29807 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES--USE BALL POINT PEWONLY'
CITYO CCUPERTINO BUILDING-ELECTRICAL. - PERMIT NO /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL -/Q 8 07
BUILDING PROJECT IDENTIFICATION L J lJ 1
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTALDATI
OWER'S PHONE: CONTRACTOR'S NAME: - LIC NO:
�c - .,(rc�(LQ�pJ NIC CONTROL#
RCHIMCT/ENGINEER: .LIC NO: ADDRESS: ❑ �^ "
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LDG ELECT PLUMB MECH '
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC ELECTRIC PERMIT PEE
1 hereby affirm that 1 em llccnsed ander provisions of Chapter 9(commencing JOB DE$CR]PT]ON
AZO with Section 7000)nf DivisionJof the Business and Pmfessions Cade,and mylicense is -
ad in full force end effect. PERMIT ISSUANCE
V U Licence Claes Lic.# g WL ❑KITCHEN REMODEL
hZ, Date Comracmr APPLIANCES-RESIDENTIAL ADDITION' - ❑PLUMBING REPIPE
F'Jy> ARCHITECT'S DECLARATION -
Z O°G I understand my plans shell be used as public records PANELS ❑MULTI-UNIT I7 STRUCTURAL
p$ MODIFICATION
UP T0200 AMPS ❑INTERIOR El CHIMNEY REPAIR
e<F<. u�] licensed Professonal AMPS IMPROVEMENT
g-I; OWNER-BUILDER DECLARATION ,201-I OTI that
uW�G 1 hereby affirm that 1 am exempt foam The Contractor's License Law for the OVER IOOO AMPS
OGV followin p [I BATH REMODEVREPAIR El DEMOLITION
g reason.(Section]03 L5,Rosiness and Professions Code:Any city or coon[
a tL F y SIGNS ELECTRICAL []OTHER
Oya which requires a permit to canswc[,alter improve,demolish,ar repair troy structure _
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIALCIRCUIT/MISC.
aththeislicenseJpu uanuothepr�visionsoftheCom mrsLicenseLaw(Chepter9
p
(commencing with Section 7000)of Division 3 of the Business end Professions Code)or O TEMP METER OR POLE INST. MM�MERI L,
that io is 31.5 b therefrom and the basis far the alleged exemption.Any violation of - 'Eli EW BLDG/ADDITION DEMOLITION t
ti�C W Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of PoWER DEVICES
not more than five hundred dollars(5500). ❑TENANT LJI" LU}'t fy 111 11 D SERVICE
< Las mnarofthe IMPROVEMENT ^V
^�•T+O ❑ pmpeny,m isnot
moyladlalwagesrsalei(See,compensation, SWIMMING POOL ELECTRIC
will do the work,and the heCunt inalm,License Law doefared s
of apply o an Business - - THER
G and Professions Cotlor Theoves name License Lawdoesnotapplytolf owner of OUTLETS-SWITCHES-FIXTURES t i
property who builds or improves thereon,and who does such Work
te himself or through
his own employees,provided that such improvements.are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement is sold within one year of completion.the SQ.FT.FLOOR AREA VSQ.FT.
caner-builder will have the hurdenofpmvingthathedidnot build orimprove for
Plose
Q�L es owner of the pmpeny,am exclusively contracting with licensed contractors to
construct the project tier.9044,Business and Pmfessions CodeO The Contractors Li-" �\
se Law does not apply to an owner of property who builds or improve.,thereon,and QTY. PLUMBING PERMIT PEE
who eonmmls for such projects with a contractors)licensed pursuant to the Contractor'a 0.
License Law. PERMIT MOANC
❑ I em exempter S c. B&P C far thismaxon
OwnerDate . ALTER-DRAIN -WATER TEAT ' VALUATION ,
O FIR'S 1P SATION DECLARATION D BACK FLOWP OTELT. VI
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to selUinsure for Workers Compen- )RAINS'-F1 OF,AREA, l•
sation,as provided for by Section 37W of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. - FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40U TS OCG GROUP APN
My Worker's Compensation Insurance artier and Policy number ere:
Carver: 1, • Policy No.' GAS-EA.SYSTEM-OVER 4(PA) C
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTR.WASTE INTERCEPTOR
(This section need not becom leted ifthe 1 GDIVISION FEES
or less) P )smut is far one hundrul dollars(51 W) -GREASETRAP - -
PLANCHECK O
Loy anythatinThe inanyanothro ouseas
work for which tfront Workesued.IshallCompen- SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject front Workers Compen- - ENERGY FEE % LAO
0 Applicant
ant of Celifomie.Data -
O � WATER HEATER W/VENTIELECTR GRADING
7 5 NOTICE
G TVV�/���, NOTICE TO APPLICANT.If,offer making this CenlRreta of Exemption,you should WATER SYSTHM/I'ftEATING
at-i became suhjectto the Worker's Compensation provisions of the Labor Cade,you must S SOILS FEE' „
FII fonbwithcomply with such provisions or this permit shall be deemed revoked. WATER SERVICE ..
a (�
CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID -
V Q I hereby affirm that the.is a amilmetion lending agency for the performance of Date Receipt# ,
[L the work for which this permit L issued(Tec.3097,Cl,C.) _
Lender's Name
• Gia Lender's Address Wall- TOTAL:
Gs . . 1 certify that I have read this application and state that the above information is BUILDING FEE 2 �+
92 correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
7
V a building construction.and hereby authmin representatives of this city m enter upon the 'SEISMIC FEE
above-mentioned property for inspection purposes. -
'(We)agree to save;indemnify and keep harmless the City of Cupertino against Ills, PERMIT ISSUANCE ELECTRIC FEE.'
liobilitio,iminamnts,consond expenses which may many way accrue against said City ALTER OR ADD TO MECH. 'f
in consequence of the granting of this permit. PLUMBING FEE`
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO 10,000 CFM)
SOURCE REGULATIONS. - MECHANICAL FEE'
AIR HANDLING UNIT(OVER 10,(100 CFM7 CONSTRUCTION TAX
Signature of ApplicanVContmcax Date
EXHAUST HOOD(W/DUCE) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m future building occupantswreoo handle mindousmarerist HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,Cad the Health and Safety
Code,Section 25532m)? - HEATING UNIT(OVER 100 ulth)BTU)
❑Yes ' ❑Nn - '
' VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Racelpt#.,
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP LIHP OR IOO,UW BTU) ,
District? - TOTAL:
❑Yes E]No BOILER-COMP(OVER 100,000 BTU)
1 have reed the hazardous memrials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 23534.I undersmntl thm if Ne NEW RESIDENTIAL MECH. SQ.PI'.
building does nut ermantly have n mnanq that
I.,
my responsibility m notify Ne occupant
of the requirements which must h mel pdor to issuance of a Cenifca[e of Occupancy. -
Owner or authors ed agent Date - ,TO
ISSUED BY:
OFFICE .