29370 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMI1 NO. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING,-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: 1 SANITARY NO. APPLICATION SUBMITTAL DATE
1//'o-&rren� �a., 3 G 0 / (!; - 3 - G
OWNER'S NAME: ' PHONE:
p} CONACTORS NAME
GP 4e SS_ VOD _)a S� �72
4as NIC CONTROL N
RCHITECT/ENGINEER: HNO
ADDRESS: ❑ -.
CONTACT PHONE BUILDING PERMIT INFO
'❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
ee Coo en 4eg 9b>r 6061 GK
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
rA 1 hereby union that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z with Section'7")of Division 3 ofthe BusinessanP .on
d Professions Cadedm license is
X00 y t PERMI'i'ISSUANCE IDENTIAL,
F in full forceandeffete.
aUl'° License Gloss Lic.N SF WL ❑PLUMBIKITCHENREMODEL
hr. Dem Convector APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Fpm ARCHITECTS DECLARATION PANELS ❑MUI-TI-UNIT []STRUCTURALy O n z I understand my plana shall he used as public records MODIFICATION
OZ-- lJP'f021q AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F� Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER exempt bantam
DECLARATION OVER 1000 AMPS ❑BATH REMODEL HPAIR ❑DEMOLITION
y d'W 1 naso affirm on I am exempt from the Contrns Co License Lew for the
N3 I' following reason.Permit
to 7HL5,Business and Prnl'essinns Cole:Any city or county SIGNS ELECTRICAL ❑OTHER
ul C, which requires issuance,permit to ptimsconnoter,alter,improve,demolish,ore.an nay swemre
yy an heisscenseprocasionto rca Phe aPPlicenP far such permit EleusigneJ armament SI'ECIAI.CIRCUITIMISC.
p. Nm he is licensed pursuanno the
provisionsofthe Contnclora License Law(Chapter9
GAO (mmmmdng whh Seninn 7t0klpd Division3nf the Business and Prnlbssions CnJe)nr TEMP.METER OR POLE INST. COMMERCIAL:
o p{ that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ZZ}W Smd,m703IS byany applicant for a permit subjects the applicant macivil penalty of POWER DEVICES TENANT ❑FOOD SERVICE
not more than five hundred dollars(E50H IMPROVEMENT
6p ❑ Los.wnerufine property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC /�
will do the work,and the structure is not intended or offered for sale(See.7014,Business % OTHER
and Professions Code:The Contractor's License Law docs not apply to an owner ofOUTLETS-SWITCHES-PIXTURES
L - property who builds or improves themon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or oBem l for NEW RESIDENTIAL ELECTR SQ PT.
sale.If.however.the building or improvement is sold within one year ofeompletinn,the SQ.IT.FLOOR AREA $/SQ.Ff.
ner-builder will have the burden of proving that he did not build or improve for pu
pop
go son)e tea, O`
F7 1,
I,esowner
wrnf the property,ore exclusively contracting with iicemed amvemorsm TOTAL: O/l �-JI
convect the project(Sec.7044,Business and Professions Code:)The Contractor's Li. -
censeLawdoesnotupplytounownerof property who but ilds or improves thereon,and QTY, PLUMBING PERMIT FEE ^� �' S
whoaontmdsfor wch projttts withacommemr(sl littnsed purs^vtuo Ne Convacmr's J
License Law. / PERMIT ISSUANCE
C]I am exempt under Sec. B&P C for this...
Owner pate
ALTER-DRAIN&VENT-WATER HA) VALUATION
/���/
WORKER'S COMP17NSAIION DECLARATION BACK FLOW PROTECT.DEVICE s(/ Q ^S 8' 7 —c 9
1 hereby ulErm under penalty of perjury one of the following declarations:
❑I have and will maintain.CenificmcofConsem to self.insure for Wedaes Compen- DRAINS-FLOOR,ROOP,AREA,GOND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workes Compensation Insurance,as required by SectionJUN 4 inn,I
W of the Labor Cade,for the Performance of the work for which thia Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work9[s GynPe to Insu9t� br and Policy M- are:
Cotner:G-dJ• L �IJ/ILTY Policy No.:�4;M GAS-EA.SYSTEM-OVER4(EA) CI(Y yr u utcll I Hk�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the Permit is for one hundred dollars ISI W) BUILDING DIVISION FEES
or less.) GREASE TRAP
Toy any tern^in performance oftbe work furwbich sPennit is isnued,ISM1aII PLANCNECK FEE aO
not employ any person in any manner �[ SEWER-SANITARY-STORM EA.2W IT.
Z seta..Laws al Da ny E]taamaFJti ct to the Workers Cnmpen- ENERGY FEE
A Y// WATER HfiATF.R WNf?NT/ELECfR
7�7 NOTICE. Pa J �y / GRADING FEE
r7h NOmae,sujctto he AN'1'.IL ufmu,shouit this Certificate the Lane,Casio.
should WATER SYSTENUTREATING
a ^ femmeh comp y the Workds C^tens or this provisions of the Imedr voko you must SOUS FEE
{il G forthwith comply with such provisions or permit shall be deemed revoked. Wpl'ER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
UO k for by that 1.111 issued(Seeconstructionlending agency fonhe performanre of Date Rceiptg
0 (" Newark for which this permit is issued(Sec.3W7,Civ.CJ
O Leader's Name TOTAL:
Lender's Address TOTAL:
fD" a 1 certify that I have read this application and state that the above information is BUILDING FE
�^ IA comet.I name to comply willing city and county Ordinances unit state laws relating m QTYMECHANICAL PERMIT FEE
U building construction.and hereby euthonm representatives of this city reenter upon the SEISMIC
above-mentioned Property for m"clian purposes. q
(We)agreemsave,indemnify and keep harmless Ne City of Cupertino egtinxt PERMIT ISSUANCE ELECTRIC � E
Habilitiesjudgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH.
in se
conquence of the granting Of this Person. PLUMBING FEE a
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'T(TD 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS. e3O
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TA 36geaW
Signature dApplicanRontorem, Data EXHAUST HOOD(WMUCD
HOUSING MITIGATI NFEC
HAZARDOUS MATERIALS DISCLOSURE
Will the a,Cu eat m future building a.Clm,am 9.12,handle haealth and Safe,, HEATING UNIT(TO I W,OIp BTU)
as defined by the Cupcnino Municipal Coda ChuP¢r 9.12,veil the Health and Safety
Coda,Section 25532(x)1 HEATING UNIT(OVER 100,000 BTU)
QYes ❑No
VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or future building ant use c ui t or devices which Date Receipt N
PP, 8^ccuP 9 Pate^ OILER-COMPLIHPOR 100,OWBTU) n e
emit hazmB
dous air contaminants as defined by the Bay Arca Air Quality Management TOTAL: aI p O a I r
Distnct7
Fly. ❑No BOILER-COMP(OVER 100.000 BTU)
I have mad The hanudous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATF.
forma Health&Safety Code,Sections 25505.25533 and 85M.1 understand that if dte NEW RESIDENTIAL MECH. SQ.En
building it. I dy have a temmt.that it is my responsibility to notify the osupant
Of
the mrnts w must be met pan,to inimare Of.Cur ificnte of Occupancy.
�y��'�"
' Ownermamhanxcd it Dam TOTAL: ISSUED BY�r -a`
OFFICE