29528 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 2952
9 r 2 8
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL v� V1L
BUILDING PROJECT IDENTIFIC'A'TION
LNG ADDRESS: SANITARY NO. . APPLICATION SUBMITTAL DATE
6Z4� So Pa" e '3..Z;aB
R'S NAME: H NE: b C TRACTOR'S NAME: LIC NO'.
1 e: A g I. -NIC ((( {/L� .
IIiNGINEER: LIC NO: q DRESS: V F-1 �k
III 1 G4 `
CONTACT, PHONE: BUILDING PERMIT INFO
-: -
G �PaV.;; ❑ Consultant Fms Paid by Applicant(initial) BLDG ME
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FE ff yJ\(
I hereby affirm that I Orn licensed under provisions of Chapter 9(commencing JOE OESCRI^ON
OHO wnh Section]000)ofDivisionJoflhe Business and Professions Cale,unit my licensees PERMIT ISSUANCE RESIDENTIAL:
�U� n fall farce and cRaL SFDWL ❑KITCHEN EMODEL
j Licenu Clan Li<.N APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F W Dem Conmacmr
N7yCHITECTS DECLARATION C Aja L1 MULTI-UNIT ❑STRUCTURAL.
PANEL$
Z 1�'LL 1 undcrslnnd my plain shall M used as public records � MODIFICATION
OZ-t UPTO 2W AMPS
Licensed Pro(essionN ❑INTERIOR EI CHIMNEY REPAIR
OWNER-BUILDER DECLARATION NII-IIXNIAMPS IMPROVEMENT
yy C 1 hereby uIirm that I am exempt fent the Contractors License Law for the
OVER 1060AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
Dd 3 6 U following reason.(Section 7031.5,Business and Professions Code:Any city ar county SIGNS ELECTRICAL ❑OTHER
4W1 LL which requires a permit to ematrtml,elm,,improve,demolish,ser repvr any swdute
�Fy prim to its issuance,also acquires the applicant for such pem tto rile a signed aluminum SPECIAL CIRCUIT/MISC. 2d
thin he is licensed pursuer,m Ne provisinrxof Ne Camrunm'e License Law l Chapter9
ItCIa O� (commencing with Section 70M)of Division 3 of the Business and Professions CDde)m TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
14 Section 7031.5 by any applicant for a permit subjects the applosim to o civil penalty of POWER DEVICES
.r ANT ❑FOOD SERVICE
} not more than five hundred dollars($500).
� C ❑l,as owner of the property,or my employees volt wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do Ne work.end Ne dwmure id nal imenslW oroffertd for Bale[Sea 7()aI4,Business ❑OTHER _
and Professions Code:The CDnwcmr's Licenu Law does mol apply tD an owner of TUTS-SWITCHES-FIXTURES
property who builds or improves Ithereon,and who does such work himself or through
his awn employees,provided thatsuch improvements ere not intended or offered for NEW RESIDENTIAL ELECIR', SQ Fri.
sale.If.however Ne building or impowememis sold withirimm years(emapklion,the ,SQ.PT.FLOOR REA $/SQ,P-r
ownerlaidder will have Ne burden or proving that he did not build or improve for put.
pose of sole.).
❑.1,asowner ofthe property,amBexclusively contracting withlicensedCconvacmrdm
construct
constructa ]641,Business the project($ .]6usiness end Professions Cad[::)The anllvcl4fa U.
