29070 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PHRMI'I No /�970
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL -/L0
BUILDING PROJECT IDENTIFICATION TJ 1
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DAT
[)141 Er L+"ts a 2-20
OW—t III N PHONE: CO 'S NAM LI :yp:I
/%//W� NIC CON ROL
UICHITECT/ENGINEER: LICNO: AD FSS: ❑
cod PHONE: "�I / BUILDING PERMIT INFO
3 q � l I{.-S ❑ Consultant Fees Paid by Applicant(Initial) BLDG F.LEC PLUMB
]jV ❑ ❑
1 CENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under pmvisions of Chapter 9(commcncin
JOB DESCRIPTION
FDMZ iII",. n]OW)nf 3aOhe 0usinexs and Rvfession ode, nJ ylicene8 PERMIT ISSUANCE RESIDENTIAL,
UW� Limit force aM eR
o F ,D ivision ❑SFDWL ❑KITCHEN REMODEL
in<V Licene CVs Lica ❑ADDITION ❑PLUMBING RTsPIPE
,�Qi Da¢ COn Dr.CL APPLIANCES-RESIDENTIAL -
F.Dm ARCHITECTS DE Pub . - PANELS ❑MULTI-UNIT [3 STRUCTURAL
ZO4? IumlerstanJ my plans shall be used as public records MODIFICATION
O Z— UPTO 2W AMPS
F"FtOi1 Leersud Professional ❑INTERIOR ❑CHIMNEY REPAIR
EMENT
3:014Q 1 hereby affirm h��am axern,WritheLDER Cmunsc DECLARATION'.License Law far the OVER["AMPS
AMPS BATH R MOD!
OVER LBW AMPSTH REMOU' EPAI [�D�OLp'IO � 1,
X G6 U following reason.(Section]W L5,Business and Pndeszimns Cade:Any city or coumy SIGNS ELECTRICAL HER f'- (/ FY.
U.y which requires a permit to construct,alter,improve,demolish,or repair any structure FSO¢
pd., its Lmence.vlso equire,the.pplicvnt forsuch p:rmirto file. igned smtement A/
yJ SPECIAL GIRGQIT/MI$G. V i
C Q�
that me ccemmd pursuantto )od Disionsof the Conuiness License Loons Cook)or
H2O (commencing with Semion]OL`0)ofDivision3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL.
6 d c that be is exempt therefrom and the Iasis for the alleged exemption.Any violation of [I DEMOLITION
X^N Senior]031.5 b oe a licam for n ❑NEW BLDG/ADDITION
not more Nan five hunted dollzm(S5Wr).�it subjects the applicant Penalty of POWER DEVICES ❑TENANT - ❑FOODSERVICE
�~^,Sp
El 1.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
^a will do the work,and the structure is not intended muffered for sale(Sm.0044.Business ❑OTHER'
3 m and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
es. propomy who builds or intpmves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTS SQ ET..
sale.If,howebenthe building.rimpmvement is sold ahmorr,cmr ofcompletiun,the SQ.FT.FLOOR AREA $/SQ.En
mer-builder will have he burden of proving that he did not build or improve lin put-
❑ I,a owner ri the property,7(M ,B exclusively contracting lmg with licensed cnmtructos i- AL. o
onstmet he pnrjett(Sea]uV4,Business and Hnfessinms Gulc:)The Contmdnr'a Li-
cense Law does not apply to an owner Of property who builds or i reproves thereon,and QTY. PLUMBING PERMIT FEE
whocontm4Ys forsuch Projects with aco.tmemr(s)licensed pursuant tole Contractors P' O
Deme Lou. PERMIT ISSUANCE 996
tum exempt under Sc,. ,I{&PCfor hia ramnn ra Y .'
