29827 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELE:CT'RICAL PERMITNO /� 7
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CIIANICAL / Q 8 /
BUILDING PROJECT IDENTIFICATION L J V L 1
BUILDINGADDRESS: SANITARY NO. APP LI CATION SUBMITTALDATF
OWN R'SNAME� il'110 CONTNA OR'S A �NS .ICN}
llnen��ll�� f/Ci N/C CON OL#
•1 CHITECT/F.NGINEPA LIC NO. ADDRESS. r�,� „�� �� �� ❑
CONTACT: '' //ma�kk pHONE: BUILDING PERMIT INFO
4&e4 ,g�g�{,((. 5 e'1 7 2 2._� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
((�{JJ({ll..O����ICLLL,, II L a7 /`7`(� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECons of CON QTy, ELECTRIC PERMIT EEE
I Hereby arum mm I anti figee.ed ander add
P..ont ore oda,r9(em Ii....is JOB DESCRIPTION
I 0 withS1 ve a000)oeDivlsirn3ol the Butincs,and PndessirnsCade,and myllernveis RESIDENTIAL
p„�O In lull livcc and eR¢n �2y PERMIT ISSUANCE'
aFUU License Class Lick v OSFDWL D KITCHEN REMODEL
N6S Uma Contracmr A./ APPLIANCES—RESIDEN [A], ❑ADDITION �/p��LUMBING RE-PIPE
F.pm ARCHITECTS DECLARA'1 N PANELS ❑MULTI-UNIT LJ STRUCTURAL
2 p y 2 I understand my plans,ball be used as public recoNs MODIFICATION
02 — UP TO 200 AMPS
(-.,4 Fad Licensed Professional DINTERIOR DCHIMNEY REPAIR
�sdE; OWNER-BUILDER DECLARATION 201-1010AMPS IMPROVEMENT
'a,' I hereby affirm the 1 am exempt from to Contractor's License Law for the OVER 1090 AMPS El BATH REMODEUREPAIR ❑DEMOLITION
X�Op�.0 following reason.Section PndeWor,Gvlc:Any airy or countySIGNS ELECTRICAL
❑OTHER
ID 3 C)N which requires a permit to construct,alter,improve,demolish,or repair any structure
O far in its issuance,also termites he applicant for such permit to file it signed statement SP17CIAL CIRCUIT/MISC.
that he is licensed pursuant,,theprovisiona or the Contractor's Ucene Law Chapter
O (conturcing with Semirn]OXp of Division 3 ofthe Basions,and Pndcssions Code)or TEMP.METER OR POLE INST, COMMERCIAL:
a q o e that he is exempt therefmm and the basis for the alleged exemption,Any violation of D NEW BLDG/ADDITION D DEMOLITION
W m Section]031.5 by any applicant for a permit v.dreconhe applumn for civil Parth,of POWER DEVICES DTENANT OFQQD SERVICE
F 2} not mom than five hundred dollars(9500). IMPROVEMENT
D1.as owner oftlae property.or my employees with wages as their sole compensation. SWIMMINGPOOLELECfRIC
O:F' will dodnewurk.andtheswcwmisnot imendedorafferal fim,cdc(Sec.]0c14.Business OOTHER
W and Professions Cade:no Comranort License Law dres not apply m an..at of OUTLETS—SWITCHES—FIXTU
6'3 propcny who builds or improves thereon,and who does such work himself or through
his own nnpbyess,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELEC R SQ
sale.If.howcvem the building or improvement is sold within one year ofcantpletiaa,the SQ.FT.FLOOR AREA $/SQ.FF
twner-builder will have behurden of proving that he did not build nr improve for for,
P...c
o-
povc ofsalc.).
