29804 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I .BUILDING-ELECTRICAL PERMIT NO. 2 9 8 0 zl
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL IJA VX 4
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'SN MP' /n' PHONE: CO R'`NAME:/ /(�L LIC NO:
P t (p U NIC /a`k CONTROL M
4R HITECT/ENGINE IIJJ LIC NO AT ld CO l a ✓ /�� ❑ rT ) f�
CONTACT: PHONE: /113 -Y BUILDIN(((G PERMIT INFO
a��-s9so ❑ Consultant Fees Paid by Applicant(Initial) B EC _ PLUMtl MECH
LICENSED CONTRACTOR'S DE LARAHON QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provi ions of Chapter 9(commencing JOB DESCRIPTION
{zO{s��at with Section]000)uf Division 3ofthe Bminnsand Professions Codr,and my license is
FZ full force and effect. PERMIT ISSUANCE
W r" WL ❑KITCHEN REMODEL
FU�j
License Class Lic.M
NGL Dau Comeart.r APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
w ARCHITECTS DECLARATION. PANELS OMULTI-UNIT El STRUCTURAL
I understand my plans shall be used as public records Rf�yas //�� MODIFICATION
OZ � UP102WAMPS [I INTERIOR VI G41ErCHIMNEY REPAIR
Licemed Professional 201-1000AMPS IMPROVEMENT
fir , OWNER-BUILDER DECLARATION OVER 1000 AMPS
[I BATH REMOP DEMOLITION
�j C 1 hereby affirm Mut t nm exempt from the Contractor's License Low.fur the
?pS�O U following reason,(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
t`+ 0 ye which requires o permit to construct,alter,improve,demolish,or repair any structure TIVglayff.
prior in its issuance,elm requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. lJF(L n.
CCy that he is licensed pursmmmNeprovislonsofthe Commctons License Law(Chapter 9 `ziJ/f(commenting with Swtiom](XXljrfDlvLrlon3 of the Business and PntessionsCod<)or TEMP.METER OR POLE INST. COMMERCIAL: Y(J
that he is exempt themfmm and Me M
basis for e alleged exemption.Any violation of O NEW RLDG/ADDITION ❑DEMOLITION
LLXl Y• Section 90313 by any applicant for a permit subjects she applicant to a civil penalty of POWER DEVICES w []TENANT ❑FOODSERVICE
ZZZZZy60 not more Men five hundred dollars(E500). C. IMPROVEMENT
qE] I,ns owner rf Ne properly,nr my employees with wages as their sale compcnsminn. SWIMMING POOL ELECTRIC OTHER
5F❑ will do the work,and the structure is not intended oroffered for sale(Sec.]094,Business
�_ and Professions Code:The Corrosions License law dues net apply m an owner of OUTLETS-SWITCHES-FIXTURES
Is. progeny who builds or improves thereon,and who Jrcs such work himself or Nmugh
his own employers,provided that such improvements are out intended an olrcred for NEW RESIDENTIAL ELECTR SQ IR.
sale.If,however the building or improvement is sold within one year of completion,the .` = SQ.FE FLOOR AREA $/SQ.Fr.
owner-builder will have the burden of proving that he did not build or improve for pun- {/
KJ � �a /]k
poseof ole'). _ 4 V
O 1,as owner of the property,am exclusively contracting with licensed contractors to
consumer the project(Sec.7(/44,Business and Professions Code:)The Contractor's LI- Iia^
cane law three not apply to an owner of property who builds or improves Hereon,end QTY. PLUMBING PERMIT FEE
who comment for such projects with a contrat licensed parsuantto the Contractors
License Lew. PERMI'p ISSUANCE.
O Ir a,exempt under See. ,B&P C for this mason
Owner Dam ALTER-DRAIN&VENT-WATER(EAT V�ALUATIfONN
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE r^ y{.� 1
I hcmbyaf0rm under perithyuf p jury one of the following deelnmmal: ✓ J a ` JV
❑l have and will maintain o CertConsent Certificate of Conseno selbineare be Worker's Comped. DRAINS-'FLOOR,ROOF,AREA,COND,
action,as Provided for by Section 37W of the labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this pcurm is issued. FIXTURES-PER TRAP
O 1 have and will maintain Worker's Compensation Insurance,m required by Section
37W of the Labor Crude,for the perforinance of the work far which this permit is issued GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
XMy orker's Compensation Insurance eerier and Policy mmnberare: GAS-EA.SYSTEM OVER 4ERA)
'er. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRI,WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed if the Permit is for one hundred dollars Hi 100) GREASE TRAP
or Ins.Ic PLANCHECK FEE L I/R
Ioy my Perhatm the pefforany
ani theas t become suork for bjectch to themitisies'Comer. SEWEN-SANITARY-STORM EA.200 FT.
not enrPiny any person in any munncr so as to become subject io the Wnrkere'Comped- ENERGY FEE
0Z satiunlawsrf Culifumim Date WATER HEATER WNENT/EI.ECIR
r
Z 2 Applicant GRADING FEE
fl) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a [ become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
LiI ry forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
Q
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID I
U p work
by which his
that main isaconstruction lendi v.agency for the Performance of Dam a iPt
W s�-t the work for which this pertnir is issued(Sec.7(Yd],Civ.CJ - '
0 U Lender's Name ASYTOTAL:
Lender's AMhesa
04 I� it
1 certify that I have mad Nis application end mile that Ne above information is BUILDING FEE D
toren.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE �
U `7 building construction,and hereby authorize representatives of this city to enter upon the SEISMIC F' M
abrve-mentioned property for inspection purlxses.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC 2�
liabilities,judgments.costs and expenses which may in anyway occrun against said City
ALTER OR ADD TO MECH. PLUMBIN
nseyuence of the granting of this permit.
APPLICANT�LWPnOERSTANDS AND WILL COMP Y WITVALL NON-POINT AIR HANDLING UNIT C-0 10,000 CFM)
SOUR En t'CcuLAN�^ / MECHANICAL /L ,
(//f/` 7� �-/ff AIR HANDLING UNIT(OVER 10,0011 CFM) CONSTRUCTION
X
S ryIicunHCtRDOtUS MATERIALS DISCLOSURE Data EXHAUST HOLD(W/DUCO
HOUSING MTHG ION FEE �1
Will the applicant or future building occupant Bou ser hon hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cnde,Chapter 9.12,on the Health and Safely
Code,Section 25532(a)? - HEATING UNIT(OVER 100,000 BTU)
O Yes [3 No VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or future building am use equipment or devices which' Data Receipt p
pp dby the yuipmen BOILER-COMP(3HP OR IW,000 BTU)
emit hazuodnus air rnntaminanB as defined by the Bay Area Air Quality Management
District? TOTAL❑Yes Otho BOILER-COMP(OVER 100.001)BTU)
I have real the loccomus intervals requirmarrs under Chapter 6.95 of the Cali- AIR CONDITIONER ISS ANCE DATE
foods Health&Safety Crile,Saunas 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdoss nn currently have a temanr,Nat it is my responsibility to notify the occupant
of the requirements which must M met pricato issuance of a Certificate of Occupancy.
Owner or authorized agent Date ISSUED BY:
OFFICE