29654 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. w a.,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L k9J {6
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
i 3 7&15raw
OWNER' NA PHOa.NE: C(�'7' CI'OR:S N � LIC NO:
,.' H 2 Cz5 k4
C CONTROLp
ARCHITE NEER: LICNU: DURESS: ❑
Z3 S+v.•
CONTA : PHONE: - BUILDING PERMIT INFO
as ❑ Consultant Fees Paid by Applicant(Initial) BLDG E&- PLGMB _ MECH/
LrJa/ LEC �/ 14H
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEC
R80Z w, I hereby.f lmo ds,l am licensed ander,ni mus of Chapur 9 aammeramg JOB DESCRIPTION
th Section 70007 of Division 3 of the Business and Professions Cade,and my license is RESIDENTIAL:
O O PERMIT ISSUANCE
WZ(:. in
f^11 Tome and°� ❑SFDWL ❑KITCHEN REMODEL
CIU Liccnu Cl s Lic.M APPLIANCES-RESIDENTIAL ��• ❑ADDITION C3 PLUMBING RE-PIPE
Z<nl Dutc Coronae
F-Dv ARCHIT[CTS DR RATION��� � PANELS ❑MULTI-UNIT ❑STRUCTURAL
OO Z 1 derstual yplan all heusedaspu ds MODIFICATION
::4J UPT0200AMPS
p ❑INTERIOR ❑CHIMNEY REPAIR
sed Pmfcssiraal 201-IEW AMPS IMPROVEMENT
OWNER-BUILDER iCLARATION OYER IOOOAMPS ❑BATH REMODEUREPAIR El DEMOLITION
p 1 heuby affirm that 1 am exempt tram the Comm ons License Law for me
t[t�I aC.FFF following mason,(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL []OTHER
whiilh obuires a Fermi,to con to al,alter,improve,demolish,m repair troy stmeture A
Friona its issuance,also requires the applicant for such permit to file a signed stammers SPECIAL CIRCUIT/MISC.
y •
that he is licensed pu...at to the pnwisi.m of the Coruscate.License law(Chnpter9
<O (commencin with Section 7021 Division 3nf the Business and Prrfessiom Code)or COMMERCIAL a g wi TEMP.ME1ER UR POLE INST.
6 o LL ,hat he is exempt therefrom and the basis for the allege)exemption.Any violation of E]NEW BLDG/ADDITION [I DEMOLITION
Ix• Section 7031.5 by any applicant for a Permit subjects me applicant o a civil penalty of POA BR DEVICC•S
'room ❑TENANT ❑FOOD SERVICE
d more then five hundred dollars($5010),
F. O ❑ Lasowark,the property,structure
withwred for alei(role70*1,B sines SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and theheCo is not intended m offered for sale(Sec.o as Business []OTHER
and Professions Code:The Contractors License Lnw das not apply m an owner of OUTLETS-SWITCHES-FIXTURES
6 3 property who builds or improve,thereon,and who dos each wind harralf or through
his own employeas,presided that such improvements are not intended or one for NEW RESIDENTIAL.ELECTR SQ FT. '-�
sale.If.however.the building or improvement is sold within one yearnfcompletion,the SQ.Pf.FI;QORrARBA SISQ.FT.
CY
owner-builder will have the burden of proving that he did not build or improve for put- /g+r "
pose of salcontractors). ^
El 1, 1
I,as owner of to property,am exclusively contracting with licensed contractors to
-�•+U
c ..tract the project(Sec.7W.Business and Professions CNet The Cnntrucme.Li- 1 Q(�
cense Law Jas not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a coacktorls)IiavM purmantto the Crntracmrs L`.(..,
License taw. PERMIT ISSUANCE Ck/qyU
E]I am exempt under Sm. ,B&PC fnnhis rtason _
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
/ WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE [aV DO
_/'hereby affirm under penalty of perjury one of the following declarations: J(�/
•(A'havaend will maintain a Certificate of Consent to se)Ginsure for Worker's Compen- DRAINS-FLOOR,ROOF,ARM,COND. STORIES TYPECONSTRUCTION
radon,as provided for by Sation 37W 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 required by Section
3]00 of the laborCNe.for the peRormancmhhe work for which this permit is issued. GAS-EA.SYSTEM-IINC.40UTL11TS OCC GROUP - APN
My WoheryCampep,5@B felanierolicyNcy ytrybgyal�D_ �I GAS-EA.SYSTEM-OVER 4(EA)
Carrier. e C /�t0 Policy N".(Jdl Ii
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASI%INDUS'I'RL WASTE INTERCEPTOR
Mi.same.ream be completed ifthe permit is faro.hundred dollon IS 100) BUILDING DIVISI FEES
or less) GREASE TRAP PLANCHECK FEE
I certify that in the Performance of Ne work for whistUhis permit is issued,l shall SEWER-SANITARY-STORM G.200 IT.
