29623 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBING MECHANICAL - n C
BUILDING PROJECTIDES'FIFICATION G v
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
E. E �-L
OWNE NAME: Pit CON I RACTO 'S NAME LIC NO:
NICP64 ?6ve 1:544 Ka=,=-eqTipPj
CON'TROLa
�O(CHITECf/ENGINEER: LIC NO. ADORE:S: ❑
CONTACT: PHONE: '`irPMLxk ICA BUILDING PERMIT INFO
QfIYIN Dodgsvn -�qZ _1990 ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB M[yEECCIH
1:1 1:1 El IX
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
ADO y
Woo with Section ANMD of Division 3 ofthe Business and Podemstor,Code,endo license is
PERMIT ISSUANCE RESIDENTIAL'
FW�FU
I.fail force and of&n.
aVV Date -C.-I []A*SFDDITION
❑KITCHEPLUMBINREMODEL
FZuI Date Comextfr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
w Q L ARCHITECTS DIiC TION
F-7h PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z OyZ I understood my plans shall be usedns public record. MODIFICATION
O Z� UP TO 200 AMT'S
F E'W Lmcnscd Professional [I INTERIOR ❑CHIMNEY REPAIR
< F.; OWNER-BUILDER DECLARATION 201-I0RAMPS IMPROVEMENT
do mw)Q 1 herehy affirm that 1 am exempt from the Contractor's License law for the OVER.BIBB AMPS ❑BATH RE�MOa�DE,UpRE_PAIR ❑DEMOLITION
X30.F following reason(Senior]o3tS,Business and Vmfessions C.Je:Any cityarcearty SIGNS ELECTRICAL MOTHER rear.�s�/rfIIT�l��
cull which requires a permit to con.marl,alter,improve.demolish,or mpon an wcmrc •.,t
b`� y s �COs „Q �2
rm
hit he
issuance. for Contrarmiu.iecow,mv(Chid,trucm,9 SPECIAL CIRCud rAHSC.
O�G�Qf that he is licenced pnreuum to the pnrvixions of the Contractor's Liwnse how(Chapmm9
Iy IYOO (commencing with Sec[i.n])IN))of Division3ofthe Businns and Professions Code)., TEMP.MEfEROR POLEINST COMMERCIALSec :
6 d eq that he is 31.5 b therefrom and the basis for the alleged exemption.Any violation of
X LL mo dna 7031.5 by any applicant for s S500Permit subjects the appbcum nsacivil penalty of POWER DEVICES ❑NEW BLDG/ADDI'TION ❑DEMOLITION
WF not more than five hundmJ dollars(SSgll. ❑9'P-NANT ❑FOOD SERVICE
� ❑ 1.as cosi,, (the pmperly,or my employees with wages as thcirwle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
yFc willdothewmk,tndthe mmcmreisnot intendeforoffemd forsale(See.]041,Business - ❑OTHF,R
ly m and Professions Cade:The Contractors License Law dues not apply to an owner of OU1 LETS-SWITCHES-FIX AES
4i 3 properly who builds of improves thereon,and who does such work bmselfm through
his own employers,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FI'.
side.If,howevcnthe building.,improvement is cold withinone ycm.frorapictumfla, SQ.P FAOj AIIA $/SQ.FC
er-builder will have the burden of proving that he did nut build or improve for pur- H ��JJ
pose ol'salcJ.
❑ Los owner nT the property,am exclusively e.mmming with licensed commmurso. IOTA
consimet the project(Sec.]UW,Business and Professions Code:)The Cmdractors Li-
verve Law dot does napply to an owner of prelacy who builds or improves therm JAN.and QTY. PLUMBING FERMI F 2RE
who contacts,for such projects with a contractors)Incensed pucsuan,to the Contrucmr'..
C] Ion Law. PERMIT ISSUANCE CITY Ur UUMNIINU
❑ am exempt under See. ,B&P C for this reason
ALTER-GRAIN.9 VENT-WATER(EA)
Owner pate VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under scrahy of perjury one of the following declarations: .
