29011 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDBATIFICATION
11
BUILDINGADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: ' - PHONE: CONTRACTOR'S�M[� A� -3 �NO��
,T L N/C CONTROL p
RCHITECT/E' (NEER: LIC NO: ADDRESS:
/&;I4 /no
r x�
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG LECT PLUMB MECH
❑ ❑
ElLICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
CZ 1 hereby ammo that I am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION
Cl)W in full force and effect.what Section1000)of Division 3 of Ne Business and Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL'
UZ License Class Li,# ❑SFDWL [I KITCHEN REMODEL
FQ Date Contractor - APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
[NF�py ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p 7� I undeistand my plans shall be used as public renmrds STRMODIFICATIONURAL
OZ p UP T0200 AMPS [I INTERIOR ❑CHIMNEY REPAIR'
2:I Licensed Professional 201-10WAMPS IMPROVEMENT
i -= < Oat I ma IUmma from
m DECLARATION OVER IOW AMPS
yy Oa]Q 1 hereby aRrm that 1 am exempt fmm the Convacmr's License Low for the 'O BATH RF:MODF.IIRF.PAIR DEMOLITION
kC 6 U following reawn.(Section 7031.5,Business and Professions Code:Any city or county ❑OTHER
4411 which vires a t to construct,alter,Improve.demolish,or repair nn SIGNS ELECTRICAL
.a7 rW Permit pY strvcmre
m BarW'licenedPnm requires the
ovisiosofflicion to,mchperm's Licenst.Ie ned La.
SPECIAL CIRCUIT/MISC.
} root he ix licensed puruanna the provisions nfthe Commcwr's License leve(Cheptcr9
�C (commencing with Section 9000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. OMM R .IA
a y Ig that he is exempt damcfmm and the basis for ate alleged exemption.Any violation of ❑NEW BLDG/ADDITION [J DEMOLITION
IWC^tNi Section 1031.S by any applicant far u permit suhjeasthe applinmt to a civil penalty of POWER DEVICES
} not more than live hundred dollars($50(t).
❑TENANT ❑FOODSERVICE
< D I,as owner ofthe property,or my employee%with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is nor iamchijimofferest faraale(Sec.1094,Business ❑OTHER
4 a and Professions Code:The Convector's License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself a through
his own employees,provided Nm such improvements am not intended or offered for NEW RESIDENTIAL ELEM SQ PT.
sale.If.however me building or improvement Maild wimhima,ycarrocom,leaim,the L SQ.C17fVW FT
owner-builder will have Ne burden of proving that he did not build or improve for pur-
Pau of eat ow
❑1,as ow of the progeny,am exclusively convecting wird licensed contractors m TOTAL V O
eonswnthe
es not (Senoan owner
and ProfessionsCode)
or improver Thever therior's Li- 1995
c uLawdcesnsupplymaswilhaofPropenywcenseddsorinContracard QTY PLUMBING PERMIT FEE 99
who contracts for such projects with a amtmaor(s)licensed pursuant to the Commnnre
11 y Vr
License Law.
❑ m & PERMIT ISSUANCE LurElyl NQ
laexempt under Sec. ,BPCfor this I
ALTER-DRAIN&VENT-WATER(EA)
Owner Uam VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby alErn antler penalty of perjury one of the following dalamlians '
❑I baveand will mainminm Cenilicmatol Cnmcm rosel4i"m,for Worker's Compen- DRAINS-FLOOR,ROOF AREA,COND, STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3100 of the Labor Code.for the Performance of the
work for which this permit is issued. FIXTURES-PER TRAP -
❑1 have and will maintain Worker's Compensation Insurance,as requimd by Section
3100 eisbm Code.for the performance of the work for which this permit is ismed. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
writers Compensation Insurance carrier and Policy number are:
ami¢ Policy No.: GAS-EA.SYSTEM-OVER 4(FA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRI.WASTE INTERCEPTOR
(This section need not be completed tithe Permit is forma,hundred dollars lS Ho BUILDING DIVISION FEES
• or less.) GREASETRAP
PIANCHECK FEE
Loy my that in The performance myformero as to Wkfor subject
ich jethio Permit is issuCompeall SEWER-SANITARY-STORM EA,200 FT.
not employ any person in any manner so as m Mcmme subjmt m Ne Workers Cnmpcn- ENERGY FEE
C Z station Laws of California.Date WATER HEATER WNENDELECTR
Phcant GRADING FEE
Oome subject
APPLICANT.If,Co making this Cisionse of Labor o d you a must WATER SYST'EM[TREATING
become subject m the Worker's Compensation Provision of the Inbar Cale,you must SOILS FEE
forthwith comply with such provisions or Permit be deemed revoked. WATER SERVICE
Go
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM. SQ.PT. 'PAID
I'D
Q NI hereby affirm Bra them is a consmuclion leading agency for the Performance of Date4. 2ceipt#
the work far which thigKNV t�r6'app(Sec.JOp7 L
o (~ Lenders Nume /Yt!
V L
leaders Address M : :
y1 Gentry but 1 have read this applicmtmn and rate but the abate infomtation is BUILDING
W conal l agree to comply with all city and county ordinances aW state lows miming no QTY, MECHANICAL PERMIT FEE -
U building convection,and hereby Interim representatives of this city to enter upon the SEISMIC E
above-mentioned progeny for imposition purposes. PERMIT ISSUANCE
(We)agree la save,indemnify end keep harmless the City of Cupertino against ELECTRIC FEF:
Iiabilities,judgmems,costs and expenses which may in any wryinum,against said City AL1ER OR ADD TO MECH. -
in conaNuence,of tion granting of this Permit. PLUMBING FEF,
APPLICANT UNDERSTANDS AND JILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO to."CFM)
SOURCF 'GU AUONS. MECHANICAL
�/ /} AIR HANDLING UNIT(OVER 10,0(10 CFM)
z -T�� -fS CONSTRUCTIgh TAX
mare nfApplieanUC""tracmr Date EXHAUST HOOD OODUCf) HOUSINGM IGATION FEE
HAZARDOUS MAM-RIAIS DISCLOSURE
Will themplicantor fuwre building occupammareor handle hazallousntnrariol HEATING UNIT(TO 100,0(1(1 BTU)
as defined by are Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Coda Section 25532(x)? HEATING UNIT(OVER 100,0011 BTU) -
❑Yes ❑No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Da¢ Reccipt#
emit hazardous air contaminants as defined by me Bay Area Air Quality Management -BOILER-COMP QHP OR 100,000 BTU)
District? TOTAL:
[3 Yes ONo BOILER-COMP(OVER 100,000 BTU)
1 have trod the hdeard"us materials is under Chapter 6.95 of the Cali. AIR CONDITIONER
re,25533" P ISSUANCE F.
fomia Health ta Safety Code,Sections 21505,25533 and 25534.I m modify
th that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingJoes na currently have a mnam.Nm it is my respnnsibiliry m notify ateacuPent
of the requirements which must he met prior to issuance of a Cevificate of Occupancy. - ��l E:�'
Owner or authorized agent Diu, I 'TOTAL: ISSUED BY:
OFFICE