29896 APPLICANTTO'FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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[6 BUILDING-ELECTRICAL - PERMIT NO. (�(� O�[x-/
BUILDING DIVISION. APPLICATION/PERMIT. PLUMBING-MECHANICAL G J o v
• 1. - WILDING PROJECT IDENTIFICATION
BUILDIN ADDRESS - j - - - ATE
+ - - SANITARY NO ++ APPLICATION SUBMITTAL DATE
OW .WSN ME: PHONE: CONTRA O 'SNAME: CONTROL M. .,
iRCHITE T/ENGINEER LIC NO:
sT i
CONTACT: - '^ . PHONE: _ t BUILDING PERMIT INFO
-' ,' ❑ Consultant Eces Paid by Applicant(Initial) D ELECT—.. PLUMB MUCH
'. LICENSFDCONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby 0)of that 1 of
BJ under provisions of Chapter 9(comm¢ I, JOB DESCRIPTION'
xr with Section 7000)of Division3of the Bus Profession Cod dm licen is'
�pyI00 n y PERMIT ISSUANCE � + RESIDENTIAL: '
F u� annuitant force an 0 .�'J -!Y + y". ❑SFDWL ITCHEN REMODEL
p p License ? Li r ✓ - - - f
'Fa{p Date 'Can[ [r APPLIANCES-RESIDENTIAL �� ❑ADDITION + ❑Ph GING RE-PIPE
ARCHITECTS DECLARATION PANELS ElMULTI-UNIT El STRUCTURAL .
y O dens and my plans shall be us d as public retools MODIFICATION
O,Z`- t UP TO 200 AMPS • a ❑INTERIOR' El CHIMNEY REPAIR
gg� Licensed Professional - 201-1000AMPS a IMPROVEMENT '
OWNERBUILDERDECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR El DEMOLITION
y I h by off m that I a exempt f lh C erruetm's License Law for the
x 3 0.V folio g ,r n (Sedum 7031.5,Business and Profs s o Cade Any city or courtly SIGNS ELECTRICAL
/ ❑OTHER
FM OEa which requires permit to construct,alter, p demadishr repair any saucmre
m.] prim t t 1 qure
rethe ppli if min such fileasigned statement. SPECIAL CIRCUIT/MISC
Math Ic nedPursuant ttheprevisions ofthe Contractors L L (Chapter9 - ^2
00 (commencng with b 7") fD's slo 3 ftheB mess and Prof..i ns Code)or TEMP.METER OR POLE RST''- COMMERCIAL:
[hal he pt therefrom and the basis for the alleged exempt on Any violation of NEW BLDG/ADDITION [_1 DEMOLITION
'^Y• Seer 90315 by any appl t f pe t bj el Ne appl c [to a I penalty f POWER DEVICES
❑TENANT ❑FOOD SERVICE
t thanf hundred d II yempl ,i SWIMMING POOL ELECTRIC' IMPROVEMENT
G1 tthpr pettym y ply with eg.a their I mp nsef
❑
C will do the -k,andthe structure' t intended oroffiredf r sale(See 7044Bu nes ❑ ER
and Priflicasnew Code.The Commences License Law does
not apply to an'owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves[hemon and who does such work himself or through
his own employees;provided that such improvements nre not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. '
sale.If,however.the building or improveibent' sld with.one year of completion,Nej SQ.FT.FLOORNAMA„� $/SQ.Ff.
