29829 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT. PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
o l v d"A
17,1 NAME: - PHONE: C ORIS AME: LICNO:
AMLS N/C CO Art ROLA
Ak {ITE /E GI EER: 1. NO: ADDRESS ❑
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CONTACT:, PHONE: - BUILDING PERMIT INFO
_ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT -PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
egz1 hereby affirm that 1 am licensed under provisions of Chapter9(commencing JOB DESCRIPTION
�0D38 th Section 70(apof Division3ofibe Business and Professions Code,and my licensees RESIDENTIAL:
0 wt �_ PERMITISSUANCE Sa ',(�
m full force nnJ wf eci. ❑SMWL ❑KITCHEN REMODF.I.
� Licen Ince
FU Lic.p
riZ0. gppl.lANCEN—RESIDENTIAL ❑ADDITION PLUMBING REPIPE
TDate Contrucmr ❑
FOy ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL
2O z Iundnstnnd my padre shabell ued e
ss public rcPANELS wonls ..I MODIFICATION
OZ-1 UPT0200AMPS #INTERIOR OCHIMNEY REPAIR
G4~.k.S4 Licensed Professional 201-1000AMPS IMPROVEMENT'
90d OWNER-BUILDER DECLARATION OVER I(pOAMPS LJ BAT"REMODEUREPAIR ❑OGMOLRION
6,O0 I hereby eflirm Nal 1 am exempt from the Communes License Law for the
Sd ar U following reason,(Section 7031.5,Business and Pn fiction Code:Any city or county SIGNS ELECTRICAL C OTHER
u1 W which requires a permit 0 construct,alter,improve,demolish,or repair any structure
h.,90 prior m its issuance,smo requires the applicant for such permit To rile a signed stmcmeaSPECIAL CIRCUIT/MISC. 10
Ig
thmheislicensunaft
lfainsomothe provisimshe Comment's license Law(Chap
} ter9
00 (commencing with Section 7000)of Divaimn 3 of the Business and Professions Code)or TEMP.MFTER OR POLE INST. COMMERCIAL:
L o pL that he is attempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
"•y MPROVEMENT
Section 7031.5 by any applicam for a permit subjects the applicant a a civil penalty of POWER DEVICES ,
ZZZ me than five hundred dollms($5Od. IsC� ❑FOODSERVICE
OC1.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do Nework,und thestmmure isnot intended oroffercd for sale Oau7(D4,Business El OTHER _
Land Professions Cede:The Contractor's License law docs not apply to as owner of OUTLETS—SWITCHES—FIXTURES
.. property who builds or improv,,;Hereon,aril who Jas such work himself or through
his awn employees,provided that such improvements we not imcnded or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement is sold within one year of completion.the SQ.FT.FLOOR AREA S/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve for put-
paseofsaleJ.
1,os ownerof The St .7(,am exclusively contacting with Ikensed cnnuroea lm TOTAL:
construct Nc project(See.IOW,Rusincss and Professions Cale:)The Conwmor's Li- '
ans<Ww does not apply to an owner of properly who build;nr improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts forsuch projects witha comtracmrfs)licensed pursuant he Ne Contractor's
License Law. PERMIT ISSUANCE
C 1 am exempt ander.Sec. .B&P C fur Nis tea;on
Owner DateALTER-DRAIN&VENT—WATE VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hersby affirm under penalty of perjury one of the following declaration:
C lhaveandwill maintain aCenificncof Consenuo self-inswo fm Worker's Campen-• DRAINS—F LOOR.ROOP.AREA.COND.
saoom,as Provided far by Section 37M of the 1-go,Cafe,for the performance of the STORIES TYPE CONSTRUCTION
were far which this permit is issued. - FIXTURES—PEk TRAP
C 1 have and will maintain Workers Compensation Insurance,as requital by Section
3703 ofthe La o-Cak.for the performance ofthe work for which this permit is issued. GAS—EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Worker's Com�Bc and Policy number me:.
Cartier. l -I"YNJ \ �OJk)ame Policy No.:k�� GAS—EA.SYSTEM-OVER4(EA)
CERTIRCATE OF EXCMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION RFS
This section need not he completed if the permit is for one hundred dollars(S IW) GREASETRAP
or less.) PLANCHECK FEE
I cenify Nat in the performance of the work for which this permit is issued,Ishall SEWER—SANITARY—STORM EA.200f ..
not employ any person in any manner.-as he bmm
oe subject to The Workers'Compen- ENERGY FEE -
zz ration Laws of C.dif rmit.Date WATER HEA'ITiR WNENTR:LF.CfR
O Applicant - GRADING FEE
ry y NOTICE TO APPLICANT.If,after making This Certificate of Exemption,you should WATER SYSTE1,1 REATING SOILS FEE
(•^ become subject to the Worker's Compensation provisions of the Lahr Cade,you must
forthwith comply with such provisions Or this permit shall be deemed revoked, WATER SERVICE -
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.PC PAID
z Thereby oftinn Thor there inaconshumion lending agency for The Performance of baro Receipt of
U- The work for which his perm,is issued(Sec.31191,Civ,C.)
0 E" Lender's Name TOTAL:
W Lenders Address TOTAL:
I certify that 1 have read This application and state That the shove information is BUILDING FEE
N torten.l agree N comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE - ^
V z buildingcunstmctinn,and herebyauthoride represemmives ofdo,city To enterefon The SEISMIC ME � to
above-mentioned properly for inspection purposes. PERMIT ISSUANCE.
(We)agree m sam
ve,indemnify and keep huTless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses whlchmayinany way acemeaguinst said City ALTER OR ADD TO MECH.
PLUMBING HE
in maiponof the gaming of This permit.
ma
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO I0,000 CFM)
SOURCE REGULATIONS. ^ECHANICAL FELE
AIR HANDLING UNIT(OVER I0,000 CFMI 142 CDNSTRU )TAX
Signature ofApplicam Contractor Date EXHAUST HOOD(W/DUCT) HOUSIN�,AiI GATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theupplictigm future building occupant there oT handle hazardous materlul HEATING UNTTO70100,0110 BTU) (5•+
m defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cale,Section 25532(al? HEATING UNIT(OVER 100,000 BTU)) VC
ElYes C]No VENTILATION PAN(SINGLE RIS ID) ''PNDV
t+I Data Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER—COMP OHP OR 100.000 BTU)wait haeallous air contaminants as defined by the Bay Area Air Quality Management - TOTAL:
District? BOILER—COMP(OVER 100,W0 BTU)
E]Yes C]No
I have read The haemdnus materials requirement under Chapter 6.95 of The Cali-- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Salons Z5505,25533 and 25534.1 underm nd Nat if the NEW RESIDENTIAL MECH. SQ.FT.
building asses natcurTenay have a tenant,that it is my responsibility to notify ThmncuPant
of the re pin norm;which must be met poor to issuance of a Certificate of Occuponcy., {.•
Owner mauNodaed agent Data TOTALI ISSURDBY: -� D � V
OFFICE