29183 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. -PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 29183
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
N IN E. v y qPI NIL C 'I IRS IN E y LIC NO: r
11yy-J.tiU EEs/fRHRar lrJ/I /VO / JI �G�� gy(UUCI 1 rI,GGry/p /,�Y/.7 NIC 1k V3 OflITB�VQ 7.:_�b.j h LIC NO: A4 W.�� //'�- IIJ Q/' ❑ Y M l3
CONTACT. PHONE: BUILDING IERMITINFO
,T/O 7 P z-867 Cslnsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
FrJ_Il� ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{M{yWz th Secturil 0)of Div in n3 alinen usincssand RafeaionsCMe,end mylicenuis RESIDENTIAL:
FWU nrfull farce and effect. [, Gs PERMIT ISSUANCE
PGGG44 'I 7 /�8 Z ❑SFDWLRESIDENTIAL, ❑KITCHEN REMODEL
FU License Class t,
N<L -
Cm
a
- dfCiJ) APPLIANCES-RFSIDPIAL ❑ppDIT10N ❑PLUMBING RE-PIPE
ARCHITECrSTS DE DECLARATION ❑
PANELS MULTI-UNIT C STRUCTURAL
f. N
Z p�/1 Z 1 code rsmnd my plans shall h used ns public recants MODIFICATION
O Z J UPTO 210 AMPS
F-�f? Licensed Professional ❑INTERIOR El CHIMNEY REPAIR
9 p OVER 1000AM IMPROVEMENT
^�S OWNER-BUILDER
at I am eU rapt from
DECLARATION Cone ON UVER 11X0 AMPS O BATH REMODCL/REPAIR El DEMOLITION
1 hereby affirm that I am exempt from the Contranor s License Lew for the
�6U followingreason.Permit
to]03LS,emllmr, and Professions Case:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit re wires me idler,impmve,demolish,or minority gned statement
Q JJJ prior toslts cense perm tto the thavisio ant for softhesuchmiss permitfile ato
Law(Chapter
SPECIAL CIRCUIT/MISC.
5� that heia.....licensed 00O provisions 34t eBea et,tars Licenu LawsCocI 9
(commencing with Senion]fX0)nf DivisionJaf the Rosiness and Professions Code)nr TEMP.METCR OR POLF.INST COMMERCIAL:-
ti ps M eG Nem
at he is expt therefrom and the basis fur the alleged exemption.Any Anlution of - [I NEW HLDG/ADDITION DEMOLITION
at Y. Section 103 IS by any applicant for u permit subjects the applicant to acted Penalty of POWER DEVICES
say nm more than five hundml dullors(SSW), ❑IMPROVTFNANT ❑I'OOD SERVICE.
❑ Q 01...... eetthe mupartynntyemployee,withwagesastheirmlecompensation. SWIMMINGPOOL F.LEC'I'RIC
IMPROVEMENT /`n.t't�.
CCC2 will do the work,and Ne structure is not intended m offered for sale(Sm.J044,Business ❑OTHER w- �r
G3 and Portentous Code:The Consmnors License Law dues.1 apply ro an owner of OUTLETS-SWITCHES-FlXTUR ,vV�y _ e
property who builds or improves thereon,and who does such work himself or through 'n
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECI'R SQ FTIt A
sale.If,however.the building or improvement is sold within one yearofcmr,clian,Ne SQ.FT H'1 AgEA
ter-builder will have the burden of proving that he did not build or impmve far par- e7fT i]
pose of aIle.).
❑1,as owner of Ne property.am exclusively contracting with licensed commeors to9
construct the prejecl(Sec.7044,Business and Professions Code:)'ibe .........a Li- r Uh Q
cense Luwdoesnot m1lymvnownol'property whohoilds orimpmvesthemen,and QTY. PLUMBING PERMIT' L/•��
m
who contracts for such projects with a<ort r catch)licensed pursuantto the Contractors
License Law. PERMIT ISSUANCE.
