29606 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES=USE EIALL POINT PEN ONLY » „
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CITY OF CUPERTINO V W BUILDING-ELECTRICAL. 1 PERh11T NO '29606
BUILDING DIVISION APPLICATION/PERMIT PLUMRINC-NF.CHANICAI:
BUILDING PROJECT IDENTIFICATION I '`
BUILDING/AJ E'f.'' au . SANITARY NO' - APPLICATION SUBMITTAL DATE
IOW NA PHONI 01jS'NANIE -
LIC NO �^ '•`-, t' •'
„_''YNiMnc"` (//`/J(/,�wol-,^_'y��l NIC•,'. ' CONTROL#
•ARCHITEcur,NGINFER ;- LIC NO' • ADDRESS '❑ �', ` '
CONTACT I PHONE' ',• '„ '��� �' � '
BUILDING PERMIT INFO '
- . " Consultant Fees Paid by Applicant Unnum) I ,BLDG IELECT MECH '
s - a ❑ ❑ ❑
' LICENSED CONTRACTOR'S DECLARATION QTY 'ELECTRIC PERMIT .FEE
JOB DESC
1 hmehy affirm that I am Iieaased aaaer pmasmas or enapier 91-amormaag - ION
I "Z with Section IlHlm of Div iaio 3ufib BUSUress anu Prolcssi' Code,and my leans,is RESIDENTIAL;
O0 mfull lnrco and few PERMIT ISSUANCE
C V 1-:came Class Lic.# � �0/ - ❑SFDWL ❑KITCHEN REMODEL
6Z U ,.. ) 'AF'PLIANCF.S-RF.SIDLNTIAI. �� DADDITION UMBING RE-PIP&
ya0. Data Cmtmcu,r
ARCHITEc'fS DECLARATION _ ❑M1ILILTI-UNIT STRUCTURAL
I unJenwnd my plan—hull humiclopuhhc records PANELS - MODIFICATION
n LP TO )O AMPS ID INTERIOR El CHIMNEY REPAIR
941W Licensed Pmfea,onA. - ' . ��FI '201-1000AMPS IMPROVEMENT '
,y 2 OWNER BUILDER DECLARATION
yyx CC44 CYLI a 1 hereby alfmn that I am xcrom from the Contractor's L.eme Law Ina the OVER 1000AMPS ❑BATH REA10DEUREPAIR 0 DEMOLITION
W O6 U following to...o (Section 70315.Busmess and Professions Code,Any aty or county.( SIGNS ELECTRICAL, w. ❑OTHER `
F. W y which requires a permit to consumer,alter,improve;demolish,or repair any structure f 0
�Q, parr to its owanec'.1'o requires meappleaat for such permit to file a Vaned statement ' ,SPECIAL CIRCIII'fIh11SC. ,
P+ that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter 9
�� (commencing with Section 7000)of Division 3 of the Bmmuvs and Professions Code)or TEMP.MF.TF.R Olt POLE TEST.- '1••' COMMERCIAL: � " '+
d o y that he is exempt therefrom and the basis for the alleged exempuoit Any viola of , El NEW BLDG/ADDITION [I DEMOLITION
`
-ym Sechas70311 ar amp applicant Leapenall subjan dm applicant m ecno penalty of 'POWER DEVICES' •s , -1 TENANT ' OFOOD SERVICE
FZY not more than five hundred dollars t$5001, a IMPROVEMENT
QOl,as owner of the property,ormy employees with wages as their side comperoomn, SWPsfMING POOL ELECTRIC I
will do the work,and the structure is nectmtended mothered for sale(See 7041,Business' _ ❑OTHER
3^ and Professions Cade The Contractor's License Law does ass ,,Iy ai an owner of OUTLETS=SIX)'TCHE$-FIX'fURFS /
.. property who hnilds at improves thereon,and who does such work himself dr Nrotigh
his own employees,pro.Wed the,such improvements are not intended or offered far NEW RESIDENTIAL LLECTR SO Ff
sale If,however the building mnmprovemem is sold within one yemol motdclion,the -SQ.FT FLOOR AREA $ISQ FT.
