29064 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY l
i CITY OF CUPERTINO ... BUILDING-ELECTRICAL a PERMIT NO. O
BUILD64
APPLICATION/PERMIT
BUILDING DIVISION APPLICATIOPLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - 'SANITARY NO. ` 'APPLICATION SUBMITTAL DATE
_10-70
OW R' NA E: PHO 0NTRACfOR'
�,•, . N/C, CONTROL#
IRC ITECT/ENGINEER: - LIC NO: pp ❑
.. CO CT PHONE BUILDING PERMIT INFO
t❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB' M6Ciy,
waw ❑ ❑ ❑ may(
' LI NSEUCONTRpc roesof Card QTy. ELECTRIC PERMIT FEE
1 ima70 affnn that I em licensed code,tourism,of Chapter 9(wmme clog JOB DESCRIPTION'
aO ZO wth Sect an]O(IO �I��Ign 3cafthe BusmessandP f si d m liamwai, PERMIT,ISSUANCE RESIDENTIAL,'
r to full force and e t(w�
�UFU" License Class—a--.•�--Lie.# _ ❑SFDWL ❑KITCHEN REMODEL
FZzW Datea. l-I-\LComractnr APPLIANCES. m¢s .ADDITION - C1 PLUMBING RE-PIPE
ARCHITECPS DECLA y PANELS
) ElMULTI-UNIT
O OZ y 7a 1 understand my plans shall be used as Public records _ ❑STRUCTORAI.
UP TO 200 AMPS
MODIFICATION
RN�.y.("IOy LicensedPraf al - 2111-1000AMPS ❑IMPROVEMENT INTERIOR 0 CHIMNEY REPAIR.
¢a' -ajOWNFR BUILDER DECLARATION ❑BATH REMODEL/REPAIR DEMOLITION
1 h by off th t 1 pt from theContractors License Law far the OVER IIXIOAMPS
O�U fallow ,reason (Scott..]0315 B .m ss adProfession,Cade Any city or county [J LITHE
which re u res a - SIGNS ELECTRICAL
q P Ito t t Ite,improve demo)sh p y i cram -
{� m.] prom t .0 1 requiresthecant pplf hpermit t file zg d tatemeoi SPECIAL CIRCUIT/MISC." " I
d5 Neth lee dp atounu the prarvilions-cho Corrosives Lie La (Chapter9
WL' q0
(wernmenciag withSection]000)ofDivision 3ofthe BusinessuralP f .0 le)or TEMP.METER OR POLE INST. COMMFR IA
that h rapt therefrom d theba.'. f thealleged exemption.A y I t r r of El NEW BLDG/ADDITION ❑DEMOLITION
Seaton 71315 by any applicant for o permitsubjectsthe applicant to a civil penalty of POWER DEVICES ".
F'y'y nm more than five hundred dollars($500). ,- - [I TENANT El FOOD SERVICP.
6 Dl,as owner of the propeny,nr my employees with wages as thcirsole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
G will do the work.and the structure is not intended rr offered forsale(Sec.71 ,lfome, DOTTER
tim and Professions Code:The Contractor's License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES -
projohly who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
aide.If,howeveq the buil ding or improvement is sold within one year of counnelinn,the SQ.FT FLOOR AREA $/SQ.FE
owner-builder will have the burden of proving that he did not build or improve for pro-
Pro.of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to - TOTAL:
construct the'invot(Sac.7044 B nes.and P fie x Code:)The Commerce,Lt '.
ase Law does notapply t w of property who builds or p v Neutron,and QTY PLUMEINGPERMIT FEE DEC, � ��
hocontracts f hp J s 'di orat rt)licensedpnr a theContractors
L'easel PERMITISSUANCE 95
❑1a pt d 9c ,B&Per the - C�(l"
., trice Owne Data ALTER DRAIN&VENT WATER(EA) VI IsUY
VALUAT N(,J
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
,c. by off der penalty to ofCoYomoftbefollnwardeclarations:
❑Ih a,andwll maintain ociete 3700 of the sent Labor
Cocm:surehe Workers Cbmpnn DRAINS-FLOOR.ROOF,AREA,COND.
artium,
uckfas which this
forbySociete 3700 of the Luboo Code,for the pnrfnrmnnce of the STORIES TYPE CONSTRUCTION
El IIrarwhich lbie autumn issued,
on",' FIXTURES-PER TRAP- I'
❑ 1 have a will
autumn Won",',CompensationIn....narequired' 1 y Section -
3700ofN r are, theperformance
Of the workf weto this p oril is�issue�/) GAS-EA,SYSTEM-1 INC.4 OUTLETS OCC GROUP pPN.
