29505 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LEC7TRICAL PERMIT NO.
BUILDING DIVISION APPI,ICATION/PERMIT PLUMBING-MECHANICAL 29505 C O C
BUILDING PROJECT'IDENTIFICATION G J J
9UILUIN ,A RESS SANITARY NO. AN'LICATION SUBMITTAL DAT L'
OWNE N PHON^ CO C[OES NAME: LIC NO:
w P N/C CONTROh a
A111111111111,1
\RCHITECr/ENGINEER: LIC NO: ADDRESS: [� ❑
CONTACT. PHONE: BUILDING PERMIT INFO
El�,pqr 0972 ❑ Consultant Fees Paid by Applicant(Initial) nO ELES. PLUMBM
LICENSED CONTRAC OR'S DECLARATION QTY ELECTRIC PERMIT FEE --�I�-
I hereby affirm than 1 am ucen.ed under provisions of chapter 9(commencing JOB DESCRIPTION
C=Z with Section 3 of Ne Business and ProfessionsCade.and my license is RESIDENTIAL'
Fly n'full force and effect. PERMIT ISSUANCE ❑SFUWL ❑KITCHEN REMODEL.
�UU, IamocC,.,a Lt... APPLIANCES-RESIDENTIAL. ❑AUDI'T'ION [I PLUMBING RF,-PIPE
rn Z a Dam Con.mmor
b.,Dh ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z OVa Z L understand my phonation M used as public meads MODIFICATION
OZ=p UPT0200AMP5 ❑INTERIOR 11 CHIMNEY REPAIR
H-anFanF-a Licensed Professional 2111-IM)AMPS IMPROVEMENT
OWNGm exemDI3RDECIARATION OVER INSAMPS ❑BAI'1 I REMODEUREPAIR ]DEMOLITION
I hereby affirm o n1 11. exempt Irons the Contractor's r'r Licence Law lin the
aq5 6 U following reason.(Stenion]8715,Business and Professions Code:Any city o,county SIGNS ELECTRICAL ❑OTHEH
u+3
LLI which"Nims a permit to construct.alter,improve,demolish,or repair any swnure
F'4'�� prior to its issuance.atm requires the applicant for such permit m file a signed statement SPECIAL CIRCUIT/MISE.
GE Hythat he is licensed pursuant an the previsions ofnc�Contractor's License Law(Chapter 9
(commencing with Section YlgNB of Division 3,,l'the Business and Professions Calc)or TETER EMP MOR POLE INST. COMMERCIAL'
Hoo y e y Ihm he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NBW BLDG/ADDITION ❑DEMOLITION
tlXlI a,iY• Section 903 IS by any applicant fora permit subjects theapplicam m a civil malty of POWER DEVICES ❑TENANT ❑['001)SERVICE
not mom than five hundred dollars($501). IMPROVEMENT
ISD (] 1,ex invorof the property.or my employees with wages as their sale compensation. SWIMMING POOL ELECTRIC ❑OTHER
p, will do the work.and the structure is not intended aroRered for sale(Sec.1034,Business
m
ou and Professions Code The Contractor's Licenm Law docs out apply to an owner of OUT'LETS-SWI"[CHIPS-FIX TURES
property who builds or improves thereon,and who docs such work himself or through
his we employees,provided that such improvements sm not intended or offered Tot NEW RESIDIP- IAL ELF.CfR SQ PL
sale.If,however,the building or improvement is.sold within tete year of completion.Nc SQ.FR FLUOR AREA $/SQ.IT.
overser-budker will have the burden of proving that M did not build or improve for put-
peae of tele.).
