29808 .. APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO r .' BDILDING-ELECTRICAL PERMITNO.
• BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PRUJECr IDE.NTIFICA'fIUN
BUILDING ADDRESS: - I "SANITARY NO. APPLICATIONN SUBMITTAL DATE
\0121 L�k� knn P\4 ' =O 4, �,
OWNER' NAM ' - PHONE: CONTRACTO_R'S NAME:kQAX� LIC NO:
NIC .CONTROL#
ARCHITECT rNGINEER:- LIC NO: ADDRESS: ❑ /rx
(lprt`/�TL/
lo-ON TACT. PHONE', - BUILDING PERMIT INFO
' ❑ Consultant Fees Paidl6y Applicant(Initial) BDG ELECT PLUMB MECH-
DE
LICENSED CONTRd under S DEC its of CON r• QTY ELECTRIC PERMIT t
OW Z I hereby affirm that l am.ftheBmnwal provisions ifs Code. 9(commencing 'JOB DESCRIPTION
Wrwith llpeacnndefecDivision J of the Business and Professions Code,andmylicenseis-
�� in full force and effect � PERMIT ISSUANCE
U p License Class Liv.# ❑KITCHEN REMODEL
Z Date Contractor APPLIANCES-RESIDENTIALrnQM N ❑PLUMBING RE-PIPE'Do>n -ARCHITECT'S DECLARATION
ZOm❑ Iundersand my plans shall be used as public records PANELS NIT ❑STRUCTURALOZ O MODIFICATION nsed Professional UP T02W AMPS R.. - ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-H)W AMPS EMENT
I hereby affirm that I am exempt from the Contractor's License Law fordo OVER 1OW AMPS MODEUREPAIR ❑DEMOLITION
7!a 4 F follow g rens' (Section7031.5,B e and Professmns Cud Any cly of my _ SIGNS ELECTRICAL ❑OTHER
{R°ll 0 which requires a permit s construct,rotor,tmpmve,demolish, repair an,muchim,
y
prior to its issuance.alo requires the applicant for such permit to file asigned tatement SPECIAL,CIRCUIT/MISC.
y
that he"slicensedp ant to they ions of the Contractor's License Use Ch eter9
QE ormar Ing with Sectio 'IWO) fD"v' on 111 he Bustue..ad Prfes' sCode)or� -
O TEMP.METER OR POLE INST. COMMERCIAL
4y M t•L mat he is a mpftherefr m d he basis for the alleged exempt on Any violation of - El NEW BLDG/ADDITION ❑DEMOLITION
X tt"ee Sectio ]031.5 by any applicant f a permit subjects me applicant m a civil penalty of POWER DEVICES
4E+ not more mon five hundred dollars(1500).
El TENANT ElFOOD SERVICE
❑I,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL EL CTRIC IMPROVEMENT
sp�� o will do the work,and the svuuurels Out intended oroHercd for eels(Sec.7044,Business []OTHER
E] 'm and Professions Code:The Contractor's License Law does not apply m an owner of OUTLETS�S WITCHES-F TURES-
L
his o nywho builds or improves thereon,and who does such wnrk himself or through 1
his own employeese provided that such improvements are not intended or offered for NEW RESIDENTIAL TR EQ FT.
sale,If,howevegthevilthe g or buds of moving that he lid nine yenroffinite tion,the ,SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder Will have the burden of proving that he did nm build or improve for pur-
poseofsale.). �f
t ❑'1,as owner abihe property,am exclusively contracting with licensed contmnors to OTAL:
' construct the project(Sm.](14Q Business and Professions Code:)The Conaacmr's Li-
cense Law dues not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING P R FEE
who contracts for such protects with a compop rEd licensed pursuant to the Gmtmeturs '
License Use - PERMIT ISSUA C
❑ Iron exempt under Sec.. ',B&P C for this ocamn
Owner - ALTER-DRAIN&V -WATER
Date / O VALUATION
munder WORKERS COMPENSATION n DECLARATION BACK FLOW PROTF.LT. CE I O O
I hereby affirm under Penalty of perjury enc ofthe insure for declarations:
❑on.as and will maintain eCion 37 to of the sent to Lahr Code,for the erfamWetath'eCe mper.of the DRAINS-.FLOOR,ROOF,ARE ,C
sabot,as which this
for mi Section J]W of the Labor Code,for the pedormvnce of the STORIES TYPE CONSTRUCTION
work for which ill ria-rmitie issued. - a FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,h required by Section
My othe labor Code.for nthepedomtanceofthe wlic for which this permit is issued. GAS-EA.SYSTEM-IINCAOUTLETS - OCC:GRPUP APN
My Worker's Compensation Insurance carver and Policy number are:
Carrier Policy No,: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFBATEOF EXEMPTION FROM WORKERS' "
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This section need rivals, ifthepermids forma,hundred dollars(SIOq - B 'DIVISION PEAS
orinsJ - . - GREASETRAP - PLANCHECK FE 0
I certify that in the pednrmaneve nfine work for which this permit is issued,Ishall SEWER-SANITARY-.
not employ any poison in any manner so as to become subject the Workers'Compen- STORM EA.200 FT. ENERGY FEF.
0 cation Laws of California.Date WATER HEATER W/VENTMLECTR
O Applicant GRADING FEE l
F7 VI NOTICE bj APPLICANT,If,Co making this Certificate of Exemption,you should WATER SYSTEMGRP.ATING
a become subjecttothe Worker's Compensation provisions of the Labor Code,you most _ SOILS FEE
W forthwith comply with each provisions dr this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY `, NEW RESIDENTIAL PLMB. SQ.,Fr.. PAID
V - Ih by affirm matin 0Immuvmtb ding agency for the performance of - Dam Flit
t#,
!-v the week far wh ch this Permit I ued(Sec.309]Co.CJ '
Lepolar's Name - - TO L: -
LK4 Lender Address TOTAL
1 candy that 1 have read this application and star,that the above information is - BUILDING FEE �r
tr h correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building constrvdion,and hereby aothodze represenmtives of this city to enmr upon the SEISMIC FEE Q
above-mentioned property for inspection purposes. -
(We)agree to save,indemnify and keep harmless the City of CupertinoPERMITISSUANCEino against OPAIDI_'Z�
liabilities,judgments,costs heaindafthis expenses which may in any way accrve vgeinst said City ALTER OR ADD TO MECH. '
inconsequence of the granting of this permit. r�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,WO CFM)
SOURCE REGULATIONS. EE �
AIR HANDLING UNIT(OVER 10,000 CFM) N TAX
Signature of AppbcanUCamraco" ti. - Date EXHAUST HOOD(W/pUCT) ••
HAZARDOUS MATERIALS DISCLOSURE. ATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO IW,OW BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Code.Section 25532m)?, _ HEATING UNIT(OVER,WOOD)BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RESID)WII the applicant'r future building occupant use equipment or devices which ��attttffPP r Receipt N
emit hazardous air contaminants as defned by It Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) -
Distric[? TOTAL:
❑Yes .❑No .- BOILER-COMP(OVER IOO,OWBTLO
AIR CONDITIONER F
1 have react the hazardous materials requirements under Chapter 695 of the Cali- - —ISSUANCE Aire
fomia Health&Safety Code,Seniors 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building dobe not currently have a tenant,that it is my responsibility tin notify the mcupant /,• `
of the quirementy which moot be met pdonoissuance ofa Cenifcam of Ocevpancy. (;I{Y Vr V r ID V
Owner or authorized agent Dale TOTAL: ISSUED BY:
OFFICE