29605 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAL PERMIT NO. /� /� r
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2 5
9 6 0
BUILDING PROTECT IDENTIFICATION L �! V V
-' BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: CONTRACT R'S NAM 'LIC NO: N/C CONTROL#
a
'2 -3 v7- sz _30.5,01
ARCHITECTMNGINEER: - LIC NO: ADDRESS: ❑ -
CONTACT: - exorve: v BUILDING PERMIT INFO
^ ❑ Consultant Foes Paid by Applicant(Initial) BLDG . ELECT - PLUMB MECH
❑
- LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE El ❑
I hereby affirm drat I'am lioeneed under prnvieions a[Chupmr 9(commencing SOB DESCRIPTION
D�j�Z wilh5ection"1Of10)bfl ivision 3ofthe Business and Professions Code,and my licensees - - RESIDENTIAL
FF full force end ,Q PERMITISSUANCE
FUZUP LicenseC ss Gsf I.m.# 3 s (" _ DSFDWL KI HEN REMODEL
N6 Dare Convector APPLIANCES-RESIDENTIAL' ❑ADDITION BING RE-PIPE
I
ARCHTECPS DECLARATION PANELS !!STRUCTURAL
!!!!
F no - ❑MULTI-UNIT ❑
ZO IZ 1understand my plans shall be usedis publicrecords - -F
OZ ` - UP TO 200 AMPS -
MODIFICATION
F', tOy Licensed Prcdmr mnal ❑INTERIOR D CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1"AMPS IMPROVEMENT
1 hereby affirm that 1 am exempt frota•the Contractor's License Law further OVER 1000 AMPS ❑BATH REMODEIJREPAIR ❑DEMOLITION
p(a G U following reason.(Section 7031.5,Business and Professions Code:Any city or county - - - ❑OTHER
W 0i. which requires re SIGNS ELECTRICAL
q penrdtt i construct, Iter,improve demolish r repair ny.wemre
H prion isit,
s ,also rey prtinovisions
t far ofthesuch peanut is g dstammem SPECIAL CIRCUIT/MISC.
that 6C) (commencing
licensed pursuant 00 p ironso of
Contractors License L (Chapter 9
ode)or _
(cont nangwmSect Section 7000) fDivision 3of the Business dProfessions Coide)oir OMM IA :
p O - TEMP.METER OR POLE.INST. COMMERCIAL,
4 c that he is exempt therefrom pnA the basis for Ne alleged exemption.Any violation of
Section 7031.5 6 an applicant for a permit subjects thea applicant to a civil y o - ❑NEW BLDG/ADDITION C DEMOLITION
Y ratio p I pp penalty f POWER DEVICES
y not more than five hundred dollars($500).'. - ❑TENANT El FOOD SERVICE
[]I as as owner of the property,or my employeas with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended or offered Amish,(Sec.7044,Business C OTHER
and Pmil ssions Code:The Contractor's License Law does not apply m as owner of OUTLETS-SWITCHES-FIXTURES
6 3^ property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such mproveminav are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. "
sale.If,however,the building or improvement is add within one year mcompletion,the LirX.FT. RAREA .E/SQ.FT
owner-builder will have the buNen of proving that he did not build or improve far pur. /� g Jtf
las,of sale).. c a7 N x. r
❑1,as owner of the property,«m`exclusively, contracting with licensed contractors to TOTAL: SE
convect the project(Sec.7144,Business and Professions Code:)The Contractor's Li- P
I catile Law does not apply to an ownerofpmpeny who builds or improves thereon,and, QTy, PLUMBING PERMIT F '
whLicense Law.o contracts for such projects with a bontracmr(s)licensed pursuant to the Contractor's
- 9g
PERMIT ISSUANCE (^y!,"
C 1 am exempt under See. ,B&P C for this reason - - • Vlq-`/
Owner Dote
ALTER-DRAIN&VENT-WATER(EA) VALUATION '
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby«Elam,• under penalty of perjury one of Ne following s
dechmatio Dlhave and will maimaina Certificate ofConscm to self-insure Por Worker's Coimpen- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
amion,es provided for by Section J2W of the Labor Code,for the performance of the -
' work for which this permit is issued FIXTURES-PER TRAP
El I have and will maintain Worker's Compensation Insurance,as required by Section
3200ofthe Labor Cade,for the perforrnanceofthe work for which Nis permit issued. GA_S-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Worker's ompegs In los once carrier and Policy number are:. s
Cartier: Policy No.: A3S// 2-�/Y GAS-EA.SYSTEM-OVER4(EA)
ERTIFICATEOP EXEMPTION FROM WORKERS' CREASPJINDUETRL WASTE INTERCEPTOR
COMPENSATION INSURANCE. _ BUILDING DIVISION FEES
(TTia seetloin need not lrecomplded iPthe permit is forone hundrod dollars(E 100) GREASETRAP
or less) PLANCHECK FEE
(certify that in the Performance of the work for which this thepermitshall SEWER-SANITARY-STORM EA.2LD FT.
not employ any person in any me o 1 yte subjem m the Workers'Compen- ENERGY FEE
,�.' cation laws of ifomat n L - _
O e - WATER HEATER WNENT/ELECTR
z E (1 - _ GRADING FEE
NOT(
F-t h NOTICE APPLICANT:If,after tanking this Certificate ofE.ampumt,y ?
You should WATER SYSTEMREATING
become subject to the Worker's Compensation provisions of the Labor Labor Code,you must, ' SOILS FEE I
forthwith comply wiNsuch provisions or this permit shall be deemed revoked. WATER SERVICE _ Lt L9
_
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FF. PAID
V'Q Thereby affirm thauhere is econstmction lending agency for the perfannance of Date Receipt# - r
the work for which this permit is issued(Sea 3092,Civ,CJ
Lender's Name TOTAL:
Lender's Address TAL: -
1,'Cy^ 1 certify that I have read this application and state that the shove information is BUILDING FEE
In correct.1 agree to comply with all city and county ordinances and state laws reaming to QTY, MECHANICAL PERMrr FEE
U buildingconsmuctian,and hereby amlimimmIntsenmtives'ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection porpoises.
(We)agree 1.save,indemnify and keep harmless the City of CuNnino against PERMIT ISS UANCE ELECTRIC FEE''
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
.in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO
SOURCE
AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS:: MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCTIONTAX
Signatureof Applicant/Conttactor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATIONFEE
`
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future hidding oceoparil store.,handle hazardous material HEATING UNIT(TO((10.000 BTU) - -as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety `
Code,Sea m,25532(a)P HEATING UNIT(OVER 100,000 BTU) -
El Yes ❑Nn .. VENTILATION FAN(SINGLE RESID) PAID
Date Reeeipt#
Will'hedmis air contaminancant.1 ts as
building itcatilby the B yAic ea Air Qualitil or y
,nage ant BOILER-COMP(3HP OR 100,000 BTU) .
,toil hazardous aicrontuminant as defined by the Bay Area Air Quality Management '- TOTAL
District? BOILER-COMP 100,000 BTU)
❑Yes DNo• .,
I have read the havudman material,requirements ondef Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.PI'. t
building do s ria cutrendy have a tenanh that it is my responsibility m notify the oiccupent
Its tow 'ch mus metprl Issuance of a Cenifir. t'4 pancl. - ..
wourmantrucarin,atia f Date TOTAL: ISSUED BY:
OFFICE