er-builder will have the burden of,proving that he did not build or.......a for pur-, •�
w pre`f sale)' " _
❑ I,as owner of the prolwny,am exclusively comrdcmng with hcen ad fou rdcuin ni - TOTAL:( •
onstrucuhe protect f Sec 7(}00,Bwmms and Poirnswin Cade:I The Conimelor's l.t- I it•'•r•
c rase Law dnas ram apply n,an nssn,r of pnspony who h ll,i imp uses Imo on,and QTY. PLUMBING PERMIT FE& r
:t�. who aonvaias farsuch Pnsjens with o cnmractonsl licensed purivanuo the Contraction's
L¢ansc Law.' PERMIT ISSUANCE
❑ I am exempt under Sec.' ,B&P C for this reaso n _ t
AI.' R7 DRAIN&VENT- (E WATER A '
,, / VALUATION -
' Owner n,.. .... - -- V(/ 1
p, WORKF.RSCOMPE,crRr, mvfthc RATION . BACK PLOW PROTECT.DEVICE ', s•�99�con(hereby opiate under penaltyof of Coyeneafihefallowmg dedara'Cram
•❑-1 have and will maintain aCennicate nl Consent to far Workers Compcn- DRAINS-FLOOR,ROOF, COND s . STORIES =TYPE CONSTRUCTION
arum,-as Founded for by Sectmn 37W of the Lab oa Code,for the Performance ofd IlOzs-
huh this cetmuns issied its d° NIX'1'URES-PER'fRAP
w 1 have and will maintain Worker's Compensation Insurance,as reyuimd by Semten c - s
3700oftlw l-dbor Ccaddeee;f..the perfnrmancenf mexnrA faVrVwhmh this permit is issued GAS-LA.SYSTEh1-I INC:40UTLETS 'OCC GROUP APN '+
My CanWrr(S.2-.,L:TIPIC;nr EXEM, pal my No U //Z� GAS-EA..SYSTEM-OVF.RJfEAI A
s 7 COMPENSATION INSURANCE - f GREASF./INDUSTkL WASTE INTFRCF.PTOR 'r This section need not be completed it the permits torone but food dollars M 00)s BVILUINO DIVISION FEES +
or lenn.l - - ,.f '. GRGSE TRAP
� PLANCHECK PEE -
Icerirfythmmihepernorme rceofihe work forwhehthrs cer"mnnissued,ISha1P ' SEWER-SANITARY-STORM BA 200 UP
not employ y person in any manner r)pti`to lygvnµsubject to me Workers'Compan- - ENERGY FEE
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Z. canon La f Ittuma.LLJm-3-� / b WATER I]BATE R_W/VENT/ELECfR a _
z O Applicant �(�Y-3�-5 GRADING FEE
iti h
NOTICE 10 APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMeFREATING v +
became subject m me Worker's Condwrotmn prosriina,of the Lahnr Code )ou most SOILS FEE
forthwith comply wam+um trust mms ar tars perms shall betteemedevised. ', WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY p' NEW RBSIUEN'UAL PLh1B SQ Cr' •'�t'� (PAID
U 0 . I hereby affirm that there is a consmimmn lending agency for the performanm of Date Receipt#
V. F" the work for which this permit is issued(See 3097,Civ_C.1 + s
Lenders Nam= .,v ' TO
• W Lender's Addm,s ITOil,
I candy that 1 have read this uppheatim and state that the'bmc mf siren ii u - BUILDING FEE
IA correct 1 agree to comply with diary and county oWmarsef'oul xtme law;renting m QTY, 'MECHANICAL PERMIT FEE
U budding construction,and heiehy nuthanze reprosenbiuvesorthis ufly In enterupon the SEISMIC FEE - -
above-mentioned progeny for inspection purposes PERMIT ISSUANCE _
(We)agree to save,indemnify and keep harmless the Cry of Cupertino agnm=, ' ° - ELECTRIC FEE s
handnres,ludgments,contnand expert>eawhichmaymanyway accrue agamstsard City ALTER OR ADD TUMECH. PLUMBINGFEE ~ ''`
APPLICA UNDERSTANDS ANU WILL COMPLY•WITH ALL NON-POENT, AIR HANDLING UNIT TO 10.000 CPA1) Y h1ECHANICAL FEE
SOU - ECULATI
r .. 7 �S�/ AIR HANDLING UNIT LOVER I(I,IKNI CFMI ^ CONSTRUCTIONTAX " :e
� Srgnalure nfgpphcanCnnnaclor" r Date+ EXHAUST HOUD(WIDUCI
14AZARDOUS MATERIALS DISCLOSURE. HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT fT0160,000 BTU) ,
as defraud by the Cuperlmo Muniaipol Code,Chapter q 12,and the Health mid Safety
ct +
' Code,Sea 25532(aY' - ^," - e ' HEATING UNIT 100,00sh BTU) '
0Yet ❑No,"r' . ,t r
VENTILATION PAN SINGLE RESID)' .• (PAID Data Receipt# s {, '
Will the eppinam+nr fuure bmldm,o,rt ,,lm usee equipmm�t m devices which - 'r
•emit humrdoris air conmminants as defined by the Bay Area Air QuWry M1fanugemem BOIL-LR-COhIP,(?HP OR IUO,IXIII BTU(
District, TAL 1.
i ❑Yen' ❑No r BOILER-COST(OVER 100,0000TU) I \ �y
1 have read the hazardous materials regwrements under Chapter b 95 of me Cali'' AIR CONDITIONER
ISSUANCE DATE ATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL NEED SQ PT, ,
bmldingdoes not currently bavcammam,that ris my responnibllny to notify the occnpam
mile iequnemenss whmhmou be met poor m owanw surd Cenificale of Oreupnncy v '
f
Oseerorauthonzed agent Data + •, 0 + TOTAL( (ISSUED BY -
'» OFFICE '
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