mum Law does non apply to an owner of property who builds or improv[x themor,mad QTY PL MBING PERMIT FEE D
who contracts for such projects with a contractor(&)licensed pursuant to the Contractor's 1 'r1MR 19oa
License Law. - v7U
1 mm exempt under Sec. ,B&P C far Nis reason PERMIT ISSU NCP rF
Owner Date ALTER- RA & -WA'TERIG) a1 ,NAIIUATION
WORKER'S COMPENSATION DECLARATION BACK Ff.OWP F, ICE ��\wT11;�
I hffi
ereby wrm under penalty of perjury one of the following declarmions: V/ {i
❑ I have and will maintain a Certificate of Consent to self-insum for WDker's Compen. DRAINS-FI R. OF, OND. STORIES TYPE CON$TRUCf10N
basion,as provided for by Section 3700 of the Labor Cale,for the perf....._ a of the
ole far which Nis pemnil is issued. FIXTURES-PER
1 have and will maintain Workers Compensation Insurance;as required by Section -
OOofNelaborCWe,for lheperfnmmnccoflhewnrk for
fnw�hicchhthis pimmmiitt is issued. GAS-EA.SYSTEM'l INC. U sTS OCCGROUP APN
MyWnCortier:rku CT,VeLi1-gl4 tlu _{eM rOgPnlicy Nn.I a it Palm �N1L� 1R Dl9 GAS-EA.SYSTEM OVER 4(EA)
XF CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BULLDINGSI NfE1S
(Th,ucfob real net bacompined IfNc permit is foume hundred dnllam I$IN) -
orle&sg GREASE'IRAP PLANCHECK FEE 1.
Loy my Neiin Ne peymannrso se,i wok for which this thepeoWnit isirs'Cimpr-ued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any penin iany manner u m m become subject m the Workers'Cooper- ENERGY FEE
50 union Laws of California.aData WATCR HEATER WNENTNLECTR
O C NOTICE
GRADING FEF.
C
NOTICE TO APPLICANT.If,after making this CeniMam of Excmplinn,you should WATER SYSTEM/TREATING
I" become subject to the Worker a Compensation prnvisiane of the Labor Cale,you muss SOILS FEE
Qforthwith comply with sachpmvisionsm this permadhall be dacnrJ revoked. WATER SERVICE -
CONSTRUCTIONLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
C.10 Iherehy ufftm Ihm Oterc is uconstructinn lending agency far the performance of Dole Receiptg
Drs the work for which this pe.air is issued(Sec.3097,Civ.C.)
is
0 Lender's Name _ TOTAL:
W Lender's Address
CO
I cannily that I have read this application and stateNot Ne above-information is BUILDING FEE I'a
i-r Tai) cared.I agree to comply withal)city and county ordinances and stem rows relating to QTg MECHANICAL PERMIT EE
L)z building construction.and hereby umhome representatives of this city to enter upon the SEISMIC FEE `
Anve-mentioned property for impenion pmposea. PERMIT ISSUANCE �7^
(We)agree nose ,indemnify card kap brainless she Cityof C.Partimo against ELECIRICFEE {� //
babililies;jud mcros,cons and ex which mayimanywaymermitioinrt snit City ALTER OR ADD TO MECH.
in causal egNn' 1 is pen iL 'PLUMBING FEE
tft-
APPLIC D 'AND. LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.1100 CFM) MECHANICAL
34�SOUR
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIO TAX
al of Applictint/Cmancom rte EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURFi HOUSING MITI ATION FEE
Will the applicant or future buildingoccupnnt store or handle hazardous material HEATING UNIT(TO IN."BTU)
.s defined by the Cupertino Municipal Code.Chapter 9.12,and Ne H.IN and Safety
Cade,Section 25532(.)] HEATING UNIT(OVER IN,0f1(1 BTL)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID..
Will the applicant or future bniidin occupant use equipment or devices which Dam Ra 1 g
pp tiding pBOILER-COMP(3HP OR 100.000BTU)
emir hamrdous air contaminants as defined by the Bay Area Au Qualify Menagemrnt AL:
District?
❑N4 BOILER-.COMP(OVER 100,000 BTU) se
❑Yes
I have read the hazardous materials requirement under Chapler 6.95 fshe C.li- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cede,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
looking dos mos currently have a term,dot it is my responsibility to notify the occupmtl
of the irtme which mv. trcv prim to ixsuentt ofe Cenilispte pfd�pancy, _
Owner Nonud&gem r— f a-DDalledl/Y') t 6 ISSUED BY:
OFFICE