❑1,as owner of Ne pm,f,,ata enchvi vel,um ostria,with licensed contractors to p�
construct the Fancier(See.]W4,Business and Professions Crate:)The Commct,,r's Lt. UIY
mase law does not apply to an owner of property who builds,,,improves(hereon.end QTY. PLUMBING PERMIT FEE 2 U 1996
who contract-for such projects with a commuters)licensed pumuantto Be Contractor's
License law. PERMIT ISSUANCE .fill j 1J, I
I am exempt under Sec. .B&P C for this mown U(�m r 111 Lk/
ALTER-DRAIN&VENT-WATER(EA) VALIDATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
1 hereby a[[rem We,Pewlny of perjury one of the following dcelamlums: -
❑ I havered will maintain a Certificate ofCorLmm to self-inrvm for Worker's Court DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sabot,as provided for by Section 31W of the Lbot Code,for the Perfonnanm of the
work for which this Perini[is issued. FIXTURES-1.17R TRAP
Fl 1 have and will maintain Workers Compensation Insurance,m requirat by Section
3100 ofthe��qq��..d,3 [he crfoman of the work few
which this Pertain is is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My WCimiake,
kelaboPpene tiYn l ��b P�licy No.y/V�S T^ZJ [. GAS-EA.SYSTEM-OVER 4IRA)
4 CERTIFICATE OF EXE T'ION FROM WORKERS' CREASF/INDIISTRL WASTE INTERCEPTORCOMPENSATION INSURANCEBUILDING DIVISION FEES
(Thixsection need net M:completalif Nepctmi[isfornncbundmddollmx(51(U) GREASETRAP
or less) PLANCHP.CK HE
I certify that in Ne afforanarcraf[be work for which this permit is teased,lshall SEWER-SANITARY-STORM EA.200 FT.
Pe
not employ any rson in any manner m ser to become subject m the Workers Counter- ENERGY PEE
zZ cation Taws of California.Date WATER HEATER WNENT/ELECI'H
Q Applicant GRADING PIPE
y NOTICE TO APPLICANT.If,after making this Certificate of lixcmption,you should WATER SYSTENU TREATING
h; become subject to the Workers Compensation Provisions of Ne labor Code,you most SOILS hili
foMwirh comply with such pavisi,,m r Nis permit shall be dccmad revoked. WATER SERVICE
Q
=) z CONSTRUCTION NIiW RESIDENTIAL PLMB. SQ,IT. PAID Date Receipt#
UO k for
rwhich Bo Nun Nemisaed(SecW. .uJilending agency lin the perfnrmnnee of
F-' Ne work for which Nis permit is issued(Sec.31W1.Civ.CJ
TOTAL-'
U Leeders Address 1i
fy I certify that 1 have real this applicant-and state that the above information is BUILDING FEE
f/1
comet,I ngrec to comply with all city and county ordinances and state laws relaning to QTY. MECHANICAL PERMIT FEE
U 7 building Construe[ion.and hereby nation,represealansc-lthis eity to enter open the SEISMICITY
above-meati,, try for irepeetion pmPces. PERMIT ISSUANCE
egret[ sa ,inY-�Z,
harmless Nie Cliof Cu,mh o.g.in. ELECTRIC ITS ll yy
liabil' es.judgn¢ ¢anwyin any w.y aecme against sail CityALTLRORAUUTOMECH. PLUMBING FEE9ncc Ne"anninAPPLICA ' NDER TANCOMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO I(k000CPM) MECHANICAL FEE lr �a
SOURCE 'GU AT NS.
AIR HANDLING UNIT(OVER 10SM CFM) CONSTRUCTIONTAX
Signaw of AppB a.VCmm�mbn Date EXHAUST'HWD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or futons building mcuupum store or handle haxenhoomumnal BEATING UNIT(To IW.000 BIT)
as defined by the Cupcnino Municipal Cole,Chapter 9.12,and the Health and Safety
Code,Section 25532(m 1 HEATING ONE(OVER 100.000 BTU)
C]Yes No VFMILATIONIAN(SINGLE RESID) PAID
WSII rhea applicant or turn buildin weeper use equipment or devices which Dae Reccipn a
PP B he
aAirQ BOILER-COMPCHPOR 100,00OBTU)
emir harmdous air nonmmiwnls sea def noJ.hy the Bay Area Air Quality Management 'I'OTAI.
Dr°not! BOILF,R-COMP(OVER Ig1,rYJp BTU)
❑Yes ❑No `.,.
I have read Ne ltvarNmc materials mi,iremenra under Chapter 6.95 of Ne Cali- AIRCONDD'IONEH r_6T ISSU E
f rada Health&Safety Cole,Sections 255(15,25533 and 25534.I undermaod that if the Nli W RESIDENTIAL MECH. SQ.FT.
building does not cumcn0y has.a moans,Nm it Is my ars tr mality to notify the¢cmpam
of the mquirententa which ons,theme,prior It,nwaaecala Certificate of 3ce.,ancy.
Owner maatborieeA agent Date (j[/ ISSUED BY:
OFFICE