29313 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 29313
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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t OWNF. 'S w M1iT• PHONE:7 q3/ CONTR R'S ME: p�S LIC NQ
` e N/C CONTROL If
RC ECT/ENGINEER: LIC NO: ADDRESS: ❑
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CONTACT: k PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG HE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby arum that 1 ant licensed under provisions of chapter 9(commencing JOB DESCRIPTION
,F,OOWZ with Section 90001uf Division 3ofthe Business and Professions Cade,and my license is RESIDENTIAL:
z iafallforcemide0ect. PERMIT ISSUANCE
V$ Li he a C 4 Lot, 6 Z ❑SFDWL ❑ CHEN REMODEL
QL Date �ConlmetuflLl( APPLIANCES-RESIDENTIAL ❑ADDITION MBWG RE-PIPE
ARCHITECTS DECLARATION
[I MULTI-UNIT STRUCTURAL
Z O(/1'z I understand my plans shall M usedas public records PANELS MODIFICATION
O Z:1 UP TO 2W AMPS
[Ip INTERIOR [I CHIMNEY REPAIR
0.s^ � Licensed Professional 301-IgI0AMP5 IMPROVEMENT
Y Oat I am eUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEVREPAIR-❑DEMOLITION
0.' Q 1 mase affect that 1 nm exempt tram Ne Cantons Co License Law for Ne
?pS.O L V following reason.(Section 7031.5,Business and Professions Cnde:Any city or county SIGNS ELECTRICAL ❑OTHER
s't F' which requires a perosis to commuct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such penman file asignedstincmen, SPECIAL CIRCUIT/MISC.
ythat he is limnsetl pursoanuothe provisions of Ne Contractors License law(Chapters)00 (commencing wi"ectio 7000)of Division 3 of Ne Business and Pmfessians Code)or TEMP.METER OR POLE ST. COMMERCIAL:
e C that he is exempt therefrom and the basis for are alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION'
^
Section 7031.5]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POW CR DEVICES
^rn []TENANT ❑FOOD SERVICE
t roam Nan Ove huudeed dollars .
F. Y IMPROVEMENT
Za ❑b
I
us owner ofN<pmFerty,lir myy employees
empioyms with wages as their sole compensation, SWIMMING POOL ELECTRIC
� the structure is not intended proffered for sale(Sec.,D_Business ❑OTHER
will do the work,and
a and Professions Code:The Commences License Low does not apply to an owner of OUTLETS-SWITCHES- -
IR
5S
who builds or improves thereon,and who does mch work himself or through
his own employees,provided this such improvements arc had intended ar olTered for NEW RESIDENTIAL CLECTR 1 Q
aid ,If.however.the building or improvement is sold within one year of completion,the SQ.PT.FLOOR AREA ESQ.FT.
ownerhuilder will have the burden of proving that he did not build or anatomic for tour- - t
pose of sale.l
❑L as owner of the property,am exclusively contracting with licensed contractors to - TOTAL.
construct the projttr(Sec.70,1,1.Business and Professions Cade:)The Contrvctoes—
cenes,Use does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such pmjmts with asontmetods)licensed pursuaano the Commences
License law. , PERMIT ISSUANCE 1 ce
❑Iamexemptunder Seca ,B&PCfor Nisreasan n 8
ALTER-DRAIN&VENT-WATER(EA) I'AFftION
Disinter Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE OhZ-Ur�h�� e
1 hereby affirm under penalty of perjury one of Ne following declarations:
❑Ihuve and will maimnin aCertificme o(Co..car to self-insure for Warkers Co.,.- DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPECONSTRUCTION
a numn,es provided for by Section 37 00 of the Labor Code,far the performance of the - _ '
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section -
37Mofdr.lsbor Code.forum,peeformartce of the work for which Nis permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCCGROUP APN
My WmkersFF �pensutyyn Insu4rdlince catrier and Policy nu are
Cartier. 4VATC� _ I�.Jt'Vq Policy No.: I4 ;�f/17�Cg� GAS-EA,SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Ihiasation need not be completed if Ne pcnrdt is(prone hundred dollars IS BID) GRFASI?TRAP
or less) PLANCHECK FEE
tcenifyslartm,eperfmmanceaf ewo-/k forty ieh this permit is issued,I shall SEWER-SANITARY-STORM EA.20)FT.
not employ say Fen a mann so by oe hjjsel to the Workers'Cmopen- ENERGY PER
z ,z smion Lawn to ttt ��- WATER HEATER WNENT/ELELTR
O Applicant r GRADING FEE
Vj NOTICE TOA LICANT:
If.adifrinaking Iit
ificate of Exemption, IT
mct uvisyou should WATER SYSTEMREATING SOILS FEE
a� becoesubjes the Workers Cnmpensmion omsof the Lalntr Cale,you must
W s.. forthwith comply with such provisions or this permit shall be domed revoked. WATER SERVICE -
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U z Done Receipt If
L)O r I herebywhihthapmumt1 them isacd(Ser.097. gency for the Performance
Ne work for which this permit is issued(gee.J0'P,Co,Civ.CJ
0 U Lenders Name TOTAL:
Lenders Address
�—
1 sonify that I have read this application and state Nat the above information is BUILDING FEE
4 correct.I agree to comply with all city and county ordinances unit state Iowa relating m QTY. MECHANICAL PERMIT FEE
V Z building commuction,and hereby authorize represenmtivesof thiscity m enter upon Ne SEISMIC FIiE
above-mentioned property far inspection purpose'' PERMIT ISSUANCE
(We)antes,to save,indemnify and kap harmless the City of Cupenino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
ns .
in consequence of the granting of Nis permit. PLUMBING FEC
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CIG 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I0,00o CFM) CONSTRUCTION TAX
Signature of ApplicanVCommetor Dam EXHAUST HOOD DVMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will she applicant or future building occupolstore orhmWle hmnNous mrrenal HEATING UNIT TO 100.000 BTU)
as'di fined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Station 2S53200? HEATING UNIT(OVER that"BTU)
Fl Yes ❑Nn PAID
VENTILATION FAN(SINGLE.RP.S1D1 Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous oar cpnmmiaants as defined by the Bay Area Air Quality Management TOTAL:
Dtsmet? BOILER-COMP(OVER 1(10.000 BTU)
❑Yes ON.
I have mail the hazardous materials requirements CONDITIONERmenis under Chapter 6.95 of the Cali- ISSUANCE DATE
fame Health&Safes Cade,Sectio 25505,2551)aril 255J4.1 undersand drat if the NEW RESIDENTIAL MECH. SQ.FT.
buiMing does ecu mly have unt,Natit ifl my respmsibility to rase the oecupwt
of doe m ichm ssuancc ate Ccnif cu y.
Ow rase crud agent Date TOTAL: ISSUED BY:
OFFICE'