29779 (2) 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 n Q
BUILDING PROJECTIDENTIFICATION
29779
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
6387 /-/Z// )r cod k
OW9Iy�1IS NAME: PHONE: CONTRACI OR'S N/.ME: LIC NO:
;Ka6ti f Ntry�/� ,tS,Z—h�/� M• �- M- Tac% NIC corrrxoL«
RCHITECT/ENGINEER: LIC NO: ADDRESS: , / U ❑
16;76, Moar��e <✓
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am liceired under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ with Section 7")of Division 3 ofthe Businessand Professions Cade,and my license is
F-(0 PERMIT ISSUANCE O RESIDENTIAL:
HIy in full force vnd eRect. G3S3S 3� 7 � ❑SFUWL ITCHEN REMODELcP�.0 License Cl s Lic.« APPLIANCES-RESIDENTIAL
fnz0. Dem ' Contmc�• TA tit rise []ADDITIONPLUMBING RE-PIPE
Fly ARCHITECTS DECLARATION PANELS [I MULTI-UNIT ❑STRUCTURAL
z O n., 1 understand my plans shall be used as public records MODIFICATION
Oz—pp UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
g�45 i Licensed l'nifeasional 201-Ifa10AMPS IMPROVEMENT
4'1277 OWNER-BUILDER aUILpt from
DE CLARATION OVER 1000AMPS [-]BATH RF.MODEVREPAIR ❑DFMOLITION
LiLa a 1 heathy affirm that 1 1. exempt from the Csdom,C s License Law for the
>d 3 d U Mowing reason,(Section 701L5,Business and Professions Cale:Any city or ceumy SIGNS ELECTRICAL []OTHER
YY1I LLO Which requites issuance.permit so re cordae,aper,improve,h permsR or repair any nrvcmrc
p athe stits cndpu uanitoirepmvpplicanfthet for Cohpermis E.icele asigw(Chned tement SPECIAL CIRCUITIMISC.
of thatro islicn with
7")
the provisionsofthe Contactors License Law(Chapter9
a gnmcis.cn,o mixioo.and)of Division Sof the Rumness enJ Professions Cook)or TBMI'.MI?'E'ER OII POLE INST. COMMERCIAL,
d a o�L�'+i he is exempt therefrom and the basin for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m m Section 7011.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
rot more than Eve hundred Jnll-n($5(10). ❑TENANT ❑FOODSERVICE;
C ❑1,ne owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will de the work,and the swaurt m not intended proffered f...le(Sec.7044,Business ❑OTHER
add Professions Code:no Contractor's License Law does not apply to an owner of '87 OUTLETS-SWITCHES-FIXTURES ,
property who builds or improves human.end who does such work him.)(or through
his own employees,provided that such improvenienu am not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ.FT FLOOR AREA LSQ.FT.
owner-builder will have the burden ofproving that he did not build or improve for pun
v L
peso of sale J,
❑1,as r of,be pmpeny,am exclusively commands with licensed contractors to TOTAL: SII
commuctthe pmjcm(Sec.74«r4,Business and Professions CMc:)The Contractor's U. q
cense Law dson not apply to an owner of property who builds or improves antenna and QTY. PLUMBING PERMIT FEE APR 19 1996
who connects for such projects with a contractors)licensed Pursuant w the Contractors
License Law. PERMIT ISSUANCE
I am exempt under Sec. .B&P C for this reason I�IIi Ur Lvi-LFaI It':�
Owner Data ALTlilt-DRAIN&VENT-WA'1'I?R(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under pcnuhy of perjury one critic following declarations:
I have and will maintain a Certificate of Consent to self-insure for Wprkcrs Compere- DRAINS-FLOOR.ROOF,AREA,COND, 9TORIF_S TYPE CONSTRUCTION
dation,as provided for by Section 37W of the Lain Cale,far the performanceof the
work fur which Nis permit is issued. FIXTURES-PERTRAP 8 D
bd I have and will maintain Workers Compensation Insurance,as required by Section
370 of the hard,One.far the performance of the work for which this panni,is issued GAS-FA.S YSTUM.I INC.4 OUTLETS OCC.GROUP APN
M WnrkeJJ's Cot�J�endation Ins-mJce carrier end Policynum G
Cam'cr.0'TLL/( FLI/ / Policy No.: d80 3 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION II'.
( s section need not be completed HOW perndt Is for one hundred dollars($1 W] FS'
nr
he'.)(Ons GREASETRAP PIANCHECK FEE
I certify that in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.20X1 PT.
not amploy any person in any manner to as to become subject m the Wmkers'Compere- fiNERGY PEE
0 ,`L unianlawsuf Califnmiv.Dem WATER HHATER WNENT/L'LECIR
O, Applicant GRADING FEE
4 NOT ICE TO APPLICANT:11 aper matin ,his Cenifcate of Excant hould
ti g pian,you s WATER SYSTFMRREATING SOILS FEE
(-' become subjccn m the Workers Compamatinn provisions of the labor Code,you must
forthwith comply with such provisiar,or, this crant shall lie decided revoked. WATER SERVICE
y O.
z• CONSTRUCTION LENDING
erdh'aAGENCY NEW RESIDE?NTIAI.PLMO. SQ.FT. PAID Dam Receipt«
U work
wh.fOrmthat there issued(m.309 ,Ch,agency lnrthc performance.f
11. the work for which this permit is issued(Sec.309],Civ.CJ
Q U Lender's Name 3. TOTAL:
Lender',Atldrtxs TOTAL:
G 1 many that I have read this application and state than the shove information is BUILDING FEE
h a.Wwt.I.,me m comply withal1 city vad county ordinances and were laws reining to QTY, MECHANICAL PERMIT FEE
U Z bulldi......Friction,antl hereby maden.re,evemativenof Nln ci,ytn emerupe.the SEISMIC HE
,hove-mentioned properly far inspection purposes. PERMIT ISSUANCE?
(We)agree to save,indemnify and keep handless the City of Cupertino against ELECTRIC HE
Iiabilities,judgnients,costs and expenses which may in anywayeccme agvinstsaid City ALTERORADDTOMECIL ,
in consequence or the Starting of this permit. PLUMBING FEE 0
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To 10,(100 CFM) MECHANICAL HE '
SOURCHRF UTAGONS.
c,t ` 'f ,/-/ �, AIR 11ANOLING UNIT(OVER IQ(IfIO CFM) CONSTRUCDONTAX
Signature of Applicant/Cnmracmr /, 't Dam 17XHAUST HOOD(W/DUCT) HOUSING MITIGATION FEU
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building cacupuni store or handle haamdous material IMATING UNIT TO 100,000 BTIH
us defined by the Cupertino Municipal Code,Chapter 9.12,add the Health and Safety
Code,Section 25532(a1? HEATING UNIT(OVER 111,000 B'N)
❑Yes E]No
VENTILATION PAN(SINGLE MID) � PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt«
.nit hamrdoas it cnnlaminema as defined by the Bay Are.Air Quality Management BOILER-COMP(3HP OR W,IXO BTU)
District? BOILER-COMP(OVER 100,000 BTU) TOTAL:
❑Pos [-I No
I have read the hmsndnus materials WiFitemenu under Chapter 6,95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
form.Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that irthe NEW RPSIDFIJTIAL MUCH. SQ.ET.
huthe dedoesnon.which
have amnadl Nat.ismy caresof.0 mbri.otheoccupant
of the rtquiremm�u which must he tan prior in issuance ofa Celty so notify of Occupancy. yW/_
Owner or muddied agent Dare TOTAL: /� ISSUED BY:
OFFICE
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