29818 APPLICANTTO FILL IN INFORMATION WITHIN REDDLINES'-USE BALL POINT PEN ONLY,
CITYOFCUPERTINO f';' BUILDING-ELECTRICAL PERMIT NO. Z9O1O
BUILDING DIVISION APPLICATION/PERMIT' PLUMBING-MECHANICAL' - L J o 0
*o-'"' BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - t SANITARY NO., APPLICATION SUBMITTAL DATE
OW R'S NAME: / — - PHONE: CONT CTORS NAME'' -LIC NO: NIC CONTROL#,
r
RCHITEC
T/ENGINEER; ",.' LIC NO: - ADDRESS: "' v' ''�' ❑ ..
CONTACT. "/ PHONE:. � - - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) r.BLDG - ELECT PLUMB MECH
N fir ;' ,.... u.• i
- LICENSED CONTRAC70R S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I son 1 tensed under previsions of Chapter 9(commencing, i JOB DESCRIPTION
�C"aZ with Section 7001 Division 3.f the Business dProfession,Code Ind my!cense is RESIDENTIAL
O yn PERMIT ISSUANCE '
I.Lull f and effect
rIUUr License Clare- ' Lic,# - ❑SPDWL ❑KRCHEN REMODEL,,
41 Date Contract,,, APPLIANCES-RESIDENTIAL QADDITION 'PLUMBING RE-PIPE
ARCHITECT'S DECLARATION' PANELS
- El MULTI-UNIT. STRUCTURAL
Z O `I contrarian my plans shall be used as public records MODIFICATION
0•-. - - ," UPT0200AMPS0INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDR DE
F
LicensedProfessional - - ' 201-10(y)AMPS _ IMPROVEMENT
1 hEl
EDECLARATION OVERINKAMPS C1 BATH REMODEL/REPAIR ElDEMOLITION
by affirm that 1 um exempt from the Contractors L se Law far the
ad H following reason.(Section 703 1.5, SIGNS ELECTRICAL 5,Business and Professions Code:Any city or county- COMER -
y ON¢ which q ' a permit to construct, Its mpr ve demolish,or repair any shumure _
N.]
pilot to as Issuance also acquires the applicant for such Permit t file asigned sttment SPECIAL CIRCUIT/MISC. t - -
ps that he is licensed pursuant to the previsions of the Contractors License L (Chapter9 COMMERCIAL,
GAO (commencing with Sect 70(0] fD'vs,on3 fthe Business dP ft, Code)or TEMP.METER OR POLE INST, 29
p e� that he Is exempt therefrom Ind thebasis for the alleged exemption.Any violation of NEW BLDG/ADDITION DEMOLITION
W gection 7031 5 by any applicant for a Permit subjectx the applicant m a civil penalty of POWERDEVICES TENANT . ❑FOOD SERVICE
Y p yFn, not more Nan five hundred doll.($500). -IMPROVEMENT
qC ❑I,as ownerof We properly,or my employees with wages vs their sole crmpenxatirq SWIMMINGPOOL ELECTRIC -
C 'willdothewurk,madheaoue...a is nm intended oroffered for sale(See,7maL Business ❑OTHER
Y1 and Professions Code:The Contractor's License Lew does not apply to an owner of OUTLETS-SWITCHES-FIXTURES,
d'3^ property who builds in improves thereon,and who does such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. 01
sale.if.however,the building or improvement is sold within one year of completion,the - r SQ.FT FLOOR AREA $ISQ.FT.
. owner-builder will have the burden of proving that he did ant build or improve for pur-
' F11.as owner of the property.am exclusively contracting with licensed contractors to ItiTOTAL:
construct the project(Sec.7044,Business end Professions Code:)The Commerce's LI: i 4 e'
ceqse Law does not apply to an owner of pmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE - -
who comrecta for such projects with a conhemons)licensed pmauent to the Commichas "
License Law. - PERMIT ISSUANCE
'r ❑ I.exempt under Sec. - ,B&P C for this reason - "
ALTER-DRAIN&VENT-WATER(EA) ,I' VALUATION' -
Owner Data
WORKER'S COMPENSATION DECLARATION r BACK FLOW PROTECT DEVICE
hereby affirm underpenalry of perjury one of the following declarations: `
❑I have and will maintain a Certificate ofConient tri'self-insure for Worker's Compen{ DRAINS-FLOOR,ROOF,AREA,COND. t '' -STORIES TYPE CONSTRUCTION
action,as provided for by Section 3700 of the Labor Code;fur the perfrrmor.of the
_1work for which this permit is issued.' j - - FIXTURES-PER TRAP,'-
❑ I have and will maintain Worker's Compensation Insurance,as required by Section.