❑I have and will maintain a Certificate of Consent m seF i...mfo,Werker's Compen- DRAINS-FLOOR,ROOK AREA,COND.
me
action,as provided for by Section 3900 of the Iabr Code,for the performance of the STORIES TYPE CONSTRUCTION
wnr for whidi[]iis permit is issued. s FIXTURES-PERTRAP
have and will maintain Workers Compensation Insurance,as required by Section
3700.f Ne Labor Cade,for the peeformence of the work for which this permit fiosued. GAS-EA.SYSTEM.]INC.4 OUTLETS
M Work C m ynomherom OCC.GROUT' APN
y q pcnmdo❑❑1[uumnc currier and Folic
Carrior:w 6TIQN i4J'a Qa7--b'oBcy NuA.dt7d174OG,AA GAS-EA.SYSTEM-OVER 4(CA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUS'TRL WASTE INTERCEPTOR
(This section need not be emolleteal if the permit is for..hundred dollars($Iq)) BUILDING DIVISION FEES
or leas.) GREASE TRAP PLANCHECK FEE"
I certify that attic performance ndthe work for which this permit is is sued lshall SEWER EA. FT
not employ any Nesun in any manner an as to become - -
subject to de,Workers'Compen- ENERGY PEE
O Z cation laws of California.Dam ER HEATER W/VE,YT/ELECfR
z Applicant WATER GRADING FEE
y NOTICE, bj APPLICANT:IC aMe making this Certificate of of Excmptlo d You should WATER SYSTLMrtREATING
a ? become subject t. it Workers Cons or this
em n ions of the Wb.r Code,you must _ - SOILS FEL'
forthwith comply with such provisions or this permit shall he tlenneJ revoked. WATER SERVICE
a �
5Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID
V Ihemby off rat that there iso conswniun lending agency f.nhc perfo[man<e of Date Receipt#
LL 1: the work fur whichthis permit is issuoJ(See 3097,Civ,C.)
Lender's Name
Lcndcrs Address ,TOTAL. TOTAL
y I candy that I have mad this application and state that the above infonmion is - BUILDING FEE
CIO correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
L) Z building construction.and hereby authorize representatives of this city to enter open the SEISMIC FEE
above-mcounted Drupe y time III spcdinn jmgn acs PERMIT ISSUANCE
(We)agree ,, ver indemnify dke harmless the City of Cupertinoagainst ELECTRIC FEE
liabilitic,,piturent cons aadexpen ewh'hmay ioaoyway attmeagainstsaid City
inconsequence.' ego 'ng of nth' mi! ALTER OR ADD TO MECH. PLUMBING FEE
A I'PLIC "1' DE DS Ll.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO tU,(Iq)CFM7
SOU .r E AT )NS. MECHANICALFEE
_ 7 Cm AIR HANDLING UNIT COVER 10,00)CFM) CONSTRUCTIONTAX
Signcturc fgpp icaHAZARDO Dm ) EXHAUST HooBOw/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will
ytheCupentor future buildings.Chapterstore 12.handle hmaedoand Safety BEATING UNIT TO IfNl,gO BTU)
az defined by the Cupertino Municipal Code.Chapter 9.12,and the I{Batts and Safety
Code,Section 25532(ul'l - HEATING UNIT(OVER 100,01O RTU)
❑Yes [I No
VfiNTIIATION VAN(SINGLE RESID) PAID
Will the applicant or forum building occupant equipment o, Mires which Dam Receipt a
az
.at hazardous it mntamnam
is as Jelined by Ne Bayy A Arca An Quality Munagemem BOILER-COMP(TIP OR 1011,000 BTU)
DlLo
u'iC
Yes ❑No BOILER-COMP(OVER IOOJNOBTIDTOTAL1 have rend the hazardous materials[aryiremenm undo Chapter 695 of the Cali- AIR CONDITIONER
Health @ Safety Code,Sections 255115,25533 and 2534.I unde,smnd thatif[he =BY.
CE DATE
g fees a.t cumendy have atenant,that it is my[egno,ibility to notify the mcupant NEW RESIDENTIAL MECH. SQ.FL
equirement which must Ise met Timor to issuance of a Cardram of Occopmey.r unnonzed agent Dole TOTAL: �S-VY
OFFICE