29523 T
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
r - CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 29523
BUILDING PROJECT IDENTIFICATION '
BIJu.DING ADIIRPSS:2— OK� SANITARY NO. APPLICATION SUBMITTAL DAD
PI NE: C A R' NAME: L ^I�
ONAC CONTROL p
\RCHITECf GINEER: LIC NO: pR'SS: /l� ❑
CONTACT: PHONE: /lr BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION .. QTY ELECTRIC PERMIT FEE
I hereby Ewf that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION '
aZ
with S«tion0t Iof Division Jofthe Business and ProfessionsCede,and my license is [I SFDWNTIAL
�� in full force and e0 PERMIT ISSUANCE
W 2 ❑ADWL N O KITCHEN LiccnseC ss Cmib pppL1ANCFS-RESIDENTIAL ❑ADDITION [I PLUMBING L PIPE..
h�L Datc Contrecror
ARCHITECTS DECLAFat OMULT6UNIT C]STRUCTURAL
'IunderltunA my plans shall be used as public recorzls PANELS MODIFICATION
0z, UP TO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
r4l; Licensed Professional 20L10(IOAMIS IMPROVEMENT
•.1
OWNER-BUILDER DECLARATION law for OVER 100HAMPS [2 BATH REMODEL/REPAIR (]DEMOLITION
1 hffrm that 1 em exempt from the Commctors License Ne
3 6 following reasoereby nu(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Owhich regWns a permit to constmct,otter,improve,demolish.or repair any suucwre
prig to its issuanee.also an,ims theappllcamfor such penning fileasigned statement SPECIAL CIRCUIT/MISC. '
} Nos he is licenuJ Punumuin the Drovisians of the Camracmis LicenselnwfChapmr9
pC (commencing with Section 7%a)of Division 3 ofthe Business and Professions Code)on TEMP.METER OR POLE INST, COMMERCIAL:
c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
tc Section703IS by any applicant fohapeemsubjects e applicant to ucivil Xmityof POWER DEVICES
�sy licitbtthli
[]TENANT OFOODSERVICE
y not teas owner than of th ndredproina ,,arm(SSW). IMPROVEMENT
❑bus workf the pm peuctrmycmntended with wages ustheir(role compensation. SWIMMING POOL ELECTRIC
G
will Pr be Professions
and the he Coe is notact's License Law
ratl loess not apply 1.a4,Business []OTHER
6 a and property
wh ora Cade:The Convectors License w law does not apply tom owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves hereon,and who does such work himself or through
his own employees,provided that such improvement,are not intended a alTared for NEW RESIDENTIAL ELEC R SQ PT.
le.If,howeveq the building or improvement is sold within one year ofcompletion,the SQ.IT.FLUOR AREA &SQ.FT.'
ncr-builder will have the burden of proving that he did not build or improve for pur- Insas• q �T
poseofsole.). y
❑I,as owner of the property,um exclusively contracting with licensed contmcmta n TOTAL:
construct the project(See.,044,Business and Professions Coda)no Contractors Li- APR •'15
Li--
can=Law does not apply to m owner of proper who builds or improves thereon,and QTY PLUMBI IT FEE 1996
who amamct,far such projects with it commaui(a)licensed passuum to the Contractor's
Lt..law' PERMIT ISSUANCE.
0I um exempt under Sec. ,B&P C for this resents PERMIT I�' Uh L ur'Cal l I1VU
Owner DataALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty(if perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to sett-insure for Workers Coroner- DRAINS-FLUOR.ROOF.ARFA,C NU
savor,ns provided for by Sea ..3700.f me loan,Conk,far the performance of the STORIES TYPG CONSTRUCTION
work for which this permit is issued, FIXTURES-PERTRAP
1 have and will maintain Workers Compensation Ineursum,ea nyuaed by Section
of the Labor Cade.for the pesformanc<of the work far which Nis permitis issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker Ca pe 1st, tt carrier and Policy qq �771I��
Carrier:�policy Nn.: I/ 2100 GAS-EA.SYS7EM-0VER4(EA)
CERTIFICATL'O:EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(This section need not be completed ifda permit is for one hundred dollen(5100) GREASETRAP
or lees.) PLANCHECK FEE
I certify that ushe perimmmceofthe work farwhich this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so us to become subject m the Worker,•Campcm ENERGY FEE
O z gallon laws of C.IiRrnio Date WATER HEATER WNENT/HLECTR
Z 2 APPlicant GRADING FEE
w.'M NOTICE TO APPLICANB If,after making this Certificate of Exemption,you should WATER SYSTEMORHATING
become subject to the Worker's Compensation previsions of Ran"her Cale,you must SOILS FEE
{aa forthwith comply wisheueh pra,kiona or this pcnnit shallhe deemed revoked. WATER SERVICE
h Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID Date Receipt#
UQ I for which this
Net Nitre issed(Section lending agency for the Perfommnce of
wr Ne work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Nume TOTAL:
O'W lenders Address - TOTAL. BUILDING FEE
W correct
LFLww I certify that 1 have read this upplication'md state that the above information is
l agree m comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U Z buildingconstruction,andhereby authorize repmsenmtives ofthis city menterupanthe SEISMIC FEE
'-' above-mememed property for inspection pmlwses. PERMIT ISSUANCE
(We)agree m.,a.indemnify and keep hartnlese the City of CupeNms against ELECTRIC FEE
Iiuhilities,judgmems,costs and expenses which may in any way creme against said City ALTER OR ADD TO MECH.
in consequence of te hgrunting of this parent, PLUMBING FEE
APPLICANT UNIiIHRSTANDS NO WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,M)CPM) MECHANICAL PEE
SOU 'E REGUL TIO
AIR HANDLING UNIT(OVER 10,01111 CFM) CONSTRUCDONTAX
Signamteaf Appl n11amracmr Dem EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building campatn store at handle humdou.s mwcrial HEATING UNIT GO I00.IX0 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Solely
Code,Section 25532(oyl HEATING UNG'(OVER 1101,001 BTU) -
El Yes Oslo - - PAID
r VENOLATION FAN(SINGLE RESID) Data Receipt III
Will the applicant or future building occupant use equipment or devices which BOILER-COMP QHP OR IMM)BTU)
and,hamrdous air maturnnmts as defined by the Bay Am.Air Quality Management TOTAL:
Dnmcr!
OYea CNn BOILER-COMP(OVER 110,000 BTU) '
(have reed the hiaudous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
milia Health&Safety Code,Seromas 25505,25533 and 25531.1 aMerstmW that if the NEW RESIDENTIAL MECH. SQ.FT.
building does
not currently have a met p that o is ua ce ofa Ceriry to ratify the panty. -
afthe requirttadts which must be trct prior m issuance of o Certificate of Occupancy.
OwnerunuthorizW agent - Dam T ISSUPD BY:
OFFICE