29498 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 2 9 p ^8
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L 4MJ
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
O NER'S NAME: PII(yNE: ONTRACTOR'S NAME? f ITC NO6
'.
•� mea Il
-
NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO'. ❑pRfaSS: - ❑
iI S \
CONTACT. PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG Ehi PLUMB MECH
LICENSE)CONTRACTORS DECLARATION y. ELECTRIC PERMIT FEE
I Hereby affirm that I not firenxm nyder provisions of chapter 9(.ammemriitg Q JOB DE CRIPTION
cOat with Section 7")of Division J ofthe Brito and prdessionx Code,an I licameis PERM]TISSUANCE
00 wi RESIDENTIAL-
,v, and Tec �jn^#-`//
U / igye ❑SFDWL ❑KITCHEN RGMODEI.
aUzV Licem CI Contractor
APPLIANCES�Q� Dem Contrec�. ❑ADDITION El PLUMBING RE-PIPE
n an�' ARCHITECTS DECLARATION - IQMULTI-UNIT ❑STRUCTURAL
Z O PANELS I unrsta
dend my pions shall be usev d public records MODIFICATION
OZ O UPT0203 AMPS [I INTERIOR ❑CHIMNEY REPAIR
�t3P',W Licensed Professional 291-IMAMPS IMPROVEMENT
�pd OWNER-BUILDER m he Ci mete OVER 1000 AMPS ❑BATH RFMODEIJREPAIR O DEMOLITION
y fY 1 herby nfflnn that I oat exempt from me Cnnlmmnr's License Law for the
x 3 d U following reason(Section)8115,Buninws.nil Professions Cnde:Any city nr coumY SIGNS ELECTRICAL OTHER
Y7 O which mquims a permit to construct,alter,improve,demolish,or repair any structure p D1 ("'
1"i-- priormiIs isnuance,also requires theapplicnnt Torment per mit m file.ngned statement SPECIAL CIRCUIT/MISC.
Ek-
that he is licensed pursuant m the provisions ofthe Contractors License Ww(Chapmr9 AkG 1 (�
CLOG (commencing with Section 70W)of Diviumi3ofthe Business and Professions Code)or TEMP.MED_-"R OR POLE INST. COMMERCIAL:
G.6 M K that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a perm subjects the applicant to a civil Penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
} not mom Nan five hundred dollars($500).
< I.ax owner 0Cthe norm IMPROVEMENT
O ❑ trope Y. my with For
(See.
compensation. SWIMMING WIOI.ELECTRIC
will Professions
r Newons andthe he Comment's
o cIsnoti Livens arowdoffiered farsalepply.oan owner
C:1 OTHER
D. and ay who holds
or Therm.therea License Law firmanotapplymunowneral' OUTLETS-SWITCHI3S-FIXTURES
his own who builds or improves thereon,and who fines such work himself or through
his awn employees,bc building
that such mentis old within um nae intended a offered for NEW RCSIDFiNTIAI.ELECITt Q il'.
sale.ILhowevegllhave the buren ofpementisat heddaneild or improve
forthe SQ.FL FLUOR AR &SQ.Ff.
owner builder will have the burden of proving that he did not build or improve for purEl-
0 1 of nate.).
