29217 APPLICANTTO FILL.IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY + t:
CITY OF CUPERTINO •, - - BUILDING'-ELECTRICAL - ,j PERMIT NOr-
BUILDING DIVISION APPLICATIONIPERMIT 2
PLUMBING-MECHANICAL Y 29' 7'
BUILDING PROJECT'IDENTIFICATION ./ L i1
BUILDING ADDRESS. - -
.� SANITARY NO.; APPLICAT N$UB ALAl DATE.
° �rAT N
r 7 Jo
u O E'S NAME: PHO L: RACTO 'SM LIC N
Qk 110 WA
, ft N/C CONTROL
CUM
RCHITECIVENGINEER:l' ' LIC NO: R S'. - ❑
I
i
CONTACT - •PHONE; + - - BUfl:DINO PERMIT INFO
A.i t Consultant Fees Pald b A titan[ Initial
F\U �-�(. G, y PP ( j- BLDG ELECT PLUMB MECH
•" LICEN ED CONTRACTOR SDECLARATI / '^ Q^Py ELECTRIC PERMIT FEE ..
I hereby affirm that I lie ensed and previsions of Chapter 9(awnmancing "JOB DESCRIPTION T
W aO C with Section 100d)ofD"ion 3 oftheBust and Panic sic Cad andmyouitaeie pgggylT ISSUANCE • '' PRESIDENTIAL: '
F W rr m full force and t �' ;❑SFDWL ❑KITCHEN REMODEL.
�u L¢enseC ss Lit.F APPLIANCES'-RESIDENTIAL
p f=
'De��Conn'"'m - ❑ADDITION ❑PLUMBING RE-PIPE...
fN,pm> '• + ARCHITEC,i DEC PANELS ❑MULTI-UNIT- ' E:1 STRUCTURAL
Z O fv/��q 1 d land my pl Hall be usW asp blit earn - i. ;MODIFICATION
OZap a - UPT0200 AMPS MODIFICATION
❑CHIMNEYREPAIR
rr Lice dPr fe. 1 - '' 201-IWOAMPS IMPROVEMENT "i
ri4y�gl7 OWNER BUILDER DECLARATION
1 hereby affirm that'l pt from the Contractor's LicenseLaw for the OVER 1000 AMPS
El BATH REMODEVREPAIR ❑DEMOLITION
0 W U milli g e n (Sect 7031.5,B e es d Pr f n Cod Any it,or ounty ❑ E
Fat V.F SIGNS ELECTRICAL „
y O which requ re a permit to an extruct,alter.improve demolish,or repair any structure !
{n
pomm as issuance,also memos,Ne applicant fch pari tt file.signed stntment SPECIALCIRCUIT/MISC s
y Nat Thais licensedPumtoriu The provisions aftheContimatorsL n.e Law(Ch pter9
�C) (commencing winSection]000)ofDotdmn3 oflhe Business and Professions Code)or TEMP METER OR POLE INST. EOMME
0. ca that he is examIa therefrom and the basis for the alleged exemption,n Any violation of
Section703156 en applicant -- POWER DEVICES -❑NEW BLDGADDITION ❑DEMOLITION
) -❑TENANT - aih ❑FOODSERVICE
y not more than five hand d d II ($SW) - - IMPROVEMENT
C ❑I re ofthe property y ploy th g th' Icompensation, SWIMMING POOL ELECTIU
wJl do the work,and Nei tore n t nTe tl d fferedf 1 (S JM4 B s s ti ❑OTHER
m and Professions C.dai no Characters License Law does. t apply to an mw
act of OUTLETS-SWITCHES-Fl ES ' i
Q' property who builds or imroth
pves ereon,and who does such work himself or through -
his own employees provided that h-mprevemenls ore not t d d R red for NEW RESIDENTIAL ELECTR' SQ
sole If,however the build"ng r'mp mart is sold within on"y fc mpl tion,the SQ.Ff.PLOOR'AREA,�i $/SQ.FT..
caner builder will have the burden of proving that he did notbuild or ndmoo for pun _ ' I� F4 A 4:'
pose'ora.w.), 1- .°
❑1,a.owe f the pri+peny, chis velY ova 1 B nth I"en ed t actors to _ n L: ��� f,
CAmsvu t ih protect(Se ]044 Business and Fantasia.,Cnde)Th Contractor',Li- Q • I 1998
se Lew doe' t apply t an owner of pr p rxy whobuilds or improves thereon and T PLUMBING PERMIT FEE /s'frYV /�� +'
hocontracts fsuch p t n 'th'contmct rOlicensed pursuanuo the Contmetora k/I,CY VIS -
License La - i -
❑ 1 m exempi under Sec ,B&P C for Nis reason PERMIT ISSUANCE t LUWCFS
Owner - Dale
ALTER-DRAIN&VENT-WATER(EA) I - VALUATION ,.