My Work s em came IPolicy 1 '3Zr
Carrico PolicyNo. GAS EA.SYSTEM-OVP.R4(pA) .
C TI CATS( XEMPTTON FROM WORKERS' '
` COM SATION INSURANCE. - GR[gSF11NWSTRL WASTP.INTERCEPTOR '
(This section need not beaimplecia lfthe permit is future hundred dollars($10)) BUI_D.NGDWISION FEES ,
ode's.) . I I I IGREASETRAP '
I certify that in the performance of the work for which this permit is issued,l shall PLANCHECK FEE
not employ any person in any manner sn as to become suhjecunthe Woikers'Compen- SEWER-SANITARY-STORM EA,203 FP. ENERGY FEE
C) satimr Laws of California.Data - WATER HEATER WIVEM'/ELECTR
7r Applicant i GRADING FEE
tti y NOTICE TO APPLICANT:II',after making this Cenilicme of Exemption,you should WATER SYSTENPI'REATING
become smbleR to the Workers C pensat m provisions of the Labor Cnde,you must SOILS FEE
Aforthwith comply iN each Arabi, ser permit shall be deemed revoked. WATER SERVICE '
Uz C C , DING ACE NEW RESIDENTIAL PI.MB. SQ.F'I'. " PAID
V .1Ificrwt the '.ec tenet Ing for lie performance of - - - Dam Rweipt#
{lw
Now kf wic er I '' d(Se.il EEE) ld i
O Lenders Name _, TOTAL: '
Lender Add TOTAL:
yi I rrfy that a e cad heat on and state that theab information is BUILDING FEE '
O] .correct Islow t nplywth I 'ty ad counts ordimancoe and fare law,whem,to. QTY MECHANICAL PERMIT PEE
UZ building c y etion, ad hereby authorizo represen.rtrves of thisity m Int
or upon the SBI9MIC PBE
above-mentioned property for inspection purposes. "
(We)agree m save,indemnify and keep harmless the City of Cumtinoaainst PERMIT ISSUANCE -
P d ELECTRIC PEE
in ndof this Permit
which in any way accrue against said City ALTER OR ADDTO MECH. `
in caccg of to perm t, {{ - PLUMBING FEE
APPSOOD9 AND WILL COMPLY WITH,ALL NON-1 INT AIR HANDLING UNIT 10,OW CPM)
SOU MECHANICAL FEE
' • AIR HANDLING UNIT(OVER 10,000 CFM) I CONSTRUCTIONTAX.
Signa of plioanVCoa c Dem EXHAUST HOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
' Will the applicant or building occupant store cathartic hazardous material HEATING UNIT(TO 100,000 BTU)
as debuted by the Cupertino Municipal Code,Chapter 9112,and the Health and Safety -
Code,Section 25532on? - 1 HEATING UNIT(OVER 100,000 BTU)'
❑Yes ❑Na
VEN'ELATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which - '+ - Data Receipt#
emn hazard it at,communicators as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR IND) I' TU) (.
District?
- -
. ❑Yes ' - ❑No BOILER-COMP(OVER 100,000 BTU) I TOTAL'.
Ihave head the hazardous materials requirements under Chapter 6.95 of the Call- AIR CONDITIONER
forma Health•&Safety Code,Sections 25505,25533 and 25534.1 understand that if Ne - ISSUANCE DATE .
building doeinot currently have a tenant.that it is my responsibility to notify the occupant' NEWRESIDENTIAL MECH . SQ.FI'.1
ref the requirements which must he met prim to issuance area Certificate of Occupancy. 1
I
Owner or authorized agent Date TOTAL
ISSUED BY:
OFFICE