3700ofthe Labor Code fortheperfommnc fthe work for which thisp 't is issued.. GAS-EA.SYSTEM-1 INC.40UTLETS ,OCC.GROUP APN '
My Wor o pens nanlmur "c tamer end Policy num�5 - -
Carricr� Policy Na.:[�'J 7�9� GAS-EA.SYSTEM-OVER 4(EA) _
CERT! ICATE OF EXEMPTION PROM WORKERS GREASF/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE -
(Thi,,mcd,,need art bawar,denaddthe permit is parent,handled BUILDING DIVISION FEES
d doll.,(SIM) -
mless) i GREASETRAP - PLANCHECK fEE' 4"
1 fy
rtthatnth performance of the work for which this permit is issued l shall SEWER-SANITARY-STORM EA.200 FTI-
' not employ any person i y manner so as to become subject to the Workers Compen-•' - ENERGY FEE
0 ,7, whom Laws of Califon Data
''
0 Applicant WATER HEATER WNENT/ELECTR
-ti 'NOTICE TO APPLICANT:'If,after making this Certificate of Exemption, GRADING FEE you should WATER SYSTEM[TREATING -
become subject to the W rk C p of provisions f the Labor Code,you must SOILS FEE
p! z foMwtN comply with such provisions ordirsp omit shall be deemrevoked..ed reved / WATER SERVICE O -
!.W7� CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB SQ.FT " PAID
V Ihereby affirm h thaure is a construction lending agency for the perfarmance of Data, Receipt#
L4
the k far which this parranda is issued(See.3097 Civ.C.) f -
OF,
Lenders Name
_ lTOTAL
La :
W4 nders Addr. ' - t TOTAL: 6 ' -
�y, I certify that I have and this application and It t I(bar the above information is - BUILDING FEE "
Incarre t 1 agree to comply with all city and county ordinances and sate laws relating to QTY. MECHANICAL PERMIT FEE ^
U "7 building construction,and heieby authonle representatives ofthis city to enter upon the SEISMIC FEE �, 5
above-mentioned property for inspection purposes. PERMIT ISSUANCE -
(We)agree to save,indemnify and keep families the City of Cupertino against - ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue ngaimtsvid City ALTER OR ADD TO MECH. ti"'
in crnsNuence of the granting of this pe PLUMBING FEE'
APPLICANT UNDER STA S A LLC PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM).
SOLIp�p�\p REG/UL �ION _ - MECHANICALFEE 1
•'k / AIN HANDLING UNIT(OVER 10,00!1 CPM7 CONSTRUCTION TAX
SiIgo N�'afApph iDContre v s /VDete EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hinamdous material HEATINGUNIT(TO 100,00fI BTU) -
. es defined by the Cupertino Municipal Cale,Chapter 9.12,and the,Health and Safety
Code,Section 25532(mU - - HEATING UNIT(OVER 100,000 BTU),, -
❑Yes ❑No
r VENTILATION FAN(SINGLE RESID) - k PAID
Will the applicant liftire budding occupant use equipment ar devices which Date 'Receipt#,
emit hazardows hazardair contaminants as defined by the iShil
Area An Quality Management BOILER-COMP QHP OR 100,0011 BTU),
7TAC: '� Ut
DistnmEl Yes 'p No BOILER-COMP(OVER 100,00)BTU) I
I havetead the hamNomaterials' AIR CONDITIONER - Ulf f•VP IS3UAN E ATE
requirements under .1 wisl r wr of the Call- Q
fomia Health&Safety Code Sections 25505 25533 and 25534 1 understand that if the " NEW RESIDENTIAL MECH. SQ.FT.
of thengdoesnot currently have amnat priorthat o ismy uace of a Ceratmnotify the occupant-
' of the q u which t od mu primo issuance of a Cen,feete of Occupancy. t -
.i' ...
0,werorautbonmd agent Date _ TOTAL. ISg rte" a "-�s+•U�` �'✓xe ,
• OFFICE-