29544 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL: PER,MITNO. 2^5 ra 4
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL L�`.!1 4
BUILDING PROJF-C'1'IDENTIFICATION
ILDING ADDRESS: - SANITARY, APPLICATION SUBMITTAL DATE
gti Lt► Pia ca—�a
.HWNiii NAME:1 ) PHONE: - CONTRACTOR'S NAME: - LICNO:
' 1 f L Oi�c 0-9119 NIC. CONTROL#
UVHI C LEN ISPR - •LIC NO: ADDRESS, - El
CONTACT. - " PHONE - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Thal 1 am licensed under pa isiom of Chapter 9(commencing JOB DESCRIPTION
WOO with Section 7(NXBof Divisian3ofthe Buwinewand Professions CNmetidmyllmrmeis RESIDENTIAL:
F W O^ in full force and effect PERM ISSUANCE
¢UU License Class ' Lim.# 0 S WL '` �`9(`'ITCHF,NREMODGI.-
yQC Date Contractor _ APPLIANCES-RESIDENTIAL DDITION F' LJPNMBINGRE-PIPE
FOu, ARCHITECTS DECLARATION PANELS MULTI-UNIT El STRUCTURAL
Z O H Z I understand my plans shall be used as public iecordsMODIFICATION
OZ^� UP TO 201 AMPS /r ❑INTERIOR ❑CHIMNEY REPAIR
al Licensed Professional - - 201-IINNIAMPS IMPROVEMENT
C6L OWNEun exe.UBR DECLARATION OVIiRL(II)AMPS
IIIA AMPS ❑BATH REMODEL/REPAIR El DEMOLITION
X2.U 1 hereby.(Srm that I am exempt tram the CanuaetCo License y c Law for my
31 U following reasnv.(Section]0315;Husineas and Rvfessinns Code.Any city or county SIGNS ELECTRICAL - OTHER
Iy tL i7 which requires it permit to emonart,ala,improve,demolish,ar repair any sumentem
F"U.OS prim to its issuance.also requires Elle applicant for such Permit file a signed statement SPECIAL CIRCUITIM ISC
F�} that he is licensed pursuant o me provisions of the Conuarni License Law(Chapter 9
u1�00 (commencing with Section 00701 of Division 3 of the Business and Pmfassions Centel or .TEMP h1ErER OR POLF,INST. COMMERCIAL:
that he is exempt therefrom and the basis for the nllegul encmptimt Any vielmian of _ - El BLDG/ADDITION El DEMOLITION
Ii• Section]031.5 by any applicant for a Fennon suhjec¢the applicant to a civil lrcoally of POWER DEVICES
^mTENANT El FOOD SERVICE.
ESDnot more than live hundred dollars($51X1). IMPROVEMENT
❑Losowncnsfthe themmenum is e,introdedmihwadl far xIei(Sar.compensation. SWIMMING POOL ELECTRIC
IY F.o and dothewon%and, The mreisnoes License
not apps towino70,14, unerofness 0 ❑OTHER
aim andiwhob Code:Theoves henco Lndw Lawdoesnotapplymanownerof OUTLfiI'S-SN'ITCHF.S-PIX'IVRFS
property who builds or improves thercoq ipm who deer such work himself or through
his own however,
the
provided that such is sold w are not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sole If ev r will
building' improvement'.. Id within in y f plei n,theurs - ^ SQ.FTFLOOR RF.A $ISQ.FT.
