29655 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING=MECHANICAL 29655 9J J C C C
BUILDING PROJECT IDENTIFICATION v
1LDINGADDRESS: , SANITARY NO. APPLICATION SUBMITTAL DATE
/o 0o /V &*VEY Ave Gu ,D �-
��` PypNE: �� C TRA IIIN a LICNO: �
J 3 N/C CONTROL#
AR IITBCfIENGI B -�� LIC,NO ADDR�6F50 C. L UY sC ❑
CONTACC /YJ-/ry/ ONE: ,J
BUILDING PERMIT INFO
M,�� , Gt (4_1�L w— (j�� ❑ Consultant Fees'Paid by Applicant In B GEEC� PLUMB MECx
JC
G / jJ /Y� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby affirm that am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�QO with Sermon]000)of Division 3.f the Business and Prnfessinns Code,and mylicense is - RESIDENTIAL,
F in full farce and eIT 0 PERMIT ISSUANCE.
�UV License Cla - Lic.# v 6 7 ❑SFDV/L ❑KITCHEN REMODEL
❑ADDITION [I PLUMBING RE-PIPEy7il Dem CammAPPLIANCES-RESIDENTIAL
r ARCHITECESDCOW
C<AS ❑MULTI-UNIT ❑STRUCTURAL
Z 1.adermand my plans,Fall be used xs Polluter ords PANELS
O z-- MODIFICATION
[=! Licensed PmfwUPTO 200 AMPS
smnx] . ❑INTERIOR ❑CHIMNEY REPAIR
Lq° OWNER-BUILDER DECLARATION 201-IOWAMPS IMPROVEMENT
1 hereby affirm that I am exempt from the Contractor's Licence Law for the oVLR It](1(IAMPS El BATH REMODELREPAIR ❑DEMOLITION
06 U following reason.(Section]0315,Business and Professions Code:Any city or coumy ❑OTHER
3 0.
SIGNS ELECTRICAL
rn which requires a permit t0 construct,alter,improve,demolish,.r repair any structure
k+� t prior m its issoxncgalso requires theapplicam for such permit to rile a signed statement
.J SPECIAL CIRCUIT/MISC.
ii that he is licensed pumuannothe provisions of the Contractor's License Law(Chapter
DI 00 (commencing with Section]OW)of Division 3ofthe Busiues and Professions Code)nr TEMP.METER'OR POLE INST
d c that he is exempt therefrom and the basis fm the alleged exemption.Any violation of
-"„� Section 7031 5 b an El NEW BLDG/ADDITION [I DEMOLITION
m y ridded catrs($50tmit subjec¢@e applicxnno.civil penalty of POWER DEVICES
Fz p. t more than five hundre4 dollars($500). ❑TENANT ❑FOOD SERVICE
^570 ❑Lasoweer.finepnsperty.or my employees with wagesas their sole compensation, SWIMMING POOL ELECTRICIMPROVEMENT
tY ESpSp++ will do the work,and thearecmre is not intendedoroffered forsale(Sec.J044,Business I 0TH R
aad Professions Cade:The Comments',License Law does not apply to an owner of UTLETS-SWITCHES-FIXTURES
�e
-' property who builds or improves thereon,and who does such work himself or through 01,
hisawn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale
.IL however,the building or improvement is sold within one year of compleai.nthe � 'SQ, .00RAREA $/SQ.Fr.
owner-builder will have the burden of proving that he did not build or improve for par.
, pose c f sada).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.](004,Business and Professions Code)The Contractor's Li-
cense Law does not apply to an ovarwrodpomerty who builds or improves thereon,and
i-nseLawdoesnotapplytoxnownerofpfoenywhobuildsorimprovesthereon,and QTY. PLUMBING PERMIT FE
who ontacafarsuch projectswim acontencomb)licensedpursuant toth.Contractors
License Law.
