29848 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE'.RTINO BUILDING-ELECTRICAL PERMIT NO. AA8 e
BUILDING DIVINION APPLICATION/PF.RMIT PLUMBING MECHANICAL
L S�„J� yV4lyJ
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: / SANITARY NO. APPLICATIONSUBMITYALDATI
53-81 4oC ✓A c. T 5
OWNER'SNAME: _ PHONE: CONTR CTOR:S NAME' LIC NO:
ef 1A a 1`11a _ �� / x _ N/C CONTROL p
ARCHITECUENGI .ER: LIC NO: ADDR SS: Yr ❑ -
aao ✓� �j/: S/G
CONTACT: PHONE:
BUILDING PERMIT INFO
s 33 � ElConsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSEDCONTRACTOR'S DECLARATION a QTY ELECTRIC PERMIT FEE
I hereby offimr that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z with Section 7000)of Division 3 ofthc Business and Pfofessions Cuk.end I'
FOO infunmrceaodeffa y sense is PERMIT ISSUANCE RESIDENTIA
1�1...Up License Class I Li'# -c g- (7� FOWL ❑KITCHEN REMODEL
F-ZDe¢ Cionommr APPLIANCES-RESIIIENTIAL '
C1 ADDITION ❑PLUMBING RE-PIPE
,Z:). ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O n Z I understand my plans shall be used as public records PANELSMODIFICATION
0 O - UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
r4 W Licensed Professional 2p1-IIMpAMPS IMPROVEMENT
X� OW NPmoc.oLDBRD,the Co mereION OVERHM)AMPS C BATH REMODEL/REPAIR ❑DEMOLITION
W{y lY I hereby affmn that 1 um exempt from the Comrnetolde:Anye law for the
P(36 U following ches a (Section N31 mBusiness and Professions Cale:Any city or county SIGNS ELIC IC POTHER
-
aall LL. which reaches n permit re connma sites improve,tlemoo sh,or repair any structure
y
PH.,to ib issuance,elw requires the applicant for such Period
to rile a signed document SPECIAL U
} Nat he is l sensed punuuat m Ne provisions of the Contractors License Law(Chate)or ^�
OO (commencing with SectionIONS1 of Division 3 of the Business and ProfessionsCode)oh TEMP.METER OR P)LFQl COMMERCIAL:
a 6 n that he is exempt therefrom and N,basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
m N Section 703 IS by any applicant for a permit subjects Ne applicant to a civil Penalty of POWER DEVICES 20
a
t more than five hundred dollars($500).
❑TENANT ❑FOODSERVICE
C] , , SWIMMING POOL ELECTRIC IMPROVEMENT
II Prthe work,and the he Cog orrifficed Law
dos not a(Sec.71144,nosiness ❑OTHER
and Professions Code:The Contractors License Taw does not apply s if owner of O17fLEf5-SWITCHES-FL\TURFS
property who builds or improves tM1such i and who Nes such work himself or through
his awn ,he provided rm such improvements arc nm intended or peered for NEW RESIDENTIAL 1!LECI'H SQ PT. r
sole.i(however,ll have the ban en of proving
is at hewithinion build or improve,ioq the SQ.PT.FLOOR AREA S/SQ.FT.
weer-builder will have the burden of prvving that he did not buil)or improve for Pur-
pose o(xuICJ. - -
C I,as owner of the property,am exclusively contracting with licensed cotnmcmrs m TOTAL: 7.
convect the project(Sec.7044.Businns and Profession Code:)The Conunaors Li.
cense Law does hot apply to on owner of property who builds or improves themon,and QTY, PLUMBING PERMIT FEE
whitcommetsforsuch prosets with ewmmemr(s)licensed pursuunuo the Contractor's
Liceme law' ' PERMIT ISSUANCE
Cm
laesemptua &
nde,S . ,BPCha Nisreason
Owner - Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
ry / Q G
1 hereby aRrm under penalty of perjuone of the following declarations:
(hove and will maintain a Certificate ofConsen to self-insum for Workers Champion. DRAINS-FLOOR,ROOF,AREA,COND.