I,as owner of ct property,704 ,Business exdusi elysaid mmtenaing with licensed namedoo,a i, )TAI M
ase Lo the project s not pply 71114,wneoand property
is ho bus Code:)The Commcmrs Li- p
cense Lvwdceor such projeto ts ithaofpuch,h wcenseddsorimproves Combarren,and QTY. PLUMBING PERMIT
W
Liwho nwuums for such projects wish a conuunar(s)licensed pursuum m The Comnsuv's
License Law. PERMIT ISSUANCE
❑Lem exempt under Sec. ,9&PCfor chis reason
Owner UO ALTER-DRAIN&VENT-WATER(E1) //,, VALOAlli
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE VH• LUt-,I hereby affirm under penalty ofperjury one of Nr following declarations: CnII
I have and will maintain a CeuificateofCommen m sdf insum for Wmkers Compcn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES PE CONSTRUCT ION
sation,as provided for by Section 37W of the Labor Cottle,for the Performance of the
work for which Nis permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Misnomer,as required by Section
3 of the Lema-Cade.far the performanceof the work for which this permit islssued, GAS-EA.SYSTEM.1 INC.40UTLETS OCC.GROUP APN
My Work 's Com matinn rand Policyyyinae `.�
Comer: ,O�_'t_Policy Nn.'��[[b ') oC_. GAS-EA.SYSTHM-OVER 4(EA) '
CE TIITCATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRLWASTEINTERCF.PTOR
(This section read not No completed if.e permit is for one hundred dollars 0S 101 BUILDING DIVISION FEES
re lay.) GREASE TRAP PLANCHECK FEE
I certifyehat in the Performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.100 Ff.
not employ any person in any nunner so as to become subject to the Wmkea Camper- ENERGY FTE
`Z., cation Laws Of CrIaonmo Data
WATER HEATER WNCNT/F.LECTR
O Atplicant GRADING FEE
iNOTICE TO APPLICANT;If,after making Nis Certificate of Exemption,you should WATER SYSTEM/TREATING
abecome subject et,the Worker's Compensation provisions of the Labor Code,you nest SOILS FEE
W
forthwith comply with such provisions or This permit shall be deemed revoked. WATERSERVICE
Q
CONSTRUCTION NEW RESIDENTIAL PCMB. SQ.FT. PAID
UO
I hereby Bich this that there issuedSac.30 lending agency for The Performance of Data Receipt#
L4 E+ the work far which this tannic is issued(Sec.J397,Civ.C.7
Lenders Name TOTAL:
CL. Lender s Address TOTAL:
ly 1 certify that 1 have read,his application and sone and the above iofarmndnn 6' BUILDING Fl3E
W correct,I agree memody with all city and county ordinances and state laws relating to QTY. M17CHANICAL PERMIT FEE
U Z building eonswnion.and hereby authorize representatives afthis city to enter upon the SEISMIC FEE
above-mentioned property far inspection purposes. PERMIT ISSUANCE
(We)is me m save,indemnify and keep hatless the City of Cupertino.,.Inst ELECTRIC FEE
liabilities,judgments,msn.nd expenses which may in any wayaceme against said City ALTER OR ADD TO MECH.
in conxquence of the,Bring of,hi, arm PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- OINT AIR HANDLING UNIT TO TO,.CFM)
S URCE REGULATIONS .MECHANICAL FEE
G ((�'7 AIR HANDLING UNIT(OVER 13,(199 CFM) CONSTRUCTION TAX
ignm e f pile Von actor ate EXHAUST HOOD(W/DUCT)
AZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Willm plicam or future building mention store no handle Notorious material HEATING UNIT(TO 100.000 BTU)
m defined by a LLpeNno Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255320x)? HEATING UNIT(OVER[Oh"BTU)
C]Year ❑No VENTILATION PAN(SINGLE RFS ID) PAID
Will the applicant nr future building occupant use equipment or devices which Date Receipt#
is pp g pa Area
Qu BOILER-COME'(3HP OR 100,003 BTU)
limit District? us air contaminants as defined by the Bay Arca Air Quality Management TOTAL'
Distric'[
'I]Yes; [7 No BOILER-COMP(OVER 100,001)BTU)
I have read the Warders materials1�6/�MOIN
regoirtmenu under Chapter 6.95 of be Cali. AIR CONDITIONER W 1 3 "s•��+s ISSUANCE DATE
forma Health&Safety Crile,Sections 8595.8533 and 75534.1 understand That if the NEW RESIDENTIAL MECH. SQ.Fr
building does.1 anomaly have a mmmt that it is my resptmvbility to notify The occupant
of the rryuirements which must he me,prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE