29314 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No 2 L 9 31
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L
BUILDING PROJECP IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL D:
l Co •,�^e 1 ' 6rdoe,; i r
, leas
OWNER'S NAME: PHONE: CONTRAqf00.'S NA LIC NO:
&UArrI, /Le NIC CONTROL#
:ARCH / NGINEER: LIC NO'. ADDRESS: ./ ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG. ELECT PLUMB MECH
❑ ❑ K ❑
LICENSED CONTRACTOR derp DECLARATION QTY ELECTRIC PERMIT FEE
I hereby Tfirm that Into licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
I K wifeSecrce ndeffecDivirion3of rhe BusiressanO Professions Code.and mylic<aeix
SOC � PERMIT ISSUANCE RESIDENTIAL
.U; m��li farce and effect.Ls ` 696 ar ❑SFDWL CI KITCHEN REMODE
UU<U�j License Class Lich D �ADDRION ' BING RE-PIP[
p, DaIe�GOalmcrof APPLIANCES-RESIDENTIAL ��'��{w,,.M
no,p, ARCHITECI-S DECLARATION PANELS E3 MULTI-UNIT LJSTRUCTURAL
Z O,Rjfz I understand my plans shot]be used a public records MODIFICATION
OZ—n UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�FYI Licensed Posit,x.....I 201-IWOAMPS '��- IMPROVEMENT
ad OWNER-BUILDER DECLARATION
< 1 hereby affirm that 1 um accept from rhe Commnar'x Liccae Law for rhe OVER 10X)AMPS ❑BATH REMODEVREPAIR ❑DEMOLITION
k31F following reason.(Seen..7071.5,Business and Professions Cale:Any city or county SIGNS ELECfRIGL ❑OTHER
ttl a y which rcgmrts o permit ro oman t.ager,marmot,demolish,or repair any soma.F'=0g Prior o its issuance,alt requires Ne applicant for such pemdr to file a signed statement SPECIAL CIRCUIT/MISC.
fly— that he is licensed Pursuant o the Provisions of,hC Cmarnatois License Law(Chapter 9
W G'QQ Icommemingwith Secdon7")ofDivision3ofthe Businessad Profusions Cade)m TEMP.METER OR POLE INST.
S a m lir that he is exempt therefrom and the basis for the alleged exemption.Any violation of EW BLDG/ADOI7lON ❑DEMOLITION
Section 703 L5 by any applicant for a pemdr subjects the applicant o u civil penalty of POWER DEVICES
am are than rive hundred dollars(5500). ANT ❑FOOD SERVICE
C ❑1.a owner of the IMPROVEMENT
are
my wages as I se.compensation. SWIMMING POOL ELECTRIC 7
II do the work.and Ne swnurc is not intended oroffertd tarsale(5¢.]044,Businea []OTHER
aWl'-� and Professions Code:The Contractors License Law does net apply to we owner of OUTLETS-SWITCHES-FIXTURES
p'3 property who builds or improves Hereon,and he docs such work himself or though
his own employees,provident that such improvements are nor intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
We.If.however.Ne building or improvement is Bald within ane yemofcompleice,the SQ.FT FLOOR AREA LSQ.FT.
owner-builder will have the bursters of moving shat he did not build or improve for put.
posc of ale.]. TOTAL: n
1,at owner of the propcny,an exclusively contracting with licensed contacrors to
countmct fee protea(See.]044.Business and Professions CWe:I The Conmeor'n Li.
