29216 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO. 29216
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L�JJL kl•J�
's. BUILDING PROJECT IDENTIFICATION
BUILDI A SANITARY NO. APPLICA ONSUB TTALDATI
NE ME: all
P NB: — NTRACfOR'g NA E' LIC NO:�� I
11 N/C CONTR L
ARCHITEC iENGINER: LICNO: A f ❑
50 1 /N in
CONTACT. PHONE: BUILDING PERMIT INFO
5i01 ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
51EA)600+ ❑ ❑ g� ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm but 1 ant licensed under provisima,fl Chapter 9(commencing JOB DESCRIPTION
{sD 00 with Section 1000)of Division 3 of the Business and f dmylicmxs is RESIDENTIAL,
FOO ' fu 11 force and of t. PERMIT ISSUANCE
�W �Z�,, _ ❑SF'DWL .. El KITCHEN REMODEL
U Ocen �ay —vs-�Lic.N APPLIANCES-RESIDENTIAL [,]ADDITION OPLUMBINGRE-PIPE
h<� Daa� F��Conwctnr
[F...Orn ARCHITECTS DECLA TI ❑MULTI-UNIT ❑STRUCTURAL
Z822,7 1 understand my plans shall be used as public records - PANELS MODIFICATION
O
UP TO 200 AMPS'� Ow�y ❑INTERIOR [I CHIMNEY REPAIR
r4 .] Licensed Professional - OVER
RAMPS IMPROVEMENT
pa��( OWNER:BUILDER mDECLARATION
�+K w Q 1 hereby affirm that 1 em exempt from the Comncm/s License Lew for the OVER 1000 AMPS O BATH REMODEI/REPAIR O DEMOLITION
3 06U following reason.(Section](131.5,Business add Professions Cade:Any city or county SIGNS ELECTRICAL [I OTHER
W Fya' which requites a Famous m construct.alter,improve,demolish,or repair any structure
Prior'.its the up,fcom fmmch pemlut,file a signed nimormt SPECIALCIRCUIT/MISC.
a� that he is licensed Pursuant'.Ne provisions of due ContmctolsLicense Law(Chapter 9
00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)of TEMP.METER OR POLE INST. COMMERCIAL,
G e y that he is exempt therefrom and the basis for Ne alleged exemption,Any violation of O NEW BLDG/ADDITION O DEMOLITION
^+{�
Section 7011,1 by any applicant for m mona,ubjecla the applicam to acivil penally at POWER DEVICES
lin C1 TENANT ❑FOOD SERVICE
11ZZ8
not than five hundred dollars IMPROVEMENT
6 O I,'.owner o(thc popery,or my employees with wages as their sale compensation, 'SWIMMING POOL ELECTRIC
will dmhe wo$and the structure is not inteMed nroffeled for sale(Sec.7044.Business ❑OTHER
6 2 and Pmfmsions Code:The Contrnemis License Law does not apply to an owner of OUTLETS-SWITCHES-FTXTUR
.. property who builds or improves thetron,and who does such work himself or through
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELECTR SQ ff..
sale.If.howeer,the building or improvement is sold within one year of completion,the SQ.FT.TE ARBn4 SISQ,FT.
owner-builder will have the burden of proving that he did not build or improve for purr- ` . G'�k
pose of sale,. w
❑ 1.as owner of the pri am exclusively contracting with licensconors to TAL.
licensed contractors
construct he project(Sec.7 N .Business and Professions Code:)The Contractor's Li-
cwhoLaw does not apply to im owner of property who builds or improves meters.and QTY. PLUMBING PERMIT FEE A
cantons for such pmjcns with a comracods)licensed pursuant to the Contmemes KILN
License l<w. PERMITISSUANCE / CICS Ur 1iUrr
❑ Ism exemp r Sm. B&P C forthis assn
ALTER-DRAIN&VENT-WATER(EA) Ze VALUATION
Owner Data
ORKER'S COMPENSATION UIiCLARATION BACK FLOW PROTECT,DEVICE
I here firm under penalty of psrPa one of the fullowing dre,lamtiom: e
❑I have and will mountain a Certificate of Consent to self-insure for Worker's Compete- DRAINS-FLOOR,ROOF,AEEA,COND' S ORIES 'I YPECONSTRU(JITON
action,ex provided]for by Section 3]00 of the Labor Cade,for the perf onsco a of the
work for which this permit is issued, FIXTURES-PER THAI'
❑1 have and will maintain Worker's Compensation Insurance,as requirel by Section
3]00 of Ne La C c,fmthe performance. the k for which this permit is issued OAS-EA.SYSTEM-1 INCA OUTLETS ,OCC.GROUP APN
My Worked ti su nY Q _FA.SYSTEM-OVER4(FA7
Cartier:
CERTI• ATEOFEXEMPTIONFROMWORKEW -
COMPENSATIONINSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This sectio not becompma ifthepemaia is foronehundrW dodders(SII10) GREASE TRAP or less.) - PLANCHECK FEE
I certify that in the performance of the work forwhich ihis Permit is issued.(shall SEWER-SANITARY-STORM EA.200 FT.
person not employ any pen in any manse m us to becmeombja d to the Workers Compen- ENERGY FEE
O Zsection Laws of Caldron..Data - WATER HHATER WNENT/ELECTR li r
O Applicant GRADING FEE
tiNOTICE TO APPLICANT.IL after making this Certificate of Exemption,you shouts WATER SYSTEM/TRHATING I�' -
become subject to the Worker's Compensation Provisions of the Labor Code,you must SOILS FEE
foMwith comply with suck,mvisi.nsorthis permit shill he deemed revoked. WATER SERVICE
O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.TIME. SQ.Fr PAID
I herebyaRrmthm there isoconstruction lendingagmcy for the performance of Date ReceiptR
the work for which this permit is issued(Sea 3f19],Civ.C.)
Lemdels Name TOTAL:
II ffpL,LLLCy~tttttt �ndcr's Address TOTAL:
y 1 certify that I have read this application and state Ont he above information is BUILDING PEE
In correct.l agree to comply with all city and county tannaares and state laws miming to QTY. MECHANICAL PERMIT FEE
G Z building consometion.and hereby myronre representaivei of this city o enter upon Ne SEISMIC FEE
above-mentioned property for inspection m,mrs. PERMIT ISSUANCE
(We)agree t.save,indemnify and keep harnless the City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECN.
in asequence of the granting of this Permit PLUMBING FEE
APLf ANT DERSTA' IL OMPLY_ TH ALL>6N-POINT AIR HANDLING UNIT(TO IO,OW CFM) "
AP Lf ULAT1O /' MECHANICAL FEE
C/[/T�/_ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
nam fA icanVCantmnor -✓lam- DatFe-' EXHAUS'T HOOO(W/DUCT')
s HAZARDOUS MATERIALS DISCLOSURE. HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hiumdous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ONn
VENTILATION PAN(SINGLE RBSID) PAID
.Will the applicant or future building occupant use equipment or devices which Date Receipt M '
emit hmadom air contamiamas as defined by the Bay Ates Air Quality Management BOILER-COMP(3HP OR 100,0010 BTU)
District? TOTAL:
[]Year ONo BOILER-COMP(OVER 100,000 BTU)
I have read the hustrJws materials requirements under Chapter 6.95 of the Cull- AIR CONDITIONER ISSU
forma Health&Safety Code,Sections 25505,25533 aM 25500,1 understand Nat if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a armor,that it is my responsibility to notify the ocenpant
of Rhe requirements which must be met prim to issionam of a certificate.!Occupancy.
Owner or authomoal agent Date I I TOTAL: ISSUED BY:
OFFICE