D I,as owner of the property,um exclusively contracting with licensed contractors to ` TAL:
construct he project(Sec.](lm.Business and Professions Code:)The Contractors Li-
came Law does not apply toanowner ofproperty who build%or improves Enron.and QTY. PLUMBING PERMITFEE
whocunuacts for such patients with a eontmemr(s)licensed pursuantto the Contractors
License Law. PERMIT ISSUANCE
D I am exempt under Sec. ,B&P C for this reason
ALTER—DRAIN&VENT—WATER IEA)
Owner pate VALUATION
WORKERS COMPENSATION DECLARATION HACK FLOW PROTECT DEVICE
I hereby
andwill Hunan Certify ue(ifCryeone o the self-olare lot orker Co
D (have and will forbyneCen Certificate of he Labont tor
Co6inwmlhrwrrkeT'sea of fa- IIRAINS—FLOOR.ROOF,AREA,GOND, STORIES TYPE CONSTRUCTION
workfr provided for mi Section 3]IU of the Lahor Code,fur the Purfnrmunce of the
work for which this permit is issued. FIXTURES—PER TRAP
❑ 1 have and will maintain Workers Compensation fir,,Insurance,h requited by Section
My Waste Labor Codpi or er,pe noccanceof dPohe for which this permit is issued. GAS—EA.SYSTEM-I INC.4OUTLETS OCC.GROUT' APN
My Workers empcn. �pon los nee carrier and Policy numl+cr arc:
Cortico. POBcy Nu:C -f� GAS—HA.SYSTEM OVER J(2A)
CER FICATE OP COMPENSATION
ERA ER. GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
(Thlssection need not M completed The Permit is found hundred dollars($1 W) GREBUILDING DIVISION FEES
or Icxs,) SEWESE TRAP PLANCHECK FEE
Loy any an,
inthe an,am:y rfnht work for which this Permit i,li,ColehuH SF.WF.N—SANITARY—STORM EA.21X1 Ff
not employ any persn any nr m sn:;nob co hjnnnthe WorkeK Compen- ENERGY FEE
QAPPli ao ws WATER HEATER N'NEM1T/ELECTR
Z NOT( ' T f. H making this Cerificate of Exemption,you should GRADING FEE
F > face eWr ars Com WATER SYSTEM1VfREATING
fl,or his provisions of the lather Cole,you must SOILS FEE
[k7 forthwith co ywt ch provisions or this permit shell be decmeg revoked. WATER SERVICE
0. Q
CONSTRUCTION LENDING AGENCY
UC) Ihemb ffirm Chatham iso proximation lending agency forth, NEW RESIDENTIAL PLMe, SQ.FI'. PAID
ya 6 6 Y performance of Data Reccipta
�P the work for which this permit Is ixsucd(Sec.3097,Civ.C.) g•� �
Leader,Name
V TOTAL:
LdeA Address TOTAL:
cn
r y I certify that I have read this application and state that the above information is
coned.l agree to comply with all city and count ordinances and state laws relatin to BUILDING FEF,
U Z buildingvection,and hereby county g QTY. MECHANICAL PERMIT FEE
cons yatnhon purposes, of this city mercer upon the SEISMIC FEE
above-(Wa) red to saveroperry fur emnifyian creep ha PERMIT ISSUANCE.
(We)agree m save,indemnify and keep harmless the y re recruit
s against ELECTRIC FEE
liabilities,judgmentse granting of this pe which may in any way uccmc against said City ALTER OR ADD TO MECH.
m consequence of the grunting of this pnmit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTa
AIR HANDLING UNIT(TO lll,ll(IH CP
SOURCE REGULATIONS, M) MECHANICAL FHL?
AIR HANDLING UNIT(OVER I rob)CPM) CONSTRUCTIONTAX
Signature of ApplicanJComractor Data EXHAUST HOOD(W/DUCT}
HAZARDOUS MATERIALS DISCLOSURE: HOUSING MITIGATION FEE
Will the applicant or future building oecupam store or handle haeiMous material HEATING UNIT(TO HIBRO BTU)
as defined by the Cupertino Munic' Code.Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
D yes No
VENTILATION FAN(SINGLE RPSID) PAID
AmI Will the applicant or future huilding occupant use equipment m devices which Date Receipt k
qIIIIIIIIIIIIIp emit hnzunfous air eonmminunm us def dby the Huy Arun Air Quality Monugemem BOLLEN—GOMP(3HP OR I(IU.INXI BTU)
ill Uolned? TOTA
D Yes n BOILER—COMP(OVF.R IW.INN)HTU) a
AIRCONDITIONER n T —I
1 have read the Its, out mammals tequiremens under Chapter 6.95 of the Cali- II I ISA A Bil$ATE
forma Health&Safety Code,Section 505,25531 and 2551.1 understand that if the NEW RESIDENTIAL MECH. SQ.P C
building it.a fly have rot,that it is my responsibility to notify the use gem
ofthe tttgTricomisoureamrarticenirr rafo;'a y. (iIIY VrT%,Urk:Anijj
Own r N cm DTOTAL: ISSUED BY:—// G w •`�/
OFFICE