cense law does not apply to an owner of popery who builds or improves thereon and QTY, _r,>w PLUMBING PERMIT _ ,FEE
who conrmesfor such projects with o commucore)licensed pursuant to the Contmctoes
Lt..law' PERMITISSUANCE `•� D
1 am exempt under Sec. .B&P C for this rtaon V �Q
ALTER-DRAIN&VEST-WATER(EA)
Owntt Date iJ%• f Jr r UATION
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE trj/%n
1 hereby affimt under penalty of perjury one of rhe following declare) pU
FII have malwill maintain a Certificate of Consent o self-insure for Workerere-s CompDRAINS-FLUOR.ROOF,AREA.COND, gTQR{p5 TYPE CDNSTRDGDr
ration,a provided for by Section 3700 of the labor Code,for rhe performance of the
work for which this period,is issued. FIXIVRES-PER TRAP
I have arW will maintain Warkcrs Campensadon Ishical ecrequired by Smiom
3700 nfthe labor Cods.for the pe,f..ce.f the work for which this permit is issued. GAS-FA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Wrr�upnFuagearner aP
Policy No.: maSH
7 ]- GAS-EA.SYSTEM-OVER 4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This section deed not becompleadl nano pent is furnace hundred dallare 15100) -:'-v t; .): '% :RNIDPIGDMSI.ON FEES f'fei T:x:-
or lea.) GREASETRAP PLANCHECK FEE
I centy,that in the perfomunce of an,work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
noremployanyperso to ymmmers m laup the Workers'Compere. ENERGY FEE
OZr anion Laws of are / / WATER HEATER WNENT/ELECTN
Z O Applicvnt >9 GRADING FEE
=
NOTICE! PPL IJt If. Bcr,mak' his Cartlficae of Exemption.you should
WATER SYSTF1d/fRFATING
a , become subject m the Workers Compe s ion Provisions of the Labor Code,you must SOILS FEE
W
forthwith comply With such provisions or this permit shall be deemd revoked. WATER SERVICE
ar
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L)Q 1 herebyaffires than there is o construction lending agency for the perfomeace of Date Receipt
U. the work for which this permit is issud(Sec.3097,Co,C.)
Q f•-' Lender.Name .00" TOTAL:
Lenders Addrea
Fy 1 certify rho I hove read Nis applWauon oil arose Nat tM above inforttwitn is BUILDING FEE
to cancer.I agree to comply with all city and county oWimences and state laws rclaung to QTY, MECHANICAL PERMIT '>FEE
V Z building construction,and hereby authorizeexprcseamtives ofthis city to enter upon the - SEISMICRE
above-mentioned popery for inspection purposes. PERMIT ISSUANCE
(We)agree o save,indemnify and keep hamtless the City of Cupenino opinst ELECTRIC FEE
Iiabilirietjudgmors.cmemidexpenses which may,.any way aecmeagainst said City ALTERORADDTOMECH.
I.comionemse of rhe germing of thix permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER M."CFM) CONSTRUCTION TAX
Signoras,of ApplicunVCunrrcor Dam EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theian,icamor lumre buildingoccupanrstnre or handle harmdaus realedaI HEATING UNITITO IfX1.fX)O BTU)
a deftnnd by Ne Cupertino Municipal Code,Chapter').12,and the Health and Safety
Cde,Section 255R(aly HEATING UNIT(OVER 10(1,0X)BTU)
El Yes ❑No PAID
VENTILATION PAN(SINGLE RESID) Dae Receipt#
Wilt the applicant infuture building by the S y A equipment or devices which
mit hazardous air contaminants a Jelined by the Bay Area Air Quality Management BOILCR-COMP(JHP OR 100.900 BTU))
home?
TOTAL:
Q Yes ❑No BOILER-COMP(OVER Ifl(M)BT U)
1 have read he IozaNrms materials requirements under Chapter 6,95 of the Coli- AIR CONDITIONER ISSUANCE DATE
lomin Health It Safmy Code.Scent as 235115,255]3 and 25534.I uncensored that if the NEW RESIDENTIAL MECt{, SQ.F1'.
MailJinY tiro#ran carte IY have menmt.that it is my mxpmsibiity emwily the mcupatn
of the requi lch moa n prior ro i.amnce m a Cendimre n'Occ
4 7
Own ugem TOTAL] ISSUED IIr 674- Y:
OFFICE