ALTER-DRAIN&VENT-WA" E ti
Owner ])am V VrCytAtl(A'JI,ON
WORKIiR'SCOMI'1?NSATIOD
NECLARNI[ON BACK FLOW PROTECT.DEVICE
1 herebyind under Penalty of perjury one ofthe fallowing declarations: r
❑Ihmound will num'Ein a Cerdfivatn ofConsennU sclLinsure lin Wvrkcr's Compcm DRAINS-FLOOR,ROOF,AREA,COND.
saliva,zs provided for by Sema.3700 of he Luton Cale,for the performance Of the STORIES TYPE CONSTRUCTIOI
work fur which his permit is issued FIXTURES-PER TRAP
Ej I have a will n aim 'n Workers Compensation insurance,as required by Section
J]W of the sr de I the crfn mecoftbe wodfn it
s this nisi. GAS-EA.SYSTEM-1 INC.4 OUTLETS DEC.GROUP ANN
My Worke s, ns i n rim and Pott
Cartier. PolicyN O�"—" GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATED EXEMPTIONFROMWORKF.RS'COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This section meed nm be completed lithe permit is furore hundred dollars(SI00b BUILDING DIVISION FEES
nr IessJ GREASE TRAP PLANCHECK FEE
Loy anythatPersn the perany mannce ro the as
re for subject
ich jetho perthe Wokem't is dihall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner nn en m hecnme subject to he Workers Camper- ENERGY FEE
,� Applicant
of California.Date
Z� Applicant
WATER HEATER WNENT/ELECTR GRADING FEE
y NOTICE TO APPLICANT.If,after making this Cenificam of Exemption,you should WATER SYSTEMOREATING
become subject to he Workers Compensation Pmvimm s Of the Lobo Carle.you must SOILS FEE
W
forthwith comply with such previsions or his fiction shall be deemed revoked.
WATER SERVICE
0. La
.7Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V C) Ihmeby.M.that iso comrruction lcndingagency for the cedrourn eof Dae Receipts
❑. .. the work for which his pemdt is issued(Sm.309].Civ.C.)
p U Lenders Name 1�tTAL.DJ Lundee,Address TOTAL:gL 1 certify Nat 1 have read his vpplimu n end state hat he above information is MSEISMICME .
lA commit.I agree to comply with all city and county ordinances and state laws relating as QTY. MECHANICAL PERMITV Z building conswetion,and here authorze reptesentatives of this city m enter upon use FEE above-mention openy far' .when purposes, PERMITISSUANCE(We)a - m save,led oilyandkeephamnlastheCityofCu dinagainst inconseque mm hegrablin thi Pemies t. may in eny say accrue. ainatsaidCiry ALTER OR ADD TO MECIL �
APPLICA so the granting ihi permit.SOURC A 'U. D RSTAN S WILL COMPLY WITH A L NON-POINT - AIR HANDLING UNIT(TO 10,000 CFM)SOURCE 'GU f ) S.
to "1 AIR HANDLING UNIT(OVER 10.OoO CFM) CONSTRUCTIONTAX
Signalumof Applicem/Cv rich Date EXHAUST HOOD(W/DUCn
HA RDD IS MATERIALS DISCLOSURE. HOUSING MITIGATION FEE
Will the...ties. mfmurewilding mcupam store nr hanAlchmndnus maedal HEATING UNIT(TO 1 .000 BTU) I Z,
as defined by the CliveInn Manic pal Code,Chapter 9.12,and the Hcalth and Safety
Cade,Section 25532(x) if RATING UNIT(OVER 100.000 BTU)
[3 Yea
VENTILATION PA N IS INGLE RESID) PAID
Will he applicant or future building occupant use equipment or devices which Date Receipt N
:mit hazardous air contaminants as defined by he Hay Area Air Outlay Management BOILER-COMP(JHP OR IOIkWO BTU)
Diaaiel? TOTAL:
❑YeaF1 No BOILER-COMP(OVER IW."BTU)
I have read the hazardous materials rnquiement.Under-Chapter 6,95 of he Cali- AIR CONDITIONER
fomiu Hevhh&Safny Gate,Sutimns 25505.255]3 and 25534, tmdcrsmnd than if dm ISSUANCE DATE
builhrildoes not cun'co,1,have ammo dntit ism billl I,,rosily theom.'sal NEW RF-SIDENTIALMECIL .SQ.Ff
ofherc requirements which must be and ammolal y y
qu prionai.cvnnnce ml's Ccdilicntc nl'Occnpuncy.
Ownerorealhonzedogent Dam TOTAL: 2)0 ISSUED BY:7 \ 1
OFFICE