owner builder will me theburden of proving thin did not build tl ormprovc for Dur-
Pose of sale) A -
❑ 1,as owner of the Property,am exclusively eiratrLi ng whO licensed ntracnm to -
construct the project(See.7044 Business and Professions Cod )The C l ¢tar's Li-
cause
i -'•'A'� O �(� r
cense Law dues not apply t an owner f properly h b 'Id 'mpro es thereon,end QTY. PLUMBING PERMIT FEE 9
who contracts for such pmjeet with atom togs)licensed pursuant to the Contractors I b '
License Law. - - - 'l�t E r �� L,
❑I am exempt under Sec - ,B&P C fnr th s reason PERMIT ISSUANCE IrPI,rFI(I RV
ALTER'-DRAIN&VENT-WATER(EA) VALUATION
Owner' Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE+-• _ ..,+ I �' 0
I hereby affirm under Penalty of perjury one of the following declarations:
❑Ihave and will maintain a Certificate of Consent to self-insure for Worker's CompenDRAINS-FLOOR,ROOF,AREA,GOND: STORIES TYPE CONSTRUCTION
aetion,as provided for by Section 3]00 of the Labor Code,for the performance of the _
work for which this permit is issued. FIXTURES-PER TRAP •• ,
❑ 1 have and will,maintain Workers Compensation Insurance,as required by Section - ,,
37004.f Ne Labor Coydaeq,f+�ngr the�perforemma�a.�nnrttc�ee of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40UTLETS OCC.GROUP APN
MyWaCartierr-,a=�/ /0-7-7 Policy Nor and r:number are:+ GAS-EA.SYSTEM-OVER4(EA)' p'
CERTIFICATE OF EXEMPTION FROM WORKERS' - - - -
" COMPENSATION INSURANCE t GREASE/INDUSTRL WASTE INTERCEPTOR
- ,Cthis section need not bewmplerad ifthe Damm is for one hundred dollars($1(10) _ BUILDING DIVISION PEES
or lase.) GREASETRAP r PLANCHF.CK FEE'/
I cenlfythat in the performanceof the work forwhich this Domain is Issued,Ishall SEWER='SANITARY-STORM EA.200 -
molemploy any person y n mat h subject to the Workers'Compen- - .ENERGY FEE '
Z sation Caws of Cahfom Date n -
O er s WATER HEATER WNENTMLECTR
Applicant - - ,GRADINGFEE, i
G y NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
F become subject to the Workers Compenseak n provisions of the Labor Code you muss SOILS FEE
m
W forthwith comply with such previsions or this peul shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY '' i ]NEW RESIDENTIAL PLMB' " SQ.FT. PAI0Ihereby affirm th t there is a construction lending ager yf r Ne performaof aceip'N
,r the workfor whichhls peTilis ismad(See,309],Cis.C.)FLendersTOTAL:OLender s Address
1 certify that I have reed Nie application and stns that the above information is BUILDING FEE '
iw Val correct.I agree to comply with all city and county ordinances and elute lawn relating to QTY. MECHANICAL PERMIT FEE '
Ll z building conavuction,and hereby suthnnz,representatives ofthis city to enter upon the - SEISMIC FEE.'
�. above-mentioned property for inspection purposes.. I ,-Cups
(We)agree to save,indemnify and keep harmless the City of ertino against PERMIT ISSUANCE ELECTRIC FE
�t habilities,judgments,coers and expenses which may in any way accrue against said City ALTER OR ADD TO SEEK, _ \�
in consequence ofthe granting ofthis permit - PLUMBING E `r\
APP
NIGER ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO M,"CFM)--• -
SOUR( REO. 1 MECHANI AL FEEtA
AJ jltl+oz�� AIR HANDLING UNIT(OVER 10,00(l CFM) CONSTR
Si ire pppherrin Com acme Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
,HAZAWOUS MA IALS DISCLOSURELt
i Will the applicaatorfuture bui ng occupant smrebrhandle hazardous material" HEATING UNIT TO 100,000 BTU)
as defined by,the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532_(a)? -•- HEATING UNIT(OVER 100,000 BTU)
❑Yes 1, �Nni VENTILATION FAN(SINGLE RESID) - - PAID -
Date t' ftxciPlM
Will thedons.applicant nature building by the
Ana i -ntor Marawhmh^ BOILER-COMPLIPOR Md"BTU) • -
nit hazard us air contaminants as defined by the Bay Aren Air QunlityManngement ' TOTAL: "-
niammp - '9
Dyes C-]No '• j $ _ BOILER-comp(OVER 100,000 BTU)
+ AIR CONDITIONER e
. Ihave read Ne hazuNoos materials q itis under Chapme 6.95 of Ne Calm ISSUAN TE ,
fears Health&Safety Code Sections 25505 25533 and 25514 1 understand that if Be NEW RESIDENTIAL MECR, SQ.SFT.
" building does not currently have a tenant,that it is my responsibility in notify the occupant'
of the.,aim—ts which must he met prior to issuance of a Certificate of Occupancy. n
OwnarorauthodzWagat Dale T AL: ISSUED BY:
OFFICE ,
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