29574 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CI'T'Y OF CUPERTINO, UUIL)ING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 29574
BUILDING PROJECT'IDEN'FIFICA'I'ION BUILD/oA %NIiS� � SANITARY NO. APPLICATION SURMI'ITAL UAIE
N F,k:S NA E: /� HONK: _ TRACTOR'SNA ` LIC NO'.
1CNIC L N-IRTL11
1 ELT'NGI 'ER; ADDRESS: ❑
OMI'ACf: A�ION s HII ILDING PERMIT INFO
❑ Consultant Fees Paid by Appliwnl(Initial) g1. ELECT PLUMB MECH
LICENSED CONTRACTOR'S1,DECLAKATION • QTY ELECTRIC PERMIT FCC
1 hereby aBirm thin 1 am licemcd under provision.,of Chapter 9(ttnnmen<ing _ JOB DESCRIPTION
yyDII�Z with Soctim.70kKduf Dr,i,km3ol me gusincss and ProfeaxionxCodc.and my license isSIDENTIAL
Fin full puree and eH«t. PERMIT ISSUANCE •
- C� 1-
W0U FDWL ❑KITCHEN RE.MODEI.
CUW License Claw Court
6 U pPPLInNCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
lnQ cl Dam Contractor
ARCIII'I'IiCT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Fpm PANELS
Z Z 1 andemanJ my was shall he uad as public records MODIFICATION
0Z—O UPT02W AMPS ❑INTERIOR ❑CHIMNEY REPAIRF��W Licensed Professional 201-1010AMPS IMPROVEMENTO
OWNER-BUILDER DECLARATION OVER IINIIIAMPR ❑BATH RBMODEI-JREPAIRIO DEMOLITION
Q 1 hereby affirm that I am exempt firm the Commetnh License I,uw for the
°xx•�aU following reason.(Section70315.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 a vFi which requires o Permit to construct,aIle,improve,demolish,or repair any strremre /'/(
1�"u•cQ, prior to its issuance,also requires in applicant for such permit to file a ognedxmtemem SPECIAL CIRCUITIMISC. �G ��y �Mgn
} that he is licensed pursuant to the provisions of the Contactors License law lChapter9 w
�OL7�0 (commencing whb Scnion]U010 of Uivisinn3nfthe Rusinev',and Pmlcsxionx Gvle)ur TEMP.METER OR POLI?INST. COMMERCIAL'
Q.d o,Y that he is esempt tbemfrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�Mm Section 0031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES ❑'TENANT r{If FOODSERVICE
^K} not marc than five hundred dollars(S500). IMPROVEMENT
Q D 1.as owner of the property,or my employees with wages as their rule compensation, SWIMMING POOL ELECTRIC
will do the work,and the,macmrc is not intended orofered for xnle(See.91W4,Business ❑O'1'HI?R
C o
W eco and ny,hlons Cade:The Cotnrac..,.de Law does nm apply m1f owner of OUTI.Ii I:S-SWITCHES-FIXTURES
a'3 property who builds or improves mercon,and who Jces such work himself or through
his own employees,provided that such improvements an,not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If,however,the building or improvement ix sold within one year ofemadetion.the �j SQ.F..FLOOR A.R�E1A_. S/SQ.FI'.
