and expenses which may in any way accrue against said City p1.TCR OR ADD'I'O MECH.
in canuquence o(the granting of this permit. PLUMBING FEE
" APPLICANT UNDERSTAND�TMPLY ITH ALL NON POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOUK 'ULATIONS. MECHANICAL FEE
AIR HANDLING UNP(OVER 10,(X3CFM) CONSTRUCI'IONTAX
a,cfApphxardC Date EXHAUST EDGED OMMUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future hullding occepamsom,or handle hazardous material HEATING UNIT(TO 11X1,000 BTI))
as defined by Else Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Section 23532(v)^ HEATING UNIT(OVER 100,000 BTU)
❑Yes E]NO
VFNTILXTION FAN(SINGLE RFSID) PAID
Date Receipt#
Will Ehe vppllwnt nr fumrc hullding nmupunt axe equipment or devices which BOILER-COMP(3l{p OR 1f10,gq OTU)
•emit hazardous air contaminants as defined by Ne Bay Arco Air Quality Management
District?
❑Yes 0 N BOILER-COMP(OVER 100,000 BTU)
I have read the bazmdner materials requirements under Chapter 6,95 of Nc Cali- AIR CONDITIONER ISSUANC DATE
fomiu Health&Safety Gale,Stations 25505,25533 and 255un
34.1 dandand that if the NEW RESIDENTIAL MECH. SQ.PI'.
building does no,ca ently hove.tenant.Nat it is my respomihility'ommfy woccupant
of the requirements which mm'be me'prior Its issuance of a Certificate gf Occupancy. '
Owner or authorized agent - Data TOTAL: ISSUED BY:
OFFICE