29059 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O
BUILDING PROJECT IDENTIFICATION
59
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
3 L kJs
OWNER'S NAME; - P CONTRACfOR'SNAME: ( LICNO'.
r/ 11 A-Z NIC
CONTROL0B
\RCHITECT/ INFER: e LIC NO: ADDRESS: E3 �s / v
CONTACT:' PHONE: BUILDING PERMIT INFO
_ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECN
LICENSED CO ACTOR'S DE ARATION QTY. ELECTRIC PERMIT FEE 'El 11
1 herehy afmm that 1 am fic sed under provisions of Chapter 9(commencing JOB DESCRIPTION
QWZwith Stttion]WO)nfDlvisinnJ nfthe Buxinesaend Pmfessions Code,an myliceveis RESIDENTIAL,
00 in full force and eB PERMIT ISSUANCE -E RFCID F
aUU license ZQ hicg �� s ❑SFDWL [D KITCHEN REMODEL
I` WW Dale Cnmmctgr APPLIANCES-RESIDENTIAL. []ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION yy• i,!/ ❑MULTI-UNIT , ❑STRUCTURAL
F w PANELS
Z py Z� 1 underxmnd my plans shell he used ae Public rtcoNs - MODIFICATION
0z I-O UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
"�] Licensed PmfessionW ON 201-1000AMPS - IMPROVEMENT
4+j23 OWNER-BUIL DER DEthe Com arc
R•�X,��G I hereby affirm that I am exempt from the CotnrecroYs Licence Lew for @c OVER IIXp AMPS ❑BATH REMODEIIREPAIR �DEMOLITION
00 U following reason.(Section 7031.5,Business and Prnfcssinns Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
t++a W F' which requires a permit to construct,alter,improve,demolish,or repair my awemre
�yh prior to its issuance,also requires the applicom for such Permit o file a signed suremem SPECIAL CIRCUIT/MISC.
} that he is licensed pursuant to the provisions of the Cmunnun's License Lave(Chapter 9
00 (commencing with Sermon 1"1 of Division[of the Business amt Professions Code)or TEMP.METER OR POLE[NST. COMMERCIAL:,
mat he is exempt therefrom and the basis I'or the alleged exemption.Any violaf1'Qn o ❑NEW BLDG/ADDITION CI
0
p�yLd( ttii.. Section]031.5 by any applict for a permit so ens the appliwm m a civil perVs�1y POWER DEVICES
{L�y andon ❑TENANT FOOD SERVICE
1,,, �•
not more than five hundred dollars($511U). // IMPROVEMENT
ppppC 3-C [j 1,as owner of the p upony.11 my e 1 e w h wages."It s coram SWIMMING POOL ELECTRIC
O will Lim work,mMthe swcmrcis not i r Rece or. Ic 044,Bµ�icness [j OTHER _
and Professions Ode:The Gmir is laved upAAA��111$$SSS�,», rof OUTLETS-SWITCHES-FIXTURES
fk' property who builds o prov e , �d (((ERRR[fififi(ii w��••nrk himself or through
his own employees,pr 'id d ch i,''DD'''�qq 'e a is are not intended m offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.ILhowevm.thebn mprom
seel,issol within one yearofcomplct the SQ.IT.FLOOR AREA $ISQ.FT.
o ncr-builder will no uNen of prom g that he did not build or improve for pur- r
pose of sale.). PAID
❑1,re owner of the pro ,am exclusively contracting with licensed cormse nrs to TOTAL:
construcnhe project(Sec.70,14.Business and Pmfessions Code.,The Comramots Li- DEC l 4
apse Law does not apply man owner ofproperiy who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
whommoucts rmsuch projectswith acmdracteas)licensed pursuantm tho Contractor's
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this reason Uf' (fU1.E
Owner Date ALTER-DRAIN&VENT-WATER HEA) VALLAMON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of The following declarations
•�I have and will maintain a Certificate of Consent To self-insure for Workers Comped- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Luton Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
C]I have and will maintain Worker's Compensation Insurance,as required by Section -
37Mofare Labor Code,for the Performance of the work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work is o pcnsafcu�•�-tnjyppr)p)pn rid Policy num GAS-EA.SYSTEM-OVER
Cartier: (g ��olicy O
CF, IFIC O E S(T PITON FROM WORKERS'
COMPENSATION INSURANCE GR[ASF/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thisstttimt need not he completed if thepermit is Tanana hmrdreddollms($1110) GREASETRAP
or less.) PLANCNF.CK FEE
I cartify Nat in the peHormanceofthe work for which this permit is issued,[shall SEWER-SANITARY-STORM EA.200 FT.
an
not employ any person is y manner w as to become subject mitre Wmkerx'Comped- ENERGY FEF.' ,
sefrm laws of Coliform..Date WATER HEATER WNENTMLECTR
O Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after ranking this Certificate of Exemption,you shouldWgTER SYSTEM?REATING
abecome subjttt to the Worker's Compenmtion provisions of the labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.FL PAID
U O l hereby affirm that there is a construction lending agency for The Nrfmmance of am Receipt sit
w p•+ the work for whichthis permit is issued(Sec.3097.Civ,C.) T
O U Lender's Name '
WLeader's Address TOTAL: `
CI certify that 1 have mad this application and state that the above information is B LDING
4 h concert.l agree to comply with all city and county ordinuncesvnd state laws relining to QTY, MECHANICAL PERMIT FEE
UZ building construction,and hereby amhodze repfesemalwesofthms chymmumuponthe EISMIC AE
i0mvememianed property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harm cos the City of Cupertino against
liabilities,judgments,cushions]expenses which may in any wayvccmeagdarto said City ALTER OR ADD TO MECH.
in consequence of the granting of This pertain. PLUMBING FEE
APPLICANT UNDERSTAN S AND WILL CON WITH ALL NON-'OINT AIR HANDLING UNIT(TO 10,000CFM) '
SOURCE REGt1I.AT11 5 -
r000 14 AIR HANDLING UNIT(OVER 10, CFM) CONSTRUCTION TAX
gwmrc of
E,iir VCo cion 'Da""
m EXHAUST HOOD(W/DUCT) I{OUSING MTfIGAT10N FEE
HAlARDOUS MATER ISCLOSURF.
Wdlthe applicant or fummbuils' a anistore m handle hroodous material HEATING UNIT(BY 100,000 BTU)
as defined by the Cupertino Munici C ,Chapter 9.12,and the Health and Safety
Cole,Seemin 2592(0)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RMID) BUD "
Data Rxecila#
Will The air emarnimou a building mcupantu Aequipmentutdevmees which BOILER-COMP DHP OR 100,0041 BTU
emit hazallous air comaminanu ea defined by The Bay Arw Air Quality Mensgcment ) r
District? TOTAL:
�Yes ONo BOILL'R-GDMP(DVER I00,IKK)BTU).,'
I have read The mediations materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fronto Health&Safety Ode,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building does not ermea 0y have i tenant.that it is my responsibility m notify The occup an
more requirements which must be not prior m issuance of a Certificate of Occupancy.
Owner or authonzed agent Data s TOTAL: ISSUE OR
OFFICE