somer-builder will have the burden of proving that he did not build or improve fnr par- Z Ir .O Z 1 � 2^I ' 1\
you of avlcJ. ` G-- �T'e
❑L as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.76 ,Business and Professions Coco The Contmcmr'I Li- 3q�s ,S�j •1C�
7
nae Law does not apply to on owner of property who builds or imm
pves mere').,and QTY. PLUMBING 'R T FEE l/�a 1..G•
who,"draw fnr such projects with a cammacna("licensed pursuant ue Ihm Camra bc,
License law. PERMIT ISSUANCE
l oto exempt ander Sec. .B&P C f rr ak re ram
Caere,
ALTER-DRAIN&VE -WATER VALUATION
• DamWORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVI 11 -ZO �-
I hereby affirm under penally of perjury one of the following declarations:ns: \VIGI
❑Ihave and will tnaimeina Certificate ofConummulf-insurcfor Workers Camper- DRAINS-FLOOR,ROOEARIiA, STORIES TYPECONSTRUCHON
station,ax provided for by Section 37W of Ne Labor Code,for the performance of the
work for which this Armon is issued. FIXTURES-PER'I'RAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 nfthe Labor Code.for the performance of the work for which this Permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC GROUP AYN
My Workers Compensation Insurance carrier and Policy number are:
Carrier; Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' Cft1iASIlINUl15TR1,WASTE IN 1'ERCEPTOR
COMPENSATION INSURANCE BUILDING UIVI51pN FIiLS
(This section need not be completed if the Permit is for one hundred dullan(SI W) GREASETRAP
or less) PLANCHECK FEE
I scroy that int he peromanceofthe work for whlchlhis permit is issued.l shall SEWER-SANITARY-STORM EA.200 FT.
Z O NOTICE TO APPLICANT:If,after this Certificamrf Escarpment,vCnmpen- GRADINENERGY FE
not anploy va,person is any rournerso as to become subject to the Workers
sation laws of Cvlil'nmia.Date WATER HEATER W/VENT/ELEC'FR
O p GRADING FEE
zed g ras should WATER SYSTEM?RT:ATING
; become subject to the Worker's Co n,,mahon provisions of the Labor Code,you must SOILS FEE
lGZyl forhwith comply with,ach poi,kiun,or this peonirxholl be deerwrimvaked, WATER SERVICE
Q
G CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL 1'LMB. SQ.PH PAID
U ,Z Dam Receipt p
U O liar which
this
that Nerc isaco (Site tim30 loading agency for me performance of
U me work for which this permit is issued(Sec.3WT,Civ.C.)
� U LendeL,Name 1 TOTAL:
W Lender's Address - TOTAL: .
y I certify that l have mad m
this application and state al the above information is V 4 BUILDING FEIi VIA ba
to correct.l agree to comply with all city and county ordinances and state laws matingm QTY, MECHANICAL PERMIT FEE QD
U SEISMIC FEE
Z building communion.and hereby authorize representatives of this city to enter upon me
Ar,c.n eiriered porpen,for inspection purposes. PERMIT ISSUANCE
(We).,omm.,ave,indemnify and keep hmmless he City of Cupertino against ELIiCI'RIC FEEee 14�
liabilities.judgments.costs and expenses which may in any way accrueagaiml said City ALTERORADDTOMECH. PLUMBING FEE
in VQ
nsequenccof the granting ofmi.permit. `
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00 CFM)
SOU REGOLp'I'IONSII
. CONS MECHANICAL ({O
AIR HANDLING UNIT(OVER III,INM)CFM) CONSTRUCTION TAX
Signature of Ap,fcmrJ(-Firturael., I Dae EXHAUST HOOD(W)DUC) HOUSING MITIGATION FEE
HAtARDOUS MATERIALS DISCLOSURE
Willmsapplknnl m furore hrdldi,,x,,.pantsmre or handle haz.Nanx material HEATING UNIT(TO 1110,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532pd? I HEATING UNIT(OVER 100.000 BTU)
Yes ON.
VENTILATION FAN(SINGLE kF_SID) PAID Date Receipt p
Will the applicant or future building rwcapam use equipment or devices which
emit hazardous air commitments as defined by the Bay Arca Air Quality Management BOILER-COMP(3111'OR 100.000 RTU) TOTAL.
District? BOILER-COME(OVER Did"BTU)
❑Yes ❑No
1 have real the on.ol us materials re is under Chapter 695 or the Cali- AIR CONDITIONER ISSUANCE DATE
yni533 p
pantie Health&Safety rre Crile,Seaton,25hat i is my amp 255141 understand that if the NEW kISIDF;NTIAL MECH. SQ.Pf.
building does net currently have a tone,that o is en of a responsibility totenitrify the occupant
of drc regeirtmcnn which moa be ton prior to issuance of a Certificate of(]ecuPancy,
Owner or aumontd agent Duce TOTAL:' ISSUED BY:
OFFICE
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