29973 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 29973
BUILDING PROJECT IDENTIFICATION
BUILDINGAADDDRESS: SANITARYIN A//P/LIICATIO GENE A All
J v � J
OW ' NAME: s PHONE: C ACfOR'SN C LIG NO:� NIC CONTROL#
RCHIMCUENGINEER: LIC NO: ADDRESS: - 133 ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT P MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 heathy alErn that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION ,
qaZ th Sectioir]IXXB of Division 3ofsheBosinessand Prdessions Code,and my(dream is RESIDENTIAL,
WOp with PERMIT ISSUANCE
F�-F. in fall force and dfmtCSFDWL El KITCHEN REMODEL
�UU License Class Lia# " APPLIANCES-RESIDENTIAL CADDITION [I PLUMBING RE-PIPE
Date Contractor
Z ARCHITECT DECLARATION PANELS - ❑MULTI UNIT ❑STRUCTURAL
Z84 b 1 understand my plans shall bo used as public recoNs MODIFICATION
OZ o UPT02MAMPS ❑INTERIOR [I CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER U10)AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
C Q 1 hemm by atHr t that 1 am exempt frothe Commedoes License Law for the
as
X L U following reon.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
3
Yl u. which requires a permit to consumes,alma impmve,demolish.or mpir any stmcmre S eQ 44.z e
pnorm its issuance,also requires the applicant for such panel to file a signed statement SPECIAL CIRCUITIMISC.
toNat he is licensed pursuant m the provisions of the Contractors License Low(Chapter9
,GE (commencing with Section 7")ofDivision 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
6 y
I.;
z that he is exempt therefrom and the bazis for the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
'X V- Section 7031.5 by any applicant for a permit subject the applicant o civil penalty of POWER DEVICES ❑TENANT C FOOD SERVICE
W not mom than Eve hundred dollars 06500). IMPROVEMENT
6 C1 owner of the pmpeny,or my employees with wages in their sole compensation. 'SWIMMING POOL ELECTRIC
willdothewnrk,and the stmcwmis nosimended orofferedfor sale(Sea 71004,9usiness ❑OTHER
and Professions Code:The Comment's LicenseLaw docs not apply m an owner of OUTLETS-SWITCHES-FIXI'GRES
property who builds or improves thereon,and who does such work himself or through -
his own einpleyees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PT. .O
owneLhowev will
hveth burden
issoldhedidinon wild ort(complettoroc RAR �j-1\ SISQ,FT.
pose f u e.).will have the burden of proving that he did not build or impmve torpor. D
pose of sated, TOTAL:
1,osr of the property,am exclusively contracting with liceii cmariamis to
construct the project(Sec.7044.Business and Professions Code:)The Committers Li- — 1
cense law does not apply to an owner of property who mildsm improves theme . ad QTY PLUMBING PERMIT FEE JUN 1996
who contracts for such pmjects with a connections)licensed pursuant to she Contractors
License Law. PERMIT ISSUANCE
C Tamesemptunder Sec. ,B&PCforthis«amn _
ALTER-DRAIN&VENT-WATER(G)
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE _ CITY OF CUPERTINO
1 hereby affirm under penalty of perjury one of the following declarations:
rl I have and will maintain a Certificate ofComsem fo
to aff-ourc r WC
mkcr's ompen. DRAINS-FLOOR,ROOP,AREA,COND, STORIES TYPE CONSTRUCTION
scion,as provided for by Section 37M of the Labor Cede,for the Performance of she
work for which his permit is issued. FIXTURES-PER TRAP
C 1 have unit will maintain Workers Compensation Insurance,as required by Section
37M of she Labor Code,for the performance of the work for which this permiu is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Worker's Compensation Insurance carica and Pol icy number mi
Currier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS GREASEINDGSTRI.WASTE IN'IP.RCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thin section need not he completed if the permit is for one hundred dollars(11 ab GREASETRAP
tar IeesJ PLANCHECK FEC
I certify that in the performance addle work for which this permit is issued,l shall SEWER-SANITARY-STORM HA.200 FT. Q
not employ any petsen in any murner so as to become subject o the Workers'Campen. ENERGY FEB ,
,Z sation laws of California.Dam WATER HEATER W/VENT/ELECTR
O Applicant GRADING FEE
y NDTICETO APPLICANT:IL alter making this Certificate of Exemption,you should WATER SYSTEMITREATING
Fx ; became subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
DJ fnath.ph comply withsuch provisions m dI Ptmtit mall he demand revoked. WATER SERVICE
aQ
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.PL PAID Date Receipt#
U I far which
thi that is sued(See
30 lending agency for performance of
the wad for which Nis permit is issued(Sec.31197.Civ.CJ
D' F" Lender's Name �t a TOTAL:
{U Lenders Address TOTAL: 6V/S
I artily that 1 have rtad this application and state that the shove infonnmion ix BUILDING FEE
V) correct.l ugmc to comply with all city and county ordinances and state laws miming to QTY. MECHANICAL PERMIT FEE
V Z building construction,ction,unit hereby outherepresentatives of this city m enter upon the SEISMIC FEE
K shove-mentioned property for inspection purposes, PERMIT ISSUANCE -
(We)agree to save,indemnify and keep harmless the City of Cupertino against
against ELECTRIC FEE -
liahilitien,judgments,costs and expenses which may in any way accrue against said City ALTER ORADD TO MECH. PWMBING PEE
in a
consequence of the grunting of this permit
APPLICANT IJNDERSTANDA)PDWILL C . PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.001 CFM)
SOURCE IATIONS //t MECHANICAL FEC
Q�
461—Fel HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
iffmanre of ApplicunuCmdractor Date EXHAUST HOOD(WIDUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hmuNous material HEATING UNIT(TD 100,000 BTU)
so defined by the Cupertino Municipal Code,Chapter 9.12,and the Health it Safety
Cade,Section 25332(1)? HEATING UNIT(OYER 100,000 BTU)
C]yes CNo VENTILATION FAN(SINGLE RESID) PAID
Data Receipt
Will the applicant or future building occupant use equipment or devices which
W #
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER COMP(3HP OR 100,1100 BTU) UN TOTAL:
Drsmatt
❑Yes ON. BOILER-COMP(OVER 100,000 BTU)
V Vf VUrC
� Ihevc read! haz
the ardous materiels requirements under Chapter 69 of he Call- AIR CONDITIONER ISSUANCE DATE
foods Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does nut currently have u tenant,that is is my responsibility to notify the occupant
of Ne requirements which must be met prim to issuance of a Certificate of Occupancy.
Owner or unburned agent Date TOTAL: ISSUED BY:
OFFICE