29765 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 29765
1 /+ /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /9 7{� s'1
BUILDING PROJECT IDENTIFICATION L N 1 V V
BUILDINGADDRFSS: I/T C OIC ItM[ SANITARY NO. APPLICATION SUBMITTAL OATS
OWNERS NAME: o f �� .SH NE: CO DR'S NA LIC NO: NIC CONTROLp
V s YUGIo
ARCHITECDENGINEER��` M �_ LIC NO: ADDRESS: APO ft V' ❑
FCONTACT.-� - IAS , PHONE]� ] q N P BUILDING PERMITINFO
v s-sssu iurui(((•��A ag-2 �" /� a ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑LICENSEDCONTRACTO SDECLARATIo QTY. ELECTRIC PERMIT FEEby affirm Nat 1 um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
]IXq)n(Division J hf to Business emI ProfessisRESIDENTIAL:
{{s100 PERMIT ISSUANCEFr. nita _ ❑SMWL ❑KITCHEN REMODEL
�VUs Lic.N gppL1ANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
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A' ARCHITECTS DECLARATION C3 MULTI-UNIT []STRUCTURAL
Z p Z I understand my plans shall be used as public records PANUS MODIFICATION
UPT0200AMPS
OZ O I❑ NTERIOR I�CHIMNEY REPAIR
[+.� ul Licensed Nutritional AMPS, MPROVEMENT
•.1 OWNER-BUILDER UE CLARATION OVER I"AMPS - ❑BATH REMODEUREPAIR [I DEMOLITION
1 hereby.(Sinn that 1 1. exempt from she Contractors License Law for the
iN'� fallowing reason(Semon]071.5,Business and Professions Code:Any city or musty SIGNSELECTRICAL ❑OTHER
su O F 11
which requires a permit to construct,alter,improve,demolish,or repair any structure
res prior to its issuance,also requires the applicant for such perming file a signed statement SPECIAL CIRS'JdfIM 'C.
E(D+ that he is licensed pursuant to the provisions of the Contractor's License Law,(Chapter 9
a00 (commencing with Scmion7")of Division 3 of the Business and Professions Cale)or TEMP.METER OR POLE INST. COMMERCIAL:
a, a y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDMON El DEMOLITION
9 :2 Section 7031.5 by any applicant for a permit subjects the applicant o o civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than Eve hundred dollars($50fir 04 IMPROVEMENT
HC]I,ashwnaof lhepropeny,mary employees wit wagesas telrsola mmpensatinn, SWIMMING POOL ELECTRIC
O will do to work,anal the structure,is not intended or offered for sale(Sm.7044,Business []OTHER
m and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES _ -
�' .+ property who builds or improves thereon,and who duct such work himself or trough -a
his own employees,provided that such improvements anot intended or offered for NEW RESIDENTIAL ELECTR S
rc
sale.If.however,to building or improvement is sold witin nneyearofcomplanim she IF SQ.PRFLOORAREA $/SQ.FT.
owner-builder will have the burden of proving shat he,did not build or improve for par- II V q
poaof side.). !11 1 996
❑ h as owner of the property,um exclusively contracting with licensed ma
cnners m T - Ss v
cnnswct to project(Sec.7044.Business end Profeaionx C—;,The Conua...i Li- 011 1 ur V uni
cense Lowther not upplyman ownerof property who builds orimpmves thermal mul QTY, PLUMBING PERMIT FEE fT 111V1J
who chmmms for inch projects with.matmcmrts)licensed phrsuanuo the Contractor.
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&P C for this remain
Owner Da¢ ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I (rJ0
I hereby arum under penalty of perjury one of to following declarations: -S,)5
O l have and will maintain a CeniOcam of Consent self-insure for Wmkcrs Cumpen- DRAINS-FLOOR.ROORAN ,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37M of to Labor Code,for the performance of do,
irk for which this permit is issued. FIXTURES-PER TRA \s•J�
❑1 have and will maintain Workers Compensation Insurance,as required by Section _
3700.fte Labor Code,for the perfunnancc of the work lin which this permit is issued. GAS-EA,SYSTEM-1 4 Ur h OCC.GROpP APN
Carrieerker'sfp pen t'rmh�ncec .Pond Policy nu : 't GAS-EA.SYSTEM- iR EA) V/BNllf
CERTIFICATE OF EXXEEMPION FROM WORKERS' GREASFII STRLW STE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This action need not he completed if the per it is for one hundred dollars($100). GREASETRAP '
or Inst PLANCHECK P88
I certify that in to perfmmanceofdo,woo for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers Com ser- ENERGY FEE
z7. salma Laws of Culifomia.Data WAFER HEATER WNHISUMLECTR
O Applicant GRADING FEI?
y NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEMOFRBATING
a ^ become,subject to to Workers Compensation provisions of to labor Code,you must SOILS FEE
G fnnhwit comply with such provisions or this penniuhall he deemed revoked. WATER SERVICE
d 0
CONSTRUCTION LENDINGAGENCY NEW RLSIUENDAL PL.MB. SQ.FI'. PAID
V O hereby which n annotmisa issued(Sec.
agency for pedomantt of Data ReceiplN
ti to work(or which his permit is isauW(Sec.J09],Civ.C.) -
LL E~ Lualer's Name TOTAL:
Lender's Address -TOTAL:� BUILDING FEE" G I manly that 1 have read this application and stem that to above information is
h correct.I agree to comply withal)city and county ordinances and state laws miming to QT'Y. MECHANICAL PERMIT FEE
V buildingconsuuction,andherchy authorize represconives ofthis city tuenterupar the SEISMIC FEE
above-mentioned properly far inspection purposes. s PERMIT ISSUANCE.
twe)agree io save,indemnify and keep harmless to City of Cupertino against ELECTRIC FEE
Liabilities,judgments,costs and expenses which may in any way accrue against said City ALTBRORADDTOMECE
in consequence of the gmming of this Permit. PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING U IT(TO IBM)CIM) MECHANICAL ME
SOUR E 6 ULATIONS.
all AIR HANDLINGU (OV IDJ*JAIi4vB CONSTRUCTIONTAX
Sigmmmo ApplicanBContmcmrt{e EXHAUSTHOOD( 0 C17 HOUSING MITIGATION FEE -
HAZARDOUSMATERIALSDISCLOSURE
Will to applicant or future building nar.pamanre or handle hazardous material HEATINGUNITOR 110, V7
as dcfinai by the Cupertino Municipal Cale.Chapter 9.12.and the Heap and Safety
Code,Section M532(a)? HEADNC O TR IfIB.IXIO BTU)
E]Yet . y11`o v VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Ume Neceipt k Is,
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,1100 BTU)
District?
❑,Yen �Nh BOILER-COMP(OVER 100,0001311)
I have read the hazmdots materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DAT
fomia Health&Safety Code.Sections 25505,25533 anal 8534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does not currently have a serum,that it is my responsibility to notify the occupant
of to requirements wh' ust be het pr'ur s uncc of o CenlBwm of ancy.,
Owner or emhoriz .gem Date TOTAL ISSUED BY:
OFFICE