29889 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
Mt�I'YOrCUPERTINO BUILDING-ELECTRICAL. PL'RMITNO. 29889� � �s9^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILD I) Of)p 4 SANITARY NO. APPLICATION SUBMITTAL DATE
O N HONE' NTR VR'S NAM LIC NO:
:O LD ♦I' N/C CONTROL#
ARCHITECUUNGINF.ER: LIC NO: ADDRESS: /Y, L
CO T I Ia V �ICr: ,—_ ' '� - - BUILDING PERMIT INFO
'ul y y{Apt\ Consultant Fees Paid by Applicant(Initi BLDG ELECT PLUMP MECH
laff
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I ran licensedmale,provision,of Chapte.9(eommencing JOB DESCRIPTION
O a'Z with Section 700B.11dvision 3 of the Business and ProfessionsCale,and my license is
�00 in PERMIT ISSUANCE RESIDENTIAL
full force unl effect.
Cu ❑SFDWL ❑KITCHEN REMODEL
cFg.. License Class Lic.p
-HU Dole Contract., APPLIANCES-RESIDENTIAL. DITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑ ULTI-UNIT ❑STRUCTURAL
ZOlaa l understand my plans shall be used as public retools PAN17M f1 1 i y-c MODIFICATION
O Z- UPM 200AMPS GII
Licensed Professional ❑INTERIOR El CHIMNEY REPAIR
ppa3 2(11-11X)0 AMPS ,MPR EMENT
Y 2 OWNER-BUILDER DECLARATION
yqx!$W 1 hereby affirm that I am exempt from the Contractors License Law for the OVER 1000AMPS ❑BA E12JUP�eR ❑DEMOLITION
y 3 6 F fallowing reason.(Section]031.5.Business and Professions Cale:Any city nr counry SIGNS ELECTRICAL ❑OTHER .at.( 11// 1QA�
r y 0 which requires a)crud,to cnmwct.alcor,improve,demolish,or repair any swcture d
m poor to its issuance,also requires the applicant for such petminn file a signed statement SPECIAL CIRCUIT/MISC.
y, that he is licensed pursuantto the provisions of the Contractors License Law(Chapter 9 C
a1p0 (commencing with Section 7000)of Division 3 of the Business ami Professions Cale)or TEMP.METER OR POLE INST COMMERCIAL:
1 q o C
but he is exempt therefrom mad the basis far te halleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iuCl to Section 7031.5 byenyapplicent fora pennitsuhjecta thenpplicanno a civil penalty of POWER DEVICES
zrn n ❑TENANT ❑FOODSERVICE
me Nen fire hundred Jolters ISSOB). IMPROVEMENT
1 mmwner of the prdpeny,or my employees with w�gesmtheir sole cnmpenwtion, SWIMMING POOL ELECTRIC
deasims Crde lav Cmc is nntiamnens.naw due,
no,.(Sec.1.an amel os ❑OTHER
a3 and Iinywh ons Cod e:The Ces Onem's License Luodnenernapplytolf owner of OUTLETS-SWI'1CUE5-PIXTURPS
his o ny who builds or improves ttmrcnm and who improvements
a such wad himself or through
his own however
the)corded that such ssold ore not intended or offered for NEW RESIDENTIAL EL[CTR SQ FT. �[[pppRRR
sale.,Lhnweveotheve the hunding denprovement i0m,he within n,eyemr improve output,
SQ.FT.Fl. 'P.A gISQ.fT.
owned sale.).will have the burden of proving that he did not M1uiIJ or improve for par- /E
of
as r of the pmpeng an exclusively contracting with licensed mmmnnrs m
nstnmt the pfoject,Sec.7( .Business and Pmfessimns Cale:)The Cammctore Li-
Law does ant apply m an wn r of prnpe I,who builds nr improves thereon,and QTY PLUMBING PERMIT FEE
who conwna for such projects with a commemrts)IicenseJ pursuant to the Gnmm,nor.
License Lnw. unlPERMIT ISSUANCE.