❑1 am exempt under Sec. ,B&P C for this reason PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER EA)
Owner Dose rp VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Sep
1 hereby affirm under Penalty of perjury one of the following decimations.
❑Thous and will maintain.Certificxre of Conserv to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND.
salon,as provided for by Section 37W of the Labor Code,for the pMormance of the • r ,a t STORIES TYPECONSTRUCTION U/
work for which this'perran is issued. FIXTURES-PER TRAP
I have vad will maintain Workers Compensation Insurance,as required by Section '
3700of Ne Labor Code,for the performance ofine work for which this permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
Cnorim, y'yCompegsatipu l^Wvc carrle�ldy Pat n�e���- 11
GAS-EA.SYS9'EM-OVER 4(EA)
S�CEERTTIIFIICCAATE OF EXEMPTION FROM WORKER O IOAS I
COMPENSATION INSURANCE GRP.ASE/INDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the permit is for one hundred dollars BUILD GTVINFEES($I W) GREASETRAP
or las') PLANCHECK PEE
Icenify Nat in the perPonnance ofinework f.rwhich this permitisissued,I shall SEWER-SANITARY-STORM EA.200 FT
not employ any person in any mxnneJ�so as to lyeporo bject m the Workers Compen- - ENERGY FEE
Armon laws of/p�ahf.m�m.Dropp "I•C-91s eso
y�yO Applicant WATER HEATER WNENT/ELECTR GRADING Pick
f� rj1 NOTICE TO APPLICANT.If,after making this Cunmeitte of Exemption,you should WATER SYSTF.M/1'REATING
a5.1become subject raphe Workers Compensation provisions of the Labor Code,you must - SOILS FF.
W forthwith comply with such provisions or this permit shell be deemed revoked.
W A WgTER SERVICE
DZ CONSTRUCTION LENDING AGENCY NEW RESIDF.N IALPLMB. SQ.FT. PAID
the work for which this
I hereby affirm that there is a eonswedon lending agency for the perfumer
O of Dete ReceipaN
U noir issoed(Sec.309],Civ.C.) t _
0 L^ Under',Name er�A)p'
Lender's Address a TOTAL:
I certify that 1 have read this application and.same thm the above information is (/ BUILDING F.E
Z1 correct.I agree to comply withal]city and county ordinances and tram laws coming to QTY. MECHANICAL PERMIT FEE
V building construction,and hereby authorize representatives of this city to enter upon the SEISMICF E
above-menainned property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRI FUE
liabilities,judgments,costs and expenses which may in any way came against said City p1:fER OR ADD TO MECH.
a. asequence of the granting of this permit. PLUMBI GFEE.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO 10,000 CFM)
SOURCE IGUHATIONSMECHANICA FEE
. -
', 4 (� AIR HANDLING UNIT(OVER IO,000CFM)
CONSTRUCTION X
Signmut ofAicanUCnntuc or - Date EXHAUST HOOD(W/DUCT) — HOU
HAZARDOUS MATERIALS DISCLOSURE SING MITIGATIOE
Will lM1eapplicana or future building occupant more orhandle hazafdnus maeriul HEATING UNIT(TO]FROM BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes s'o
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which - Date Receipt
emit h.1menas it contaminxms as defined by the Bay Area At,Quality Management BOILER-COMP(3HP OR IW,M)BTU)
•Grimm? TOT
❑Yes E'Isu BOILER-COMP(OVER Ifq,t]OO RT U)
I have read the laimp as materials AIR CONDITIONER
r5,2553 a under Chaptet6 tend thhe Calle ISSU ATE
forma Health&Safety Cale,Sections 25505,25533 and 25534.1 understand ahal if the NEW RESIDENTIAL MUCH. SQ.FT
build does dot cumnOy M1aveutenanq thm it is my responsibility mnotify the occupant
of imments whichm bemea p,io,I.i,euanceofn Can Tic ateof0ccupancy.
9 5 e
O aero t Ih...ed ugem Date A ISSUED BY:
OFFICE