"Ilhave th M1d fl rvi gthat hdid hot b ld p frpun
owner-builder I )
,
r of the propetty an<xd,iv ly encasing with I'censrd commentsto
c105
ons n the project(Sec.701-1.Buntness and Professions CWe:)The Comnemrs Li
cens,lawdoesnotapplymanownermfpmpenywhobuildsorimproveslhemon,and QTV PLUMBING PERMIT FEE APR p
who contracts for such projects with a contractors)licensed pursuant to the Cmc3
nra
ors - 1O(�C
License Law. ' PP,RMI'r ISSUANCE /. 1996
I am exempt under Sec. ,[I&P C for an,mason ch t o-
ALTER-DRAIN&VENT-WATER IEA)
wren L✓_. - e r I? /� VALUAT19N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /Sy \^
1 hemby affrm under penalty of pr jury one of the helices ing declensions: `--1 !y
❑I have and will maintain a Cenifcate of Concent to self-insure for Worker's Camper. DRAINS-FLOOR,ROOF,AREA,COND.,
sation,as provided for by Seaton ONE of the Labor Code,for she performance of she STORIES TYPECONSTRUCrION
work fee which lhir pcnnit is Issued. FIXTURES-PER TRAP -
❑1 have and will maintain Worker'.:Compensation Insurance,as required by Section
3701ofthe labor Code,for Ute penfomtanceafthe work for which this pentyl is issued GAS-PA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
MyWculmrs Compenothon]as...re rattier and Policy number are: _
Cartier Policy Isu: GAS-CA.SYSTEM-OVER i IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
HUILDIN (VISION RIES
(Thissection mordma be completed lithe pcnnit is Intent,hundred dnllurs($IM)
or Ievs I GREASIi'1'RAP. I'LANCHECK Pesti 2 �*
Loy any thminthe pe,faanyanothero he weak astoParsonwhichthi.a the Wrkensed,lehell SEWER-SANITARY-STORM EA.200 FT.
not employ any parsin any another so as In become auM1jttl to the Workers Compen- 13NERGY F6
zZ tonna Laws of California.oDam MATER I fiATER WIVENIYF:LECB
O Applicant GRADING E
N NOTICE.TOobject
APPLICANT:r,C umaking this C..as.,of
Exemption.,tin, d you should WATER$YSTEM/1'REATING SOILS FE
�^ became subject y the Wodreds Cams o,do n pro vsloos of he Lobar Ooda,you mull
LIQ AN
lnhwith comply wiW such provisions nr this permit Shull bedamncd revokrA. Wgq'IiN SERVICE
Q
= z CONSTRUCt[ON LENDING AGENCY NEW RESIUF.NfIALPLMN. SQ.FT. . PAID
U O IherebyalEnn that then i,vusnsweion lending agency for Performance of ¢ Recnptp
D. F' the work for which this pemdl is is,,md Sec.309"7.Civ.C.)
O U Lenders Name TOTAL:
r l31 Under',Address -
I comfy that 1 have read this application and state mat the above information is BUILDING FE 2 Is
.E".. Ta/) morrrnaI I agree ara'mopdy with all shy and county ordiaoosca and state laws rebrmg m QTY. MECHANICAL PERMIT FEE
L) Z building construction.and hereby authorize representatives of this city m enter upon the SEISM IC FEB
above-mentioned prnpeny far inspection purposes.- - PERMITISSUANCE ELECTRIC I oL
(We)agree m save,indemnify and keep harmdevs the City of Cuperino against
Iiabilities,judgmems.costs and experts,which may in any way avenue agamnst,xid City ALTER OR ADD TO MESH.
in consequence of the granting of this permit PLUMBING F.E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ' _ AIR HANDLING UNIT(to HLIpO CFSB
SOURCE REGULATIONS MECHANIC ,FEE
- AIH HANDLING UNIT OVER 10.1X10 CPM) CONSTRUCT NTAX -
SignamreofgpplicanVCanazntor Darn EXHAUST HOOD(WMUC) HOUSING MI GATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazvdous material HEATING UNIT(TO 110,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,10)BTU) -
❑Yes- Fl No PAID
. - VEN'I'ILAI ION FAN(SINGLE RCSID) Data Receipt
Will the applicant or future building occupant use equipment or devices which
r Icmit hassrdoes in cantamineem,as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 101.000 BUT
n 1.:
District? BOILER-COMP(OVER 100.(100 BTU)
Cl Yes ❑Nn
[have read the hmanlsys materials requiremcnu under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fombHealth&Sur,y CWC Seto12550525533 and255301 understandtht if the NEW RCS I DENT1AL MECH. SQ.17.
building dt currently have a tenons.that's is my re,,mit ady the pad'
of the try tremens which must be ma prior to issuance of a Certificate of Occupancy.
• n 1 ,
Owner or aathonmd agent Dam ISSUED BY:
OFFICE