29001 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 29001
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: / / �D - SANITARY NO. APPLICATION SUBMITTAL DATE
`7J-y�o �b��Qn2�e/'ry IIQC� �
OWNER'S NAME: } PHONE: C/ CO ACTOnR'S NAM LIC NO
^ 8f7 n, 6 x3903-9 WC CONTROL
ARCHITECDENGINEER: - LICNO: ADDRESS ❑
CONTACT. PHONE IBUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ELECTPLOMB MECH
LICENSED CONTRACTOR'S DF:CLARATfON QTY. ELECTRIC PERMIT FEE
,I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�� I wide Section7")of Division J of the Business had Professions Code,and my license is RESIDENTIAL: '
I-kcin fullfooneandrffect. ti �p PERMIT ISSUANCE '
r39�c�sJ / ❑SPOWL [I KITCHEN REMODEL
�Ug. L¢ense s Lic.p - APPLIANCES-RESIDENTIAL ❑ADDITION [3 PLUMBING RE-PIPE
a, Dem Contmc <a
ARCHRF,CTS DECLARATION r ❑MULT4UNIT ❑STRUCNRAL
FF. PANELS
OZffL.O.... Z 1 understand my pions shall he used us public records � ODIFICATION
UP TO 200 AMPS IJ INTERIOR, HIMNEY REPAIR
e4iI Li<cnned i'raPossional 201-1000AMPS IMPROVEMENT
1, OWNER-BUILDER DECLARATION Contr ON OVER 1000 AMPS ❑BATH RP.MODEVREPAIR [I DEMOLITION
p, 1 hereby.(Sec this 11. exempt from the CosionsC s License Law for the
x O L U whfollich
mhson.(.it
]oJLS, t.after.
I.d.se,de ore h, ,,Any city or county SIGNS ELECTRICAL COTTER j
F O which requires n eemtm re1.coeswn,alter,imfor such
demolish,ore a sig any swment t
priarmit issuance,alta requires the epplicunl far such permino Rleasigned statement SPGCIAL CIRCUIT/MISC.
WNQ�µ y that he is licensed personal to provisions of the Contractors License Law(Chapter 9
00 (commencing with Section]fM)of Division 3 of the Business and Professore Cude)or TEMP.METER OR POLE INST. COMMERCIAL:
d ce e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION El DEMOLITION
on Section]031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES
❑ ❑
H TENANT FOODSERVICE
ILLFFF........,,, D•
net more than five hundred dollars($500).
a< I,asownerofthc norm employees with woes either solecism tion, SWIMMING POOL ELECTRIC IMPROVEMENT
❑ property, Y P Y 6 pease
will od the work,and the ctmnure is not interom moffered for sale(Su.7044,Business []OTHER
and Professions Code:The Commerce's License Law does not vpply o an owner of OUTLETS-SWITCHES-FIXTUR
�' .. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvement we not intended or offered for NEW RESIDENTIAL ELECTS
sale.If.however.the building or improvement is sold within one year of completion,the SQ.FT.FLOOsR'ARE B &SQ.FT.
ovencobuilder will have the burden of proving that he did not build or improve for pun 001"
pose assalene IOTA ��
❑1,as owner of the Sm.704,stn exclusively contracting with licensed Contractor's i- 2 as
oretruct the project(Sec.o an Business and Prowho bei Code:)Thees beeow,and
Q - a� 1^9
cense Law d«anot apply tohnowner aofproperu Aimee lduntwo improves Contractors
Ty. PLUMBING PERMIT FEE /s y
Lice se La t for such projections a commnot(s)licensed pursuant to the Cnntrucmrs ti��UJ,
License Law. PERMIT ISSUANCE. LVf-rfT JJ
E3m 1 aexempt under Sec. ,B&P C for this reason A' 1
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE -
I hereby union under Penalty of perjury me of do following declarations: '
❑I have and will maintain a Cerilicate of Consent to self-insure for Worker's Compen- .DRAINS-FLUOR,ROORAREA,GOND. - STORIES TYPE CONSTRUCTION
radon,as provided for by Section 3700 of it.Lahuo Code,for be pwf onsurre of the,
yk far which this permit u issued. FIXTURES-PER TRAP
®I have and will maintain Worker's Compensation Imamate,as required by Section
3700o17 dee Labor Code,for the perfomanceof the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Wm 'x Compensation Insurance modernist Policy num rprt
Carrier-] 702 Palmy No011i 19030 GAS-EA.SYSTEM-OVER -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section partner be completed if fire um
e permit is fnoonehlreddelluos($I00) GREASETRAP
or less.) PLANCHECK FEE
I certify that in the perf.min nce of the work for which this permit is issued,(shall SEWER-SANITARY-STORM EA.200 FT.
pot employ any petum in tiny manner sec as o beco�}e bjeq to the Workers'Compen- ENERGY FEE"
,� setonLawsof Califomia.Dato �� 9_(.e WATER HEATER W/VENT/ELECTS
. C07 6 Applicant�(/a/H+�7�� L - GRADING FEE
G'y NOTICE TO APPLICANT.1,atter making this Ce tiftcale of Exemption,you should WATER SYSTEM?REATING
abecome subject to the Worker's Compensation provisions of the Labor Cade,you must SOILS FEE
{1a fonhwidt comply with such provisions or this pemtit shall be dcemul revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
`7 ,Z I hereby affirm that thereis a construction lending agency for the lawfammnce of Date Receipt#
L) the work for which this rmit it issued S n9] iv C -
_ a c( c.3 ,C .)
Q ,\ Lenders Name
{�L{ Leaders
Addtesa TOTAL:
I ttnify thvt 1 have mad this application and stain that the above information is 1111111,11 118
i.n 110—
In overseer.1 as=to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL.PERMIT FEE
V building commonion.and hereby authtiire mprescmatives of this city o enter upon the SEISMIC THE
above-wommied prepeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino vgainst ELECTRIC FEE
liabilities,judgment,costs and expenses which may in any way accme ogainstssid City ALTER ORADDTO MECH.
in consequence of the granting of this permit. PLUMBING FEE,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALFEE
SOURCE REGULATIONS.
r.!'rZ7 AIR HANDLING UNIT(OVER MON CFM) CONSTRUCTION TAX
SignmuonoMpplicanVCa
to
Date EXHAUST FOOD(WMUCD NO USING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fatuon building occupant sooner handle hrombus material HEATING UNIT(TO 100,000 BTU)
as debt by the Cupertino Municipal Code,Chapter 912,and the Health and Safety -
Code.Section 25532(a)l HEATING UNIT(OVER 100.00)BTU)
E]Yet YNo PAID
Date .Receipt#
Will the applicant or forum building occupant use equipment or devices which VENTILATION CAN(SINGLE RFSID)
emit hazerdom air conaminants as reed by the Bay Area Air Quality Management BOILER-,COMP(JHP OR 100,000 BTU)
a TOTAL:
District? BOILER-COME(OVER 100,000 BTU)
❑Yes No
I have and the harardous materials requirement under Chapter 6.95of the Cali. AIR CONDITIONER ISSUANCE ATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.FT.
Wilding tees not stormily have a tenant,that it is my responsibility to notify the emurpost
ofthe requumments which must be met whom issuance ofa Crw Fr f 00ccu//�ppaaappttrc�wy.
�/�pZ 'ot G,
Owneror eurhar dad agent Date TOTAL ISSUED BY:
OFFICE