out employ any person in any manner seas m subject become subjeco the Workers'Compeh- -• ENERGY HE
tZ redo.Iaws of California.Date WATER HEATER WNENT/ELECTR
Applicant GRADING ME
F� NOTICE TO APPLICANT,If,after making this Cenifcate of Exemption,you should WATER SYSTEM/TREATING
become subject to Be Worker's Compensation previsions of the Labor Code•you must SOILS FEE
Qforthwith comply wire such provisions or this permit shall he dcemcd revoked. WATER SERVICE
UaCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
0 • I hercM1y affirm that hem is a construction lending agency for the performance of Data Raeiptg
the work for which Nis permit is issued(Sec.3097,Civ.C.)
Q (~ leasesName TOTAL:
V IA.dcea Address VIDA,L:
�-t Q 1 certify that I have read this application and stem that Be above information is BUILDING FEE -�
fA correct.I agree to comply with all city and county ordinances and state laws relating in QTY. MECHANICAL.PERMIT FEE
L)� building construction.and hereby authoflu represenmtircs of this city to enter upon the SEISMIC FEE
ub.se-mentioned pomaoy for inspection p.wait. - PERMIT ISSUANCE
(We).gree mauve,indemnify end lace,harmless the City of Ca time against ELECTRIC FEE
Iimbilitiesjudgmentse nand e.penses which may in any w.y.scme.giinst and City FLYER OR ADD TO MECH.
in evoloquence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT FIR HANDLING UNIT(TO 10.00)CPM)
SO rCP ULATIONS. MECHANICAL FEE
T AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
rum
of Applicam/ vector Data EXHAUST HOOD(W/DUCT)
rum 0HOUSING MITIGATION FEE
t HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accupunt store orhandle Institutions material HEATING UNIT TIO IW,0011 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.L!,and the Health and Safety
Ca. 1tion 25532(.)? HEATING UNIT(OVER 100,1100 BTU) -
4Yns ❑Nn
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant wr
or fue building oempant use equipment or devices which Date Receipt g
t hiran
ardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
TOTAL:
]sraict? BOILER-COMP(OVER 1011,001)BTU)
❑Yet No
L have read the hmard is materials requirements under Chinni,6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
fomite Health&Safety Cale,Sections 25505,23533 end 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.FT. s
build' git ofcmrcnBy have.m L Nat it is my responsibility to notify the compa"t
of a ants whir mustbe tpnortois en m u
� . .e, 6
at or authorized egcm am ISSUED BY:
OFFICE
Home Owner:Julius and Michelle Simon Contractor: Showcase Kitchens, Inc
Address: 21743 Castleton 12333 Saratoga-Sunnyvale Road
City: Cupertino Zip:95014 Sarataogn, CA. 95070
Project: KITCHEN REMODEL California Contractors License # 665395-B
New Cabinets, New Counters, New
Plumbing Fixtures, New Light Fixtures
Q �
rmn SMOKE DETECTORS ARE REQUIRED
co"i AS PER NEC 1993 IN ALL BEDROOMS
C AND HALLS LEADING TO BEDROOMS
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Home Owner:Julius and Michelle Simon Contractor: Showcase Kitchens, Inc
Address: 21743 Castleton 12333 Saratoga-Sunnyvale Road
City: Cupertino Zip:95014 Sarataoga, CA. 95070
Project: KITCHEN REMODEL California Contractors License# 665395-B
New Cabinets, New Counters, New
Plumbing Fixtures, New Light Fixtures
ea
SMOKE DETECTORS ARE REQUIRED
AS PER NEC 1993 IN ALL BEDROOMS
AND HALLS LEADING TO BEDROOMS
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