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
1hereby offirm under Penalty ofperj rY of The following declarations ' " `VV/��.�-/�/
u '
❑I haviled will miintama Certif¢meof Consentmself-inure for Workers Compen DRAINS'-FLOOR,ROOF,AREA,COND: STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3]00 of me Labor Code,for the performance of the - 1
work for which this permit is issued." FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance as required by Section-
3]00 of the Li�rC de.for t e performer` o ework for which This perm us issued` GAS-EA.SYSTEM-I INC.40UTLEfS ` + ' t
OCC.GROUP APNI,
My Worker i sat so IP fjf d Policy
Carrier. ]icy Na. GAS-EA.SYSTEM-OVER 4(EA)
CERTIP ATE OF EXEMPTION FROM WORKER -
" COMPENSATION INSURANCE " GREASE.INDUSTRL WASTE INTERCEPTOR + - BUILDING DIVISION FEES
(This seed to
ao M1e completed If,
permitisforoodhunJreddollare($100)
or lase] �, GREASETRAP 'C' ,
y NOTnot m to any ANT If.afte of�he this Corti titch ilii Exem tioI hall SEWER-SANI9ARY STORM EA.200 FT '' PLANCHECK PEE P. ".
lenity Theon Part. p employ y pe m n en so as to bac me object
Compo ENERGY FEF.
7 aauon La mi T
O
'AP IT WATERHEATEB W/VENT/ELECTR
F7 GRADING FEE
g p you sh uld WATER SYSTEM/IREATING +
become subj the Workers Compensation provisions of the Labor Co.ede,you mus SOILS FEE '
forthwith comply with such provisions or this permit shall be devoted'resulted.
IER SERVICE D
z - CONSTRUCT ION LENDING AGENCY W RESIDENTIAL FUME. SQ.FT PAIDV'� I hereby affirm tlia them is a concoction lending agency for the Performance of .Date " RceiplMwr hew rkf rwh hth p t' iss d(Sce 309],Civ C).N
V Ladder.Add ` TOTAL: TOTU gni
BUILDING FEE,
V) correct1 g t ply with II Ty d county ordnances and state laws adding to QTY
�j . MECHANICAL PERMIT FEE
V a build g construction,and hand;auTAmind representatives of this city to enter upon The SEISMICFEE,
abovo-memtioned property for inspection purposes. PERMIT ISSUANCE ,a
(We)agree+m sam,indemnify and keep harmless the City of Cupertino against" ' ELECTRIC FEE
liabilitiee,juit ", nsts a ad expengea which may in any way accrue against said City ALTER OR ADD TO MECH. '.
nsegoence of granting of this permit. - PLUMBING FEE
APPLICANT_,If6ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10..'"CFM) -
SOURCE .IULATI i`� MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTTON TAX
,.
Signawrpplicent/Colrtmemr - EXHAUST HOOD(W/DUCf)r 'HOUSING MITIGATION FEE '
HAZARDOUS MATERIALS DISCLOSURE '
Theapplicantor future building occupant sooner handle huzardnus material HEATING UNIT(TO 10(i BTU
es defined by the Cupertino Municipal Code Chapter 9,12,and the Health and Safety
i Code Section 25532(a)] ' - HEATING UNIT(OVER 100,000 BTU) -
❑Yea `i - ❑N „ VENTILATION FAN(SINGLE RESID) PAID +
• - Date ' - Receipt p
'I Will the applicant or future bidding occupant use equipment or devices which, COMP(3HPOR IOORYBTU)
haBOILER- -
vnitzamousaircomamnoms s defined by the Bay Area Air Quality Management,
District? q I - TOTAL: �♦
. -
❑Yee
ONO BOILER-COMP(OVER 100,WD BTU)'
I have read the hazeWous concerns,requirements under Chapter 6.95 of the Cali ASR CONDITIONER ' .ISSUAN IJ
fnnia Health&Safny Code Sections 25505,25533 and 25534 1 understand that of The NEW RESIDENTIAL MECH. .. 'SQ.FT.
building does not currently have a tenant,that it is my responsibility to notify Tie occupant'
of the expiremwns which must be met prior in issuance of s Ccnifcate of Occupancy.. r. /
/ Owner or authorized a gem ,Data - uTOTAL: - t
ISSUED BY:
OFFICE