29696 APPLICANTTO FILL'IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - , BUILDING-ELECTRICAL PLRMITNO, 29696
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGAD RESS: SANITARY NO.. APPLICATION SUBMITTAL DATE
OW E PHONE: ACT R'S ME:' LIC
o-MN/C - CONTROL 0,
ARCHITECI'/ENGIN LIC NO: ❑'
CONTACT: PxONE: BUILDING PERMIT INFO
❑ Con Int Fear Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
D ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
.I hereby affirm that I am licensed under provisinns of Chapter 9(commencing JOB DESCRIPTION•
RZth Section 7000)Of Division 3 ofthe Businessand Pmfeseioms Code, dmylicanscis
00 wi PERMIT ISSUANCE R MEN
'
r in fi,B fora and erre
N License Cla , Lica SFDWL O KITCHEN REMODEL
U Date Contrera APPLIANCES-RESIDENTIAL
•F Z y) ❑ADDITION .. "[I PLUMBING REPIPE
ARCHITECTS DEC ATIO ��'}{,;�l' PANELS - ❑MULTI-UNIT ❑STRUCTURAL
1 understand my pleas shall be used as public test, 1 MODIFICATION
OZ— LJPT02MAMP5
r41"e. Lice.. d Profeasio m INTERIOR ❑CHIMNEY REPAIR
4 hd.i OWNER-BUILDER DECLARATION 20LIOW AMPS IMPROVEMENT
Pj 1'Y51 1 hereby affirm that I am exempt from the Cmdowme.License Law for the OVER 1000 AMPS• C1 BATH REMODEUREPAIR El DEMOLITION
06V following reason(Seetion 703 1.5,Business and professions Cade:Anycity or county SIGNS ELECTRICAL' ❑OTHER
set 0.O F which requires a permit to construct,alter,improve.demolish,or repair any structure '
prior to its issuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUIT/MISC. -
athat he is licensed pursuant to the provisinns oldie Contractor's License Law(Chapter 9
00 (commencing with Section 7")of Division 3 ufthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C3 DEMOLITION.
xy W Section 7031.5 by any applicant for is permit subjects We applicant m a civil penahy of POWER DEVICES
47^tn ❑TENANT FOOD SERVICE
»,
notmore than fivehundreJ dollen(SSW): IMPROVEMENT
will da
Ir CFE QO Las owner of the progeny,or myemployees with wages ae theirsnle compensation, SWIMMING POOL ELE "
Ne work,and the ntvmurc is not intended oraffereJ for sale(Sce.701 kBusiness []OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES- IXTURU
a propeny who builds or improves thereon,and who does such work himself or through
his own employes,Provided that Such improvements ere not intended or offered for NEW RESIDENTIAL ELECfR SQ FT
We.If,howevOr.the building or improvement is sold within one year bfcompletion,the SQ.FT.FLOOR AREA r •SISQ.FT
owner-builder will have the burden of proving that he did not build or improve for pur v
Tom of sale.).
❑ 1,as owner of the property,am exclusively contracting with licensed cono orma in TOTA
amettom,the project(Sec.7044,Business and Professions Code:)The Came.....a Li- (y'
cams,law docs not apply to on owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT
who convects for such projects with a contractor(a)licensed pursuant to the Connector's ���
License Low. �7r
lamexemMrtd
uer Sec. aPERMIT ISSUANCE,B&PCfmfld,own 2/ 19
96
ALTER-DRAIN&VENT-WATER IEA)
Owner Dole VALUATION.
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE L)I" LUa'Lil I iivV'
I hereby affirm under penalty of perjury one of the following declarations: -
❑Ihaveand will=intaine C,,iRcateof Con..ttowlf-insure for Worker's Compan- DRAINS-FLOOR,ROOF.AREA, OND.
sedan,u provided for by Section 37M of the Labor Code.for the performance of the STORIES TYPE CONSTRUCTION
wm ,which Nis pcmdl is issued. . FIXTURES-PER TRAP -
have and will maintain Worker's Compensation Insurance,as required by Section
3]Wofthe aborCoke,fonhe ' 'nmoceof ework for which this permit' issued. GAS-EA.SYSTEMA INC.4 OUTLETS OCC.GROUP APN
My War Com ratio Imann otic n
Cartier, r �yN GAS-EA.SYSTFM-OVER4(EA)
ERTI ATE OP F.MPfION FROM WORKERS'-
' COMPENSATION INSURANCE GREASHANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This
nee nntbecomplened iftha permit ispornim,rodied daDars(SUD GREASE TRAP
or less.) - PLANCHECK FEE
lcertifythatinthe performanceofthewmkforwhichthisperdtisis.M.Ishall SEWER-
not cmin an tin an b SANITARY-STORM EA.2W Ff. -
p y y y�J^ a �s o* )atmthe Workers'Compen+ ENERGY FEE
rattan laws 1' LL7{; encWATER HEATER WNENTIELECIR - GRADING IEE
O Applicata �{r LCYpV
y NOT
emom im Oc,m m I,afm ma ration s Provisions
n s of of Exemption.you,you muldust WATER 5Y5TF.M?BEATING
become subjects,thjp//,Vnrkeh Compeor this permit
imal of the labor Coke,you must SOILS FEE
foMwith comply with such Provisions or Nie permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENPI'
TIAL PLMB. SQ. . PAID
L)Q Ihereby anion that hem is a concoction lending agency for the perfommrwe of Dam ReceiptN
{L h the work for which this permit is issued(Sec.3097,Civ,C.)
0 C.I Lender's Name TOTAL:
W lender's Address
0s 1 eenify that I have read this application and slam that the above information is BUILDING FEE
fir W) correa.l egma td comply with all city and county odinanccs and store laws relatlngm QTY. MECHANICAL PERMIT FEE
U 7- building construction,and hereby outhorim repmscntadvas of this city to enter upon the SEISMIC FEE
above mentioned progeny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to a..,indemnify end
keep harmless the City of Cupertino against
hidailities,judgmems,costs mud eaten...which may in any way reentat, it stmid City ALTER OR ADD TO MECH.
in consequence of the granting of this pemdt. PLUMBING FEE .)
as
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]'I(TO 10,04)0 CFM)
SOURCE REGULATIONS., MECHANICAL FEE
+ AIRHANDLING UNIT(OVER M."CFM) CONSTRUCTION TAX
Signamre of Applicant/Conmctor. Data EXHAUST HOLD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or far..building..Paul some or handle haysrdous memrial HEATING UNIT LTO I Wp00 BTU)
• u defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
Coda.Section 25532(x)7 HEATING UNIT(OVER IW,000 BTU)
El Yes [I No
o2 I
VENTILATION FAN(SINGLE 0.ESID) PAID
• Dote ReceiptN
Wiilthe it cotaminaumre building by me
ay Area
Air
Management
BOILER, IW,D)OBTU)
mithaudoua cert contaminants as JefinW by the Bey Area Air Quality Mvnegemcnt TOTAL. '
llsWn7 •'
Q Yea I [3 No BOILER-COMI'(OVLR��I srW�k5,IXIU ) ,
av
I have read the haeodoos marmots,aqui orcnts maker Chapter 6.95'of the Cali- - AIR CONDITION• U.aa / .ISSUANCE DATE
forma Health&Safety Code,Sections 25505,M533 and 25534.1 undenund that if the. NEW RESIDENTIAL MECIL SQ.FT.
building does not currently have u tenant,that it is my responsibility to notify the reagent -
Of the requinuman,which most be met rim,issuance of.Cenduch,of 0ov.;aey.i
1
Owner or amboriaed agent - Date TOTAL: ISSUED BY:
OFFICE