❑ Lem oaempt et Sec. ,H&PC for rennin
DALTER-DRAIN&VENT-WATER(EA) VALUATION
om
RKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Ihcreby u0 munJer penalty of perjury one of the following declarations: L
I havennd will maintain.Cenif"ate of Consent t.self inwre for Worker's Cnmpem DRAINS-FLUOR,ROOF AREA,COND. -
ton,as provided for Station 3700of the ichor Code,fs,he STORK' TYPECONSTRUCDON
p y. perfonnunec al the
irk for which Nis permit is issued. PIX'1'URES-PER TRAP
❑I have and will maintain Workers ante of the
w Lnsumncc,as require)by Section
My Wcfthe Labor ker,ConapMe,fin the Performance arnmr and Policy
lbrwhich this permit is issued. GAS-EA.SYSTEM-1 INC.)OII'fLGTS OCC.GROUD APN
Co Workers Compensation Insurance c.rzier olio Policy number ore: (��T
Camiec Policy No.: GAS-EA.SYSTEM OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASPIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUI IN DI VISION Fl?E.S
(This scenic.need not be completed if the permitis for one hundred dollars(,100) GRGASI3 TRAP
m less.) PLANCHECK FE
I cenify that in the pMormancc mf the work fnrwhich this)main is ismed,I shall
nm am to say person in an SEWER-SANI'T'ARY-STORM P.A.21X)FT. e O
p y y manner so as m become subject m the Worken'Compete ENERGY FIiF.
Znado.I.twx of Cslifomia.DateZO Applicant WATER HEATER WNENT/EL[CI'R GRADING FF.
NO'NCH TO APPLICANL If,afer making this Cenificute of Exemption,ynushmdd WATER SYSTEM/TREATING
F , become subjecuo the Worker's Compensation provisions of the Labor Ode,you must SOILS FEE
forthwith comply withsuch provisions or this permit shall be deemed revoker. WATER SERVICE
6 Q
UO
CONSTRUCTION,LENDINGng ENCYagency NEW RESIDENTIAL PLMH. SQ,FT. PAID
I hereby which
that iaaco (Sec.3nlenring agency for the lser(nrmancc of t Rec 'pith
W U the work for which this permit is issued(Sec.3097,Civ.CJ
O Lender,Name TOTAL:
{U Lenders Address T
1 crony that I have mel this application and pate that the above information is BULLI EE le
fan correct.l agree to comply with all city and county ordinances and state lows relating to QTY, MECHANICAL PERMIT FEF,
C.)Z building conaruniot,and hereby announce representatives of this city to enter upon the SEIS O
above mentioned properly fnr inspection purposes. PERMIT ISSUANCE
(We).9.to save,indemnify and keep harmless the City of Cuperlino against j ELEC R C FE
liabilities,judg..,,,costs and expenses which may many way accrue agmina said City
in cequence of the loading of this permit. ALTER OR ADD TO MECH.
omPLUMBING EE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TTO 10.000 CFM) h1ECHANI LFEE
SOURCE.REGULATIONS,
AIRHANDLING UNIT(OVER 10,000CFM) CONSTRU IONTAX
Signature of Applicant/Conmacmr Dam EXHAUST HOOD(W)DUC) HOUSING NIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant score or handle hazardous material HBAI ING ON IT('10100.1)(10 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Section 25532do? HEATING ONI'P(OVER 100,000 B'IV)
[I Yes ❑No VENTI LA'I'ION FAN(SINGLE RFSID) PAID
Will the applicant or future building occupant use equipment or devices which Date t
czmdaus air conmmiwma as defined by Ne Bay Arca Air Quality Management BOILER-COMP LIMP OR 100,001 RTU)
It! TOTAL:
[I yes No BOILER-COMP(OVER 100,0001ITU)
I have read one ham dous materialsAIR CONDITIONER ISSUANCE DATE
rtquimmcma under Chapter 6.93 of the Cali
faun B Health&Safety Cale,Sections 25505,25533 and 25534.1 understand that Base NEW RESIDENTIAL MECH. SQ.FT.
to d1ng doesnot contend,have atenant,that it is my responsibility to notify she occupant
of the mquirements which must he met prior ht issuance of a Certificate n1'Occupancy'
Owner or outhurimd agent Date Qu ISSUED BP
OFFICE