❑ 1 am exemptunderSee. B&P C medu.q reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner r Date
WORKER'S COMPENSATION DECLA RATION BACK FLAW PROTECT.DEVICE fZ w/I�i�
I hereby affiant under penalty nl perjuryone of the following declinations 7 LJI{J
I have and will maintain aCeralicate of Consent to self-insum far Worker's Compen. DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
.,mien,as provided for by Secsinn 37M of the Tatter Code,for the performance of the
work for which this Permit is issued. FIXTURES-PER TRAP
C I have and will maintain Worker's Compensation Insurance,I required by Section
3100ofthe Labor Code,for the Performance of the work for which this permit is issued. GAS-RA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
Cy or
r'a mpen.uion 1pq ns curtiyrloiy Policy number are: GAS-G.SYSTL'M-OVER 4(EA)
W GC TIP �/E/OJT LMPfF10N FRQ �o IRT
fd Sd�a,'� Wli S' GREASEANDUSTRLWASTE.INTERCEPTOR
(This section need nosMcamplc'c r t e. . is m nnehunduddollars($100) - BU .DING AVISIONI S
or less.) GREASE TRAP PIANCHECK FE
Loy my Nesinthe any niannce rin as to become
for whish this the W rkersued,lshall SEWER-SANITARY-STORM EA.21X1 F'R
not employ any person in any manner sn as to become subject m the Workers'Compen- ENERGY EEE
Z decline lawsaf CalifmniL Data
O Applicant WATER HEATER WNFNIyELECfR
GRADING ❑•
y
NOTICE'f0 APPLICANT If,after making shin Cer ificam of Exemption,you should WATER SYSTEMITREATING SOILS
a5become subject to the Worker's Compensation provisions of she labor Cade,you muss
forthwith comply with such provisions or this permit shall be decmed revoked. WATER SERVICE
CONSTRUCTION LENDINGAagency NEW RESIDENTIAL TIME. SQ.bT. PAID
1.1Q hereby which thi thauhere iised(See tion lending agency froths performance of Date Rmeiptp
L>wH
the we*fnrwhichthis permit is issued(Sm.3097.Ci,C.)
U Lender's Name TOTAL:
Lender's Address TOTAL:
I ccnify Nat 1 have read this application and state that the above information is BUILDING EEG g/�
N correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL.PERMIT FEE
V building corewction.andhembyauthoriu representasiveso(this city[center upon rte SEISMICFEE
above-memiuned property for inspection purposes. PERMIT ISSUANCE
(We)agree to.save,indemnify and keep harmless the City of Cupertino against ELECI'RW IE
liabilities.judgments.costs and expenses which may in any way seems against said City ALTER OR ADD TO MECH.
ia
the granting of is permit. PLUM BING IE'
DER.TA AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT fro 10,M)CFM)
SMECHANICAL E
AIR HANDLING UNIT(OVER IO,t1(XICFM) CONSTRUCTION
cunVConvncmr Dam EXHAUST HOOD(W/DUCI) HOUSING MITIGATIO E 1
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Imadous material HEATING UNIT(TO I no,"a DID
as defined by the Cupenlna Municipal Code,Chapar 9.12,and she Ilealth and Safety
Cade,Section 25532mC HEATING UNIT(OVER 100,000 BTU)
\ E)Year ONo VENTILATION FAN(SINGLE RESID) PAID
Will the applicant of future building occupvnt use equipment or devices which Dote Rcceip N
it harardrms air contaminants as defined by the Bay Acta Air Quality Management BOILER-COMP Dills OR]BLOW BTU)
O'mrict? - BT AL:
/ [-1 Yet ❑No BOILER-COMP(OVER Ig1,110U BTU)
I have band Ne harnrdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
India Heath&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NIi W RESIDENTIAL MECH. SQ.FT.
building does but currently have a tenant,that is is my responsibility to notify the accepts
of the requirements which muss he met prior to issuanm of a Certificate of Occupancy.
Owner or amhodxed agent Date TOTAL: ISSUED BY:
OFFICE