29158 ' APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT:PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO /''�
BUILDING DIVISION APPLICATION/PERMIT • PLUMBING-MECHANICAL l • . . 91 '5 g
BUILDING PROJECT IDENTIFICATION V i
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2.o C It ftxl�sisx
A 0 R'SN
: RA1 OR'SNAM '
i NO
N/C CONTROL k
LIC : SRCHITECT/ENGINEER.
❑ r
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT 'PLUMB MECH `
❑ ❑ ❑
—LICENSED CONTRACTOR'S nor,
of CoN - QTy, ELECTRIC PERMIT FEE
pp 1 hereby M.that I am licensed under p ons of Chaeta 9 my license
iven sing JOB DESC IPTION
ty{UWr wrNS cit Tyra) cDivrsron]ofthb eusi s dP fessionsC d and my Isco cis PERMIT ISSUANCE 'RESIDENTIAL: -
�UFF in full force add affect. ❑SFDWI. ❑KITCHEN REMODEL
Zk3 License Close 'L¢.M APPLIANCES-RESIDENTIAL
hQ� Dam Contract., APPLIANCES L1 PLUMBING RE-PIPE
F.pm
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT L1 STRUCTURAL
O o y 7, f underswrid my plans shall be used as public records MODIFICATION
OZ4O UP T0200 AMPS 'DINTERIOR ❑CHIMNEY REPAIR'
R"
yl Licensed Professional . 201-11"AMPS - IMPROVEMENT
"��"pCd •a?
OWNER-BUILDERDECLARATIONthe Comers I OVER IOIHI AMPS ,E3 BATH REMODEUREPAHL El DEMOLITION
W 'I hereby affirm that l em exempt from the Comrec[ors License Lew hairdo,h
gip$,'O LL U following reason.(Section 703115,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER _
which requses a permit to constma,alter,improve,Demolish,or repair any structure F�jO pdorm its issuance,also requires the applicant far such permit 1.Ne a signed statement -
y SPECIAL CIRCUIT/MISC.
that heir licensed pursuam to me provisionsof the Contractor'sBusiness
ines. License Law(Chapter9 -
00 (cat he
(commencing Section andt000) f basis for of theeged essand Professions Code)or TEMP.METER OR POLE INST. OMM R [ Ir
that io is exempt therefrom and the boars for the alleged exemption.Any violation of '0 NEW BLDG/ADDITION ❑DEMOLITION h
4X1 y
Section 7031.5 by'any applicant f Permit subjects theapplicant to e civil penally of POWER DEVICES 0 TENANLI El FOOD SERVICE
Z more Na f h dr ddoll ($500)
CQ fth P Pd y employeeswith ag ' thesole comistram n. SWIMMING POOL ELECTRIC IMPROVEMENT - t
PG! it do me work,and the someone t intended crocheted]fr sale(Sec 7044 Busnei. D OTHER
and Professions Code.The Connectors License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES ` t
property who builds or improves thereon,and who does such work himself or through
his own employees,Provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one your ofcompletion,the - SQ.FT,FLOOR AREA $/SQ.FT'
o enr-buddbuilder will have the burden of proving that he did not build or improve for Pur-
poseJ.
❑1,as owner of the property,am exclusively contracting with licensed contract...[a TOTAL:
onstoro the Project(Sec.7044,Business and Professions Code)ne Contractor's Li-
cerise
i-c se Law does not apply to an owner ofpmpeny who builds or imp roves them QTY PLUMBINGPERMIT FEE -
whocammotaforeachpryectswithecomracmr(e)Ilcweed purs.im to the Conon e,
License Law. PERMIT ISS ANCE
❑e se exempt under Sec. ,B&P C for s reason
Owner Dare ALTER—DRP &VENT—WATER(EA) VALUATION
WORKER'S COMPENSATION DE me fid I BACK FLOW P TELE TEVIce INSPECTION DEPARTMENT
Thereby affirm under penalty of perjury one of Ne fol mg oeclarmiom: -
71have and will maintain aCeniitoteofConvem to self-' surefor Workeel Comped- DRAINS—FLOORROOF AREA,COND. I TYPE CONSTRUCTION
salion,as provide!for by Section 37W of the Labor e,far the perfmou re of inERTIN
work for which this permit is issued. a FIXTURES—PERT P -
❑ 1 have end will maintain Worker's Co satin Insurance,as required b io
3704 of Ne Labor Code,for rhe performan enfthe work .which Nisp .'sued, —EA.SYSTEM-1 NC 40UTLETS OCC.GROUP' APN
My Worker's Compensation Insurance ca randPoliey arbor r -
Cannot:' Policy N..: - B YSTEM-OVER4HDO
CERTIFICATE OF CREST ION M KERS' [
COMPENSATE) INSURA G SFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION PEES
(Thissectiou need tube completed i he permR info o hundred t�llo(s($1XB
or less.) GREASE TRAP PLANCHECK FEE.
Icenify Natinlhepe,fo.masecofthe is for which this Permit is issued,Ishall �.
not employ any person m any manner so as to come subjen m the Workers'Cnmpen- SEWER : 0 / ENERGY FEE
ZO, satioul....f Califrmin Dvte -
- -
O Applicant WATER HEATERWNENT/ELECTR GRADING
'
IA NOTICE TO APPLICANT.If,after making this Ce 'fsare of Exemption,yo should WATER SYSTEM/`TREATING
t••' become subject to Ne Worker's Compensation provisio of the Labor Co you mush SOILS FEE
forthwith'comply with such provisions dr this permit shall me rev ed. WATER SERVICE
a CITY UI- lIxi-tn i INU
�L CONSTRUCTION LENDING AGENCY
,7 ,Z NEW RESIDENTIAL PLMB. SQ.Ff. PAID
I;)O T he
rebywhich nn that them isacoreSec.30[ending agency fanhe performance of Date ReceiptN
u, !•+
the work for which this pennll Is Issued(Sec.3097,Co.CJ
F� Lenders Name - 1
Lenders Address TOTAL
a :
9LI TOTAL:
o Icenify that have read this application end state FE
le that the above information is � � BUILDING E
rA c nett.I agree in comply with all city and coumy aNir anew and smite laws relating to QTY, MEG LAICAL PERMIT FEE
.0 building constuction;and hereby authorize representatives of this city to enter spends, SEISMIC FEE
above-mentioned property for inspection purposes. -
(We)agree to save,indemnify and keep hamdes.the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADO TO MECH.'
in consequence of the Starting of this permit. - PLUMBING FEE
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT PIR HANDLING 11NIT(TO 10,000 CFM)
S EREGUL IONS, w. - - SIECHANICALFEE s,
OSAiy Q�" �I - AIR HANDLING UNIT(OVER 10,(KKICFM) CONSTRUCTIONTAX
SilasS i,anfUaConuactt., w'�e.R1 ` Dam EXHAUST HOOD(W/DUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.,future building.acupanl stare.,handle boarmho,material HEATING UNIT(P)100.000 BTU) '
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -'
Code,Sectio.25532(a)? - HEATING UNIT(OVER 100,1100 BTU)
D Yes DNo „ "VHNTILATION FAN(SINGLE RESID) PAID -
Data Receipt is
Will the applidanl or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management. .' BOILER—COMP(3HP OR IW,OW BTU) .
District? I , ; I I I
A BOILER—COMP(OVER I W,(R10 BTU) TOTAL
❑Yes 11 No
I have read the hazardous mmenrdl 2 uircmen[s under Cha ter fi.95 of Ne Celi- AIR CONDITIONER • -
9 p - C ISSUANCE DATE
famia Health&Safety Code,Sections 25505,25533 and 25534.1 understand Nat if the NEW RESfDENT1AEMECH. SQ.IT,
'
building dcesnot cunemly have alenwl,Net it is my responsibility to notify the occupant '
of the tegmreencom which must t e met prion issuance of a Cemfrate of Occupancy.' - -
Owner..mahminedagemt Dale - - TOTAL: n
ISSUEDBY: �c'
OFFICE