29404 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - '"
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. 29404^,q 0 q
BUILDING DIVISION APPLICATION/PERML�94
4IT - PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
950 �_lY-STP .
0 HVS NAME: //ww�� PHONE:' C RACTOR'S NAME�� LIC NO:
V
N '.�i�..'NLJ @(}c� frl�J �r) N'C - CONTROL#
ARCHITECT/ GINEERn LIC NO: ADDR S: - ❑
OS Y S. '(a, yna (jl wl t �u
corrrAcr: _ PHONE: - BUILDING PERMIT INFO
- ❑ Consultant Feces Paid by Applicant(Initial) BLDGELECT PLUMB MECH
-
1 hereby.LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE '
ffirm that I am licensed ander provisions of Chapter 9(commencing JOB DESCRIPTION
{{�05 with Section]000)of Division 3 ofthe Business and Profession,Code,and my license is
F W r in full Rumored effect. PERMIT ISSUANCE '• RESIDENTIAL,
�UU License Class Lie.I I ❑SFDWL �_��_,E,,,---1,,,KITCHEN REMODEL
Dem Cmitaaor APPLIANCES-RESIDENTIAL []ADDITIONMBING RE-PIPE,
F.Otn ARCHITECT'S DECLARATION UP TD 200 AMPS PANELS ❑MULTI-UNIT STRUCTURAL
O,$ C I undasmnd my plans shall be used public recnNs I , MODIFICATION
S
yx� Licensed 1 m
11 INTERIOR
R
. ❑CHIMNEY RE
PAIR
ggOWNER-BUILDER DECLARATION 201-InN)AMPS IMPROVEMENT
I hereby affirm that I exempt from theCommuning L' L far the OR1000AMPS HATH REMODEVREPAIRDEMOLITION34U SVS LCT ❑
following ( to1. Bin.. d P fie: Code Any city county
which requires permit Iconstruct,'lr r ' p d rn p y structure SIGNS ELECTRICAL El OTHER.
h prior to its isemance,also requires the applicantf hpermit fil ,agned statement SPECIALCIRCUIT/MISC.
that he is licensed pett the provisions fthe Connector's LceLa (Chapter 9
00
(commencing with Sion]000)of Division 3 ofth Business ad Professions Code)or TEMP.METER OR POLE IN ST. COMMERCIAL,
tiy5 oy. that he is exempt nercfr d the basis far me allege.)exemption.Any violation of
W^m Sectio ]03156 applicant for El NEW BLDG/ADDITION ❑DEMOLITION
y any permit subjects the applicant to penalty of POWER DEVICES`
r„ y not more NanfivehundrW do]1.IS5W). ❑TENANT a ❑FOOD SERVICE
Q1,as owner of rhe property or my employees win wages.,their sole comparison., SWIMMING POOL ELECTRIC' IMPROVEMENT'
wdl do the work,and the swcmrc is not intended proffered for sale(Sec."/1144,Bminess ❑OTHER
F and Professions Code:The Ceamentar's License Law does not apply to oa comer of OUTLETS-SWITCHES-FIXTURES '
property who builds or improves hereon,and who does such work himself or through
his own employees,provided that such improvements are nor intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,rte building or improvement is sold within one yen of complerion,ne SQ.FT:FLOOR ARBA' PE $ISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put- LY
- pose of sale).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: ; /I� y
construct 44
he project(Sec.]0 ,Business and Professions Code)The Contractor's LI- N#''11 1 �9 6
cense Law does not apply to an owner of properly who builds or improves thereon,no QTY. PLUMBING PERMIT FEE
who contracts for such projects with a ammactor(s)licensed pursuant to the Contactors.
License Law. B&PCfor his meson PERMIT ISSUANCE �Ir V0 L:r lIPI
❑I am exempt under Sec. ,
Owner Date ALTER-GRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirmander penalty of perjury one of he following declarations: `
❑ /have andwill maintaina Cenincamof Cnnsentmself-insurefor Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
much,as provided for by Section 3700 of he Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
-
work for which this Permit isissued, FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which his permit is issued. GAS-EA.SYSTEM-I INC.40UTLF.TS OCC.GROUP -DPN
My Worker's Compensation Insurance caller and Policy nu�n4. g� -
aF. O Polley No.: ❑`RxER/097'95 GAS-EA.SYSTEM-OVER4(EA) r `
CERTIFICATEOMPE SATIONION FROM WORKERS' '
COMPENSATION ON INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR -
BUILDING DIVISION FEES
(This nectiou neednet be completed time permit is fnrona hundred dollars(4100) , GREASETRAP '
or less.) PLANCHECK FEE
/certify thio rte erfomyprrmanceo as to became
for subject
bjech thisto fire Wrke,'ed,Ishall SEWER-SANITARY-STORM EA.200 FF..
not employ any person in any Harmer sac as to become subject to the Wnrkeri Compen- ENERGY FEE
,Arron Laws,of California.Date
O Applicant � WATER HEATER WNENT/ELECIR -
PP GRADING FEE
y
NOTICE TO APPLICANT:rsaftermaking Cwtificaue of of Exemption,youshould WATER SYSTEM/TREATING
F^ 5 femme subject to the Worker's Compensation provisions of he Labor Code you must - SOILS FEE
- F-i forthwih comply with such provisions or his permit shell be Deemed revoked. WATER SERVICE'. -
Q
CONSTRUCTION LENDING AGENCY '
Uz I herebyaffirm that there is aconstmetion lending for the NEW RESIDENTIALPLMB. SQ.FI'. PAID
agency performance of Data Receipt#
Le Werk for which NJ
is permit is issued(Sec 309],Civ.C
Le -
Q nders Name
Lender's Addrces - T %_.pTOTAL:
s L, a I certify that I have read this application sad slam that rte above information is BUILDING FEE
GG V1 cone.,l agree m comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U, building construction,and hembyimborizerepresm...im
vesnfthis city to enrupot the SEISMIC FEE
nbove-meationed property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way actors,against said City ALTER OR ADDTO MECH,
in consequence of the gaming M'- 4P`L:y:W
PLUMBING FEE
APPLICANTU ST DITH ALL NON-POINTr AIR HANDLING UNIT 9010,000 CFM)
SOURCE TI - 'MECHANICAL FEE
- _(Cf_ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
'Signa reofApp v;anuccajaI I Dam - r EXHAUST FOOD(W/DUCq HOUSING MITIGATION ME_ HAZARDOUS MATERIALS DISCLOSURE
Will the applicant of future building occupant stare or handle haallous'material HEATING UNIT(TO 100,000 BTU) '
as defined by the Cupertino Municipal Cede,Chapter 9,12,and the Health and Safety
Cade,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) - -
DYes ❑Ne -
VENTILATIONFAN(SINGLERESID) PAID11 Date Receipt is
Will rhe applicant nr future building occupant ase equipment or devices which
emit hazardous air connminam,a,defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR I 00 BTIr)
D's0ict? "
I ❑Yes ❑Nn BOILER-COMP(OVER 1110,00(1 BTU) .
Y I have read the hazardous materials requirements under Chapter 695 or Ne Cali- AIR CONDITIONER ISSUANCE DATE
- fomia Health as Safety Code,Sections 25505,25533 and 25534.1 understand tar if the NEW RESIDENTIAL MECH. SQ.FT
building does not currently have a ream,that itis my responsibility to notify the occupant'
of the requirements which must be met prior to issuance of a Cenificare of Occupancy. -
O vena m ashamed agent Date TOTAL:
{ ISSUED BY:
OFFICE '