Notion,as provided for by Section 37M of the Labor Cate,for the performance of the - STORIES TYPE CONSTRUCTION
war
r which this Permit is issued. FIXTURES-PER TRAP
have and will maintain Workers Compensation Insurance,as"idne i by Section
37M of the Labor Code,for performance ofthe work for which this permit is issued, GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP - APN
My Workers Compensation lnsu 'eland Policynu It a GAS-EA.SYSTEM OVER Cesrier �xrOVar.n t feY Np.: (EA)
CERTIFICATEOF XE ION FROM WORKERS'
COMPENSATION INSURANCE ORIi SF/INDUSTRL WASTE INTERCEPTOR
(This section need not he completed if no permit is forome hundred dollars($100) BUILDING DIVISION FEES
less) GREASE TRAP PLANCHECK FEE
(certify Perin the performaacearm.work
meobje this In.Woser,CoIshii SGWER-SANITARY-STORM EA.200 FT.
npaemploy Law any penton in any manner so n,m lrernmc Xuhjem to the Workern'Compton- ENERGY FEE
,0 setipn Lows of California.Dam
Z O Applicnm WATER HEATER WNF.M/ELECTR GRADING FL•C
H.� NOTICE TO APPLICANT.If,eller making this Certificate of Exemption,you should WATER SYSTEMfTRFATING
a � becomesubjecuo the Worker's Compensation provisions of the Litho,Code,you must SOILS FEE
LiI forthwith comply with.such provisions or this Permit hill he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
"aQIhor by whicfirmth Nana i isaed Ses.0OF,Clending agency for the performanceul' Date - ReceiplM
Le work for which Nis permit is issued(Sec.3097,Civ.C.)
Q (~ Lenders Name TOTAL:
L<nder s cedifye TOTAL:
certify
1 Net 1 have rcuJ this application and such,that the above information is BUILDING FEE
N7 corral.I agate m cpmply with ell city and county ordinances vM sum lows misting m QTY. MECHANICAL PERMIT FEE
V G building convection,and hereby authorize representatives of this city an enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE . ELECTRIC FEE
(We)agree m and save,indemnify keep harmless the City of Cupertino against
liabilities,judgment.cost and expenses which may in any way scent,against said City ALTERORADDTOMECH.
in consequence of the gracing of thiN permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER W."CFMj CONSTRUCfIONTAX
Signamrc or ApplatinVCprmactor Date EXHAUST HOLD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE '
Will die applicant or foam building occupant store or handle commodious material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code.Charm,9.12,and the Health.ad Safety
Cards.Se lion 25532(.)? HEATING UNIT(OVER 100010 BTU) hf��
❑Yes CNa VENTILATION FAN(SINGLE RESID) PAID p f
Dote' R,ceip
Will thedous applicant
taorfuture building occupant use ea Air uordeviceswhich BOILER-COME(3IIPOR IW,gM ETU)
i emit heraNuus air contaminants as defined by the Bey Area Air Quality Management I!AfVTAL: LN�
District? BOILER-COST(OVER 100.000 BTU) O
❑Yes CNo ',
I have read the bemrdous materialsuiremcal,under Chapter 6.95of the Cali. AIR CONDITIONER
req p Ur QS$UANCE'DATE
bumia gHealth does&Safety Cale.Satins 25505,25533 wM 8534.I understood Nat if the NEW RFSIDLMIAf.MECH. - SQ
building docs not sew ich haveata, etre,that it is my responsCiatiymnotify Occuiccupant
' of rhe rcqui e w ich st he etpr issuance ofa Cenipcate of(kcupncy.
Ownerprauthhom, ,gent t Dom TOTAL: ISSUED BY T� 19ll`1N